For the second interview of our series on the Bamako Initiative, Jean-Benoît Falisse interviews Zan Yaya Konaré. He is the President of Mali's FENASCOM. FENASCOM is the federation of the community associations (ASACO) that have been managing Mali community health centres for more than two decades. This experience is often seen as one of the most advanced examples of community participation as communities are the legal and actual owners of the community health centres.
JBF - Mali is often mentioned for its ASACO, could you tell us when and how it all started? How does it fit into the Bamako Initiative (BI)?
ZYK - Community health initiatives emerged in 1990 under the joint influence of an engaged civil society and a new Health and Population sectorial policy. They responded to both a growing demand for health care and limited resources of the State. The health policy of that time favoured the emergence of community health associations ('Association de Santé Communautaire' - ASACO in French). It also allowed the State to devolve primary health care services to communities of users. This is done through a mutual assistance agreement which defines the obligations of each party. Community health centres are public facilities that follow national-level regulations.
The principles for creating and running community health centres ('Centre de Santé Communautaire', CSCOM) are cost recovery and community participation in the financing and management of health care. The experience lasts since 1989. Several funding mechanisms support the community health system: sectorial budget support, transfer of skills and resources from the state to local health authorities, recovery of the costs of services and the existence of a National Agency for local government investments. In addition to these CSCOM funding mechanisms, a system of mutual health insurance organisations improves the affordability of health care for the poor.
ASACOs recruit part of their staff and the Ministry of Health appoints the rest (especially in areas where CSCOM are 'unsustainable'). Yet, as the creation of new community health centres increases the health care coverage, the supply and quality of the minimum package of essential health services remains sometimes insufficient. This is mainly caused by deficiencies in community health centres’ staffing and health agents’ motivation and qualifications in poor areas (categories 1 and 2, the poorest areas).
Was there any initiative of community participation before the ASACO? Is there a tradition of democratic participation at the village level in Mali?
In Mali, the only existing community initiative before the BI was a Primary Health Care (PHC) programme which was based on traditional birth attendants and midwives paid out of the funds of the Regional and Local Development taxation. This experience had not been conclusive as taxes that were supposed to fund the wages of these health workers were often unpaid. Community health workers did not receive their salaries on a regular basis and abandoned their job or got paid directly, at the expense of the very existence of the health centre.
What has been the public support for the ASACO system? What was the motivation for setting up such a system?
In order to improve the health of the general population and of mother and child in particular, our strategy is to expand access to health services. We use a process of planning, organisation and decentralised management that follows a community-based approach (which implies environmental studies, community rehabilitation, etc.). In this approach, which seeks to set up a network of local structures, systematic and standardised implementation is dismissed in favour of implementation by the “cercles” (local authorities) and communities who are the implementing partners. To benefit from state funding and other external support, the communities that want to create a community health centre must meet a number of criteria including: respect of the national standards, existence of a development plan, financial and / or physical contribution of the community to at least 50% of the budget of the health centre, commitment of the Local Development Committee of the “Cercle” (1) to health at least 7% of the revenue generated by the local development tax local, support of the Regional Directorate of Health and Social Affairs and organisation of a sustained campaign of information and sensitisation of the population in order to obtain the participation of government and organised communities.
We also seek to improve quality through a shared technical framework and increase the viability of the health system at the “Cercle” level through the rational and efficient use of resources (personnel, drugs, finances, assets) and the organisation of community participation.
FENASCOM has a network of more than 30,000 volunteers who animate the community health movement in Mali. Volunteering is part of the tradition in Mali and our culture highlights the importance of solidarity.
Are all the health centres in Mali managed the same way? What is the strength of the ASACO health centres?
All health centres are not managed in the same way. The health-care structure of Mali has three levels:
1. The community health centre (CSCOM) is the first level health centre. It is the first contact point for the patients. It belongs to the community, which is organised in a Community Health Association (ASACO). The CSCOM is created and managed by the ASACO which represents the population in the management. The administration is provided by a Management Committee designated within a board elected by a general assembly of the population.
