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In Mali, where rates of attendance at healthcare facilities remain far below what is needed, three user fee exemption policies were instituted to promote access to care. These related to HIV/AIDS treatment, as of 2004, caesarean sections, since 2005, and treatment of malaria in children under five and pregnant women, since 2007. Our qualitative study compared these three policies, looking at their implementation provisions, functioning and outcomes. In each healthcare facility, we analysed documentation and carried out three months of on-site observations. We also conducted a total of 254 formal and informal interviews with health personnel and patients. While these exemptions substantially improved users’ access to care, their implementation revealed deep dysfunctions in the health system that undermined them all, regardless of the policy studied. These policies provoked resistance among health professionals that manifested in their practices and revealed, in particular, the profit-generation logic within which they operate today. These dysfunctions reflect the State’s incapacity to exercise its regulatory role and to establish policies that are aligned with the way the health system really works.
This was a qualitative study involving case studies [13]. We began by conducting interviews at the national level and consulting available documentation (service notes, activity reports, etc.) to understand the framework established for each policy, as a foundation for analysing the gap between those provisions and the actual conditions of implementation on the ground (Table (Table11). Number and types of interviews conducted at the national level. To study the free care policies related to caesareans and malaria, we selected Bamako and the regions of Kayes and Sikasso. For the policy related to HIV, we focussed only on Bamako. Bamako was selected because it is an urban environment that is close to decision-making and supply points. In Bamako, we selected the Commune 1 health district because it contains Mali’s first CSCOM (community health centre), has a well-recognized CSREF (referral hospital), and is made up of neighbourhoods of very different standings. The Kayes region was selected because the Canadian Council for International Co-operation is involved in maternal health in that region and has conducted quantitative studies that are complementary to our qualitative approach [14]. In that region we selected Kita district because it is also a sentinel site for malaria control, which suggested good conditions for implementation. In the Sikasso region, we selected the Sikasso district because it offered a rather advantageous health setting, with no major structural impediments to the successful implementation of major free care policies. In these three districts of the three regions, we selected three health centres. First, the three referral health centres (CSREFs) were studied, as these are the district referral hospitals. Then, we selected the two most contrasted community health centres (CSCOM) in the districts. The contrast was determined based on their degree of isolation, which has an influence on information, supervision, and drug supply, but also on health worker and community organization dynamics, as well as on the level of use of the CSCOM by the population (Table (Table2).2). The management of caesareans was studied in two CSREFs in Bamako and Kita, and at the Sikasso regional hospital, a public institution that enjoys a degree of independent management. We observed a total of 58 cases of caesareans at the three sites. The nine sites involved in the study of the three policies. To vary the management status of multiple sites (public, semi-public or private centres, which do not function in the same ways) in a single given context, we studied the management of HIV/AIDS patients in the district of Bamako alone, selecting three sites. The first was the CESAC (advice and counselling centre), an associative-and, as such, private-treatment centre run by ARCAD-SIDA (association for research, communication and home assistance for persons living with HIV/AIDS) and devoted exclusively to the management of HIV/AIDS. The second was the CSREF of Commune 2, a public health centre offering fully integrated management of the disease. The third was the USAC (care, support and counselling unit) of the CSREF of Commune 1. This unit, which specialized in HIV/AIDs, was located in a public health centre but had a certain level of autonomy; it was funded by ARCAD-SIDA with the CSREF’s backing. In each site, the research team carried out a documentary analysis (data produced by the health information service and service notes), three months of on-site observation, and formal and informal interviews with healthcare workers and patients. Our team was made up of a researcher in charge of studying the emergence and implementation of the three policies at the national level and a team of three research assistants supervised by the author of the article; each research assistant was in charge of one of the study sites, for each of the three policies. We conducted in-depth qualitative interviews with different categories of personnel (service chiefs, physicians and residents, nurses or midwives, nurses’ aides or matrons) in the services affected by the free care policies in each of the selected health centres. Respondents were selected to ensure that all categories of health workers were represented in our sample so that all possible viewpoints would be included. We also interviewed patients and those accompanying them during our on-site observation periods, whose care we were able to observe before their discharge (Table (Table33). Number and types of interviews conducted in the sites. * Community leaders are involved only in community health centres (CSCOM) and have no role with regard to caesareans or HIV/AIDS management. By triangulating information in this way and by long immersion in the field, we were able to record not only interactions between actors, but also the conditions in which patients were managed, above and beyond what health professionals reported about their practices. The data (daily observations recorded in notebooks, interview transcripts) were subjected to thematic analysis (with the construction of a thematic tree) and interpretation. The data were examined and discussed, and data relating to different themes and sites were compared. The research was authorized by the ethics committee of the INRSP (National Institute of Public Health Research: 9-000011/CE-INRSP). The field surveys were conducted between September 2010 and December 2011, and the research findings were presented at a meeting in Bamako in November 2012. The three policies are presented below. In each case we focus first on the action plan adopted for each and then on their operationalization and the results achieved. Finally, we show how malfunctions within the health system had much the same effect on all three policies, despite the policies’ very different functions.
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