HEALTH FINANCING SYSTEM ASSESSMENT (HFSA): MALI Strengthening health financing policymaking for accelerated attainment of universal health coverage in Mali June 2023 Samia Laokri and Laurence Lannes The World Bank ABOUT THE REPORT This report illustrates the efforts of the Project’s team in disseminating knowledge in support to Mali health policymaking. This work is the product of a principal investigator hired as independent consultant for the account of the World Bank, with the support of a co-author, external reviewers and contributors. The findings, interpretations, and conclusions expressed in this work are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. ACKNOWLEDGMENT The Mali Health Financing System Assessment (HFSA) was prepared by Samia Laokri (Consultant, HAWH2) under the overall guidance of HNP Senior economist and team leader Laurence Lannes (HAWH2). This work was funded by the PACSU Project and WB as part of the technical assistance program on analytics program to support UHC in Mali, with the support of the Global Facility Financing (GFF). Authors appreciated valuable guidance and contribution from the World Bank Project team and in-country key informants. The team included Patrick Hoang Eozenou, Jean Claude Taptue Fotso, Denise Magne Tamga, and Loredana Horezeanu (consultant). The report was also greatly enriched by review experts from the global health industry. Written comments were received from two peer reviewers Owen K. Smith (Lead Economist, HAWH3) and Hyacinthe Kankeu Tchewonpi, (ETC, HHNGF). Laura Macmahon (PIComm) edited the report. Dissemination of the report was authorized during a review Meeting held on June 20, 2023 chaired by Christophe Rockmore (Practice Leader and Acting Chair, HAWDR). Attribution—Please cite the work as follows: Laokri S. and Lannes L. (2023). Mali Health Financing System Assessment: Strengthening health financing policymaking for accelerated attainment of universal health coverage in Mali, The World Bank, Washington DC © World Bank. Rights and Permissions—Some rights reserved. The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522- 2625; e-mail: pubrights@worldbank.org. |samialaokri@gmail.com —Or Health, Nutrition and More Information—slaokri@worldbank.org Population Global www.worldbank.org/health |@WBG_Health |blogs.worldbank.org/health |askhnp@worldbank.org Photo Credit—World Bank Photo Collection https://www.flickr.com/photos/worldbank © 2023 The World Bank 1818 H Street, NW Washington, DC 20433 Health, Nutrition and Population (HNP) The World Bank EXECUTIVE SUMMARY RATIONALE & METHOD The Republic of Mali’s future health and human capital development depends on the government’s ability to transform its health policy by investing more and better in its health system. Health financing towards universal health coverage (UHC) by 2030 is a government of Mali’s (GOM) ambitious goal. Its success lies in the details, requiring a sector-wide approach to embrace the many challenges and opportunities. Mali’s legal framework is designed to reduce health financing fragmentation and move forward to achieve universal health coverage by the end of the decade. Effective implementation is therefore key to secure the success of the ongoing health financing reform, which requires knowledge and coherence of health financing decisions and their impact. The Health Financing System Assessment (HFSA) is tool to promote informed decision-making in support to Mali’s ongoing health financing reform. HFSA’s primary goal is to unravel the complexity of health financing data and underline the role and use of key indicators. Secondly, it aims to serve the leadership of the Ministry of Health and Social Development (MOH) and related stakeholders, by highlighting the constraints and opportunities, as well as the progress made and to be made to reach better health and human development for the next generation in Mali. Improved health financing system in Mali requires robust data to identify the obvious and hidden barriers and/or drivers to UHC, which is utterly needed to accelerate attainment of the national policy objectives and global targets for sustainable development. Our findings capitalize on an extensive literature review, including technical and policy reports, prior studies and surveys, legal documents, and scientific publications. We have attempted to incorporate all updates (newly published reports and data) that occurred during the research process. We covered local, national, regional, and global data repository sources. Mali’s HFSA follows World Bank protocol, adapted to HFSA: Mali | Technical report i The World Bank reflect Mali’s specificities and challenges. A benchmarking approach was used to better capture national progress against peer country achievements and global trends. Mali’s peer countries were selected using a mix of criteria, following the standardized methodology of the World Bank Macroeconomic, Trade and Investment global practice. The report also pinpoints the strengths and weaknesses inherent to health and health financing data production, availability, and use. Mali’s HFSA report covers eight main chapters. Chapter one serves as an