2. The reference health centre (CSREF) is the second level health centre. It is created by the state and is co-managed by the national government, the local government and the community. The state builds up the centre and installs the necessary equipment and staff. The mission of the CSREF is essentially to support community health centres within the referral / evacuation system. The local government recruits senior staff and oversees the management and decision-making process. The community helps in the functioning, in particular through the implementation of the referral and evacuation system and participation in the management and decision process. The centre uses its own funds to support staffing and operating costs. A board and a management committee are established under the responsibility of the local authority. The technical and administrative direction is provided by the surgeon/chief-doctor who is also a member of the Management Committee.
3. Hospitals are the last resort for patients, especially for specialised interventions. They are managed like an enterprise, with a board of directors and senior management.
The ASACOs' strength is that they are the emanation of the people and they are autonomous from the central government. They are the legitimate representatives of the people in the implementation of the health policy of the government.
What were the main developments of the ASACO system in recent years?
The figures speak out for themselves. There were 44 ASACO in 1994 when the FENASCOM was created. They are now 1,060, with as many existing functional CSCOM. The health coverage has increased from 29% in 1992 to 80% in 2012. The FENASCOM has also contributed to the reduction of unemployment among graduates as is the second largest employer after the state in the field of health care, with 52% of the staff in charge.
There are also less quantifiable achievements such as a better connection between health services (CSCOM) and populations and a better control of the cost of health care as the profit margins of the health centres are determined by the communities themselves, based on their income.
What are the main challenges today? How to overcome them?
To ensure efficient and effective support in the implementation of the state health policy, FENASCOM must face certain challenges which include: to medicalize (i.e. staff with a doctor) all CSCOM; to fight the illegal sale of drugs; to contribute to te reduction of maternal and infant mortality by extending the strategy of critical care in the community; to ensure good governance within the community health 'family'; to ensure an active and responsible participation of women and youth in decision-making processes; to provide efficient answers to the problem of sustainable management personnel at community health centres; to contribute to the extension of universal coverage in health, including through compulsory health insurance and volunteering programmes for young people.
You are the head of the FENASCOM, which brings together community health organisations. Could explain the purpose and functioning of your federation?
FENASCOM was created in 1994 by the ASACOs. Its aim is to ensure the necessary conditions for sustainable development and achievement of the government’s health commitments to the population. It has been registered as a non-profit organisation since 2002 and received technical and financial support from the State and its partners. FENASCOM includes 1,060 ASACO members and five mutual health insurance organisations. FENASCOM collaborates with other organisations of the civil society working in the field of health through a consultative framework that has been developed at the national level.
FENASCOM actively participates in various bodies of the health system in Mali and in various meetings related to community health. The objective of FENASCOM is households’ access to quality health services in line with their needs and in accordance with established standards. This includes the participation of ASACOs that are competent, dynamic and able enough to provide answers to the health problems of population.
FENASCOM is open to any Community Health Association and/or Mutual Health Insurance Organisations officially recognised by the competent authorities. FENASCOM is organised into 59 local federations, 9 regional federations and a national federation. A national congress meets every five years and a coordination council every two years. Daily management is handled by the executive offices at different levels. A Permanent Secretariat is responsible for the daily management of the FENASCOM at the national level.
At the moment, Mali does not appear in the headlines for its ASACO but rather for the war that ravages the north of the country. Do you know what happened to the ASACOs located in the northern part of the country? What is the political dimension of the ASACOs?
In the wake of the recent rebellion (January, 17, 2012), FENASCOM immediately organised a consortium to deal with the current situation of community health in the strip occupied by the rebels. This initiative has been strengthened with the events of the coup of the 22nd of March 2012. The goal is to gather information and propose actions. An emergency response plan has been developed; here is an excerpt that relates the situation on the field:
“Information to be confirmed indicates the devastation or destruction of socio-health infrastructures at different degrees in the three 3 northern parts of the country. [...] The health situation is worrying as services have stopped in several community health centres and hospitals in the northern regions. This is exacerbated by the departure of the majority of the socio-sanitary staff out of the areas affected by this crisis”.
Interestingly, it was reported in Gao [occupied by the rebels] the creation of a "monitoring commission of the situation" composed of religious leaders, Imams, customary chiefs, heads of districts and community leaders. It is responsible for the assessment of the crisis and negotiation with the armed rebels whenever necessary, especially in regard to various health abuses including sexual violence.
(1) the "Cercle" is the local administrative level in Mali.