An Applied Political Analysis of the Targeted Free Care Reform in Mali

Abstract

Introduction - Health financing through out-of-pocket payments is deeply inequitable and imposes barriers and risks for patients. After decades of charging patients for healthcare in Mali, an ambitious primary health care reform was announced in February 2019 that would exempt target populations from payment - “targeted free care” (TFC). This thesis is an in-depth case study of the policymaking process of introducing TFC in Mali. It aims to apply the methodological toolkit of political analysis and adaptive change to understand where things stand 32 months later (September 2021).

Methods - A literature review traces the history of user fees in Sub-Saharan Africa, distills 14 best practices for removing them, and identifies features of the Malian health care system relevant to TFC. Next, a documentary review, 21 months of participant observation and 19 stakeholder interviews provide the data for a reconstructed narrative of the reform’s development and announcement, as well as a political analysis using three frameworks: the 14 best practices for TFC, stakeholder analysis, and Kingdon’s Multiple Streams framework.

Results - Several features of the Malian context make implementing TFC difficult: small and contracting health budget, weak state capability demonstrated by existing programs, sector-wide strategic fragmentation and poor coordination, and highly autonomous primary healthcare centers dependent on user fees. These are heightened by the political and security crisis. Issues with the reform’s development, content, and announcement reduced buy-in from key stakeholders. It witnessed a loss of high-level support due to ministerial turnover and two coups’ d’ tats - inconsistent leadership made consensual policy development, coordination, and network building difficult. Stakeholders closest to the operational level with the most discretion around TFC implementation are also the most against it. The reform window for a national TFC policy has closed, and it is moving forward on a pilot-scale with uncertain ministerial support.

Conclusion - The multi-dimensional costs to families of user fees are well known and the need to repeal them urgent. However, Mali’s worsening security and political crises appear to be a more pressing priority for those in power. This could provide time to work out the policy’s design and build consensus.