introduction, focusing on the study rationale, aims and method used to conduct this health financing system assessment. Chapter two on country context unpacks the hidden challenges behind the socio-political, economic and other contextual factors. Chapter three depicts the current state of and main achievements in population health, service coverage for health and the fight against disease burden. Chapter four covers health system inputs (human resources, infrastructure, and information) and related requirements to further progress towards UHC. Chapter five highlights the health financing landscape, showing trends and levels of health spending across revenue sources for health, functions, schemes, and distribution over the past twenty years, as well as the spending adequacy and financing gap to meet national policy goals. Chapter six explores the budgetary efficiency in health and assesses potential missed resources for health. Chapter seven conveys insights into health financing patterns and drivers to orient future health decision-making, overviewing Mali’s capacity in resource mobilization, pooling and purchasing, as well as the links with public finance. Chapter eight serves as a way forward in health financing for the next generation in Mali. Most salient results highlighted across topics. HEALTH SYSTEM OUTCOMES Health outcomes – Like in many countries, Mali’s health system has lacked resources for decades and this has limited the expansion of primary healthcare for all and other cost-effective health interventions. Nevertheless, Malians have undoubtedly become healthier over time. In Mali, life expectancy (58.6 years old), health adjusted life expectancy (54.6 years old), and human capital development (0.32) also remain of public health concern compared to global achievements. At country level, several health outcomes were found to be uneven across the regions and districts. Mother and child mortality – More women and children survive today than ever before but Mali’s child and maternal mortality ratios still lag behind the benchmarked averages and are unlikely to meet the SDG targets by 2030 without renewed efforts. Significant progress has been made in Mali towards reducing child mortality, especially among younger children (infants and newborns), and in reducing the gap between Mali’s achievements and the averages for sub-Saharan Africa and low- income countries. But efforts remain important to achieve the global targets. Mali’s maternal mortality also remains high, despite having halved over the past generation. This has been estimated at about 562 per 100,000 population, among the highest compared to regional, low- income and fragile groups of countries, as well as most of its peers except for Afghanistan and Chad. Maternal mortality has reduced, on average, by 2.3% annually between 2000 and 2019, which is insufficient compared to the achievements of the benchmarked group of countries. HFSA: Mali | Technical report ii The World Bank Healthcare coverage – Mali’s trajectory towards effective UHC is halfway towards meeting the SDG target for 2030 (80) and was generally in the median of low-income countries between 2015 and 2019 (LICs). On average, less than half of the Malian population lives within a 5-km distance of a health facility, and close to 30 percent of the population are not within a 15-km reach of a health facility. With respect to service coverage for health (as expressed by the UHC index), Mali’s index has significantly improved, passing from 21.2 in 2000 to 41.5 in 2019. However, despite such progress, half of the low-income countries have reached higher service coverage for health (39.6, on average from 2015-2019). HEALTH SYSTEM INPUTS Like in most African countries, Mali’s health system is under-resourced and lags behind global standards for health resourcing. Given Mali’s limited health workforce, there must be a greater focus on efforts to supply relevant quality training, upskilling, and retaining health staff (doctors and nurses), improving their working conditions, and implementing task shifting and sharing. Similarly, digital mapping of the functional health infrastructures and equipment should help to maintain updated data and contribute to reaching improved and equitable distribution of physical resources in health. The whole health financing information system, publication and dissemination should also be reinforced to ensure the latest data is rapidly publicly available and transmitted to the relevant bodies for global and regional comparative purposes and country profile data repositories. Appropriate staffing and technical assistance could further help to achieve high- quality data in health financing. Human resources for health – Mali’s health workforce faces critical shortages, which is a significant obstacle to their mission to converge towards UHC. The density of skilled health workers at 0.57 per 1,000 population means that the country barely provides a quarter (26.1%) of the threshold requirements, as was recommended in 2006 by the World Health Organization to revitalize PHC (2.3 per 1,000 population). Mali’s skill mix ratios of nurse/midwife to doctor and