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January 11, 2010

MLI Voice: Senegal

   Dr. Ndack Ly

MLI is working with the Ministry of Health and Prevention in Senegal to refine its health sector-wide approach (SWAP) and to develop new formulas for allocating resources to the district and hospital levels. As a part of the 2009 action plan, two studies were undertaken around these focus areas and the reports are currently in the validation phase. Two separate delegations undertook study tours in 2009 in order to learn more about the sector-wide approach and resource allocation criteria: to Mali in August and to Rwanda in October. Each mission had different exchanges and priorities; however, we drew some major conclusions and learned lessons that will help the Ministry with its progress on the reforms underway in Senegal.

The study tour to Mali

The general objective of the study tour to Mali was to contribute to improving the performance of the health sector in Senegal by adapting Mali’s relevant experiences with coordination between the Ministry of Health and the technical and financial partners (TFP). Thus, over five days there were visits, meetings, and working sessions between the Senegalese mission, led by the minister’s senior technical advisor, and the different departments in Mali’s Ministry of Health, the Ministry of Finance, Ministry of Decentralization, civil society associations and federations, and the communities.

The two main findings about the organization of the health system in Mali are: first, the implementation of the community health centers (CSCOMs) by the Community Health Associations (ASACO) at the peripheral level; and second, the conversion of hospitals into public hospitals (EPH). A bona fide health inspection service, comprised of 18 inspectors, is tasked with periodically inspecting the public and private health services. The reports that are generated are distributed to the highest authorities, including the Ministry of Health, the Prime Minister, and the President of the Republic.

Stakeholder ownership of SWAP methods and tools, through efforts in information, awareness, and even training at every level, has helped make SWAP sustainable in Mali. One of the most important features of effective SWAP sustainability in Mali is due to the presence of a strong team in the Ministry of Health. This team is convinced that this is the correct approach and has mastered the technical tools. The SWAP requires a very broad management framework in the health sector, and Mali has not only created appropriate frameworks for dialogue and coordination, but it has also ensured that exchanges are held regularly and as frequently as needed.

Mali’s COMPACT can be defined as an ethical and moral commitment between a government and its partners to support the implementation of national sectoral plans and programs with the effect of accelerating the achievement of the MDGs. The COMPACT is thus strengthening the alignment of the TFPs in Mali and is harmonizing their interventions to ensure that PRODESS II Extended, Mali’s health sector development plan, is a resounding success. This COMPACT does not rule out the flexibility of TFP resource mobilization procedures, as direct sectoral support coexists with budget support, whether targeted or not.

In Senegal, it is important to have a strong team with effective leadership, in other words, informed managers who are trained in the SWAP philosophy and in the use of its various planning, programming, and evaluation tools. This will require an upgrade in our institutional framework to strengthen financial and technical data collection techniques without interfering with the operations of the departments, which today are highly effective. Drafting a Senegal COMPACT will necessitate that we carry out many studies to develop the sector, including the human resources development plan, the study on providing care for costly diseases, and the Reproductive Health Strategic Plan.

The study tour to Rwanda

The delegation from Senegal that traveled to Rwanda was led by the Director of Payroll of the Ministry of the Economy and Finance. The purpose of our visit was to learn from Rwanda’s experiences in institutional mechanisms for the allocation of health sector resources and health risk pooling, and to analyze the scope of Rwanda’s reforms. Meetings with central level officials, field trips, and working sessions were organized with the different divisions in Rwanda’s Ministry of Health, Ministry of Finance, Ministry of Decentralization, managers of mutual health organizations, and World Bank consultants. It should be noted that our visit was organized to coincide with the visit of MLI’s Malian delegation, whose priority was learning more about community-based health insurance (or mutuelles) experience in Rwanda. As was the case for Mali, our delegation identified several characteristics of Rwanda’s approaches to health insurance and performance-based financing (PBF) that informed our thinking about our own policy reforms in Senegal.

In Rwanda, funding for health services has traditionally been based on three sources of financing: the government, the people, and donors. The breakdown for this financing is planned by taking into account such factors as the populations covered, available facilities and equipment, morbidity and mortality for certain pathologies, etc. However, the sector does not yet have objective criteria for allocating government resources. The government budget is still allocated on a historical basis with new measures to meet specific and current health policy needs. However, during this visit we drew conclusions on promoting community health insurance and PBF.

The overall national financing system that was set up in Rwanda manages the financing of supply and demand in the health sector. Mutuelles, which cover 86% of the population, and PBF, are additional mechanisms that strengthen the traditional system for financing health services. The network of mutuelles throughout the country, organized around the health map, is a major asset for the system. The attractiveness of the supply of services and the fact that there is no ceiling on the amount the system will pay for treatment is what makes Rwanda’s health insurance system so appealing. These two factors also influence utilization rates for health services.

Performance-based financing (or performance-based contracting in local terminology) provides for purchasing the activities and services that the health facilities actually produced based on a performance contract that has a clause about high-quality services that are provided in compliance with the norms. The incentives for retaining skilled personnel in outlying areas are essential for the current performance of the Rwandan health system. Also, the new types of results-based incentives should improve indicator levels considerably and trigger a qualitative change in provider behaviors.

In Senegal, it would be interesting to experiment with PBF, especially for distributing incentive funds among health personnel as part of a pilot project in line with our health sector development plan’s (PNDS II) priority objectives. A pilot program in a region in which reproductive health indicators are still poor, combined with a pilot in an outlying area that has achieved universal health coverage, would be a good opportunity to learn about PBF applications in different contexts. Also, this pilot phase will allow us to explore operational mechanisms for retaining health workers in outlying areas prior to scaling up PBF.

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