community health worker to nurse/midwife are comparatively low compared with peer benchmarks and the regional average for sub-Saharan Africa. And the share of health managers as a percentage of the total health workforce is lower in Mali than the rest of Africa, indicating a rather distinctive skill-mix in Mali. Despite available health training structures, the national production of health workforce appears insufficient to meet requirements, including those defined in national planning (PRODESS IV). Although still limited, Mali’s health worker stock has improved over time, reaching WHO minimum requirements for some occupations. The health workforce is also unevenly distributed, and lack of staff availability creates territorial disparities, notably to the detriment of rural Mali. Reaching effective UHC in Mali may therefore appear hopeless without adequate investment to recruit, distribute, train, and manage health personnel. Healthcare supply – Access to health care and PHC in Mali is inadequate, therefore challenging equitable coverage and access to frontline healthcare to all. Less than half of the population (42.1%) still lack access to essential health care services within a 5 km radius. The mapping of healthcare supply indicates that care providers are predominantly located in the most populated HFSA: Mali | Technical report iii The World Bank areas of the country, therefore leaving Northern Mali with much less access to healthcare services. Overall, Mali’s healthcare supply displays the typical pyramidal features based on a central administration, with regional and district levels. The “public” supply is organized across four types of care providers, which are the frontline care service (CSCOMs), the frontline first referral (CSREFs), the second-line referral (regional hospitals) and the third-line referral (national hospitals and institutions). The system is highly decentralized, deploying a vast network of private not-for-profit community health associations in charge of managing the CSCOMs under state-and-community partnerships. In addition, the private for-profit sector, mostly medical consultation and surgery services and pharmacists (counting up to 1,679 structures), is concentrated in urban and peri-urban areas. Healthcare information – Irregular production of Mali’s Health Accounts and the scarcity of publicly available data make health financing data difficult to access. More generally, health information is organized under a master plan, establishing a national health and social information system. But it remains highly fragmented in practice, with several series of health yearbooks (nationally, locally or hospital care focused). System management would benefit from a future cross-cutting analysis, conducted by public authorities to support greater use and distribution of health spending. A literature review showed extensive amounts of grey literature but too little data availability as well as persisting interrupted or incoherent time-series data. Improving health financing information will help better orientate health authorities and partners in making the right and timely decisions. HEALTH POLICY AND REFORM The ongoing health reform – Part of a sectoral approach, Mali’s authorities voted an important law in 2018, marking a sound re-organization towards unified national health coverage for all. Health coverage will be expanded by gathering mandatory insurance schemes, subsidiary schemes (“free” policies) and assistance schemes under a single umbrella. The reform aims to significantly reduce health financing fragmentation. Supporting its implementation, Mali adopted a decree of application in 2022 to initiate the universal health insurance coverage model. Under the leadership of the Ministry of Health and Social Development, the ongoing reform constitutes an unprecedented opportunity to improve population health and invest in human capital and social protection for health. Revised in March 2020, the reform was elevated to a ‘Mali Action Plan’ designed for the decade (2020 to 2030), aiming to strengthen Mali’s health system resilience. Supported by high-level commitments and a coherent regulative framework, there is strong momentum to accelerate the convergence towards effective UHC in Mali over the coming years. However, the future universal health insurance coverage should still be implemented and adequately financed. Past policy developments and sector planning – Mali’s health planning follows a sectoral approach that is supported by the continuity of a national health policy over the past two decades. Mali's National Social Protection Policy is an instrument whose general objectives are to gradually build a system of protection against health risks for all citizens in general and for disadvantaged groups in HFSA: Mali | Technical report iv The World Bank particular, as well as to develop mechanisms for the prevention and management of calamities, disasters and other humanitarian crises. One specific objective is to strengthen the social security system through the progressive extension of health benefits, coverage and categories of populations targeted by social safety nets in Mali. The national policy for health has been designed based on two decennial health and social action plans since 1998, and four successive implementation plans. 2023 is one year to go before the end of the current Ten-Year Health and Social Development Plan and its fourth implementation program (PRODESS-IV-2019-2023) - time for reflecting on the coherence of past achievements and prospective future goals. The study also provides further details about health policy-making and other decisional and strategic orientations of Mali’s government. Under the decentralization framework, Mali’s administration of its national health system largely involves health districts and communities, which is a specificity of this model. Regarding health care strategic purchasing, performance-based financing is part of the national health plan, with GOM supporting its expansion as a strategy to move forward towards UHC. In Mali, performance-based financing is part of the health development strategy and regarded as an opportunity for the health system to transition from a provider payment system to strategic purchasing. The performance-based financing mechanism aims to purchase healthcare by directing resources to healthcare facilities using incentives targets that are linked to selected indicators of improved availability, access, and quality of essential care services. It contributes to developing strategic purchasing by strengthening healthcare delivery to achieve a greater quality of care, equity, accountability, efficiency and financial sustainability. HEALTH SYSTEM FINANCING Health financing overview – An overview of the health financing system in Mali highlights the allocative and functional distribution and trends of mobilized revenue sources and health spending areas. Mali’s total health expenditure steadily rose between 2000 and 2008 after which health financing has been affected by periods of highs and lows, particularly linked to Mali's socio- political context. On average over the three years prior to the pandemic, major contributions to health came from external partners through direct foreign transfers (23%) and transfers distributed by the GOM (12%), households through domestic private payments (32%), GOM through public transfers (24%) and the remaining 9% from prepayment schemes (essentially though the social insurance mechanism). Across functions of care, the largest shares of health spending were on average spent on curative care (44%), medical goods (20%), health system administration (19%), preventive care (16%) and the rest on ancillary services (1%). More money for UHC – Depending on the retained scenario to adequately finance UHC and primary health care, Mali’s health financing would fall short of about US$ 35 to US$77 per capita per year. The current level of health spending at US$ 35 per capita (2020) made Mali among the bottom 20 lowest-resourced health systems. Spending on health lags behind almost all identified benchmarks (e.g., below the LIs average of US$ 39.5), which suggests that higher adequacy should be found while advancing the UHC agenda. Depending on the retained scenario to finance UHC and PHC, Mali’s health financing should reach per capita levels of between US$ 71 per year (as WHO- HFSA: Mali | Technical report v The World Bank recommended by a macro-economic and health commission) to US$ 112 per year (as recommended for LICs by a recent Lancet commission on PHC financing). Moreover, in Mali, only US$ 7.3 per capita per year is devoted to PHC and funded by public sources, which can be considered as low since primary health care strategies are recognized as highly cost-effective. Regarding the share of GDP on health, Mali’s 4.3% in 2020 also fell below expectations, and behind past levels as it used to be 5.5% in 2000. Moreover, the convergence rate of Mali’s progress in investing in health is largely below the global trend, as expressed as a share of GDP over the period from 2000 to 2020. However, GOM recently committed to improving health financing adequacy through the adoption of the ‘Mali Action Plan’ for 2030. Budgetary prioritization on health – Overall, post-2012, budget prioritization on health (through the MOH or for the whole sector) has experienced a substantial decline compared to levels preceding periods of instability. Mali’s health share averaged 7.1% of public expenditure over the past two decades (2000-2020), only passing from 7.5% in 2000 to 7.6% in 2020 (peaking at 8.5% prior to 2012), according to WHO estimates used for comparative purposes. Against benchmarked trends, both referring to public spending and domestic general government spending on health, budget prioritization on health in Mali is below expectations. According to national data, health sector budget prioritization averaged 6.7% from the general government trade-off, ranging from 4.8% to 8.4% between 2004 and 2019 with a significantly lower prioritization after 2012. A unique focus at the sector level (health function) certainly hides effective budgetary prioritization given to the MOH interventions. It is worth highlighting that the ministerial budget to MOH has been, on average, prioritized at 3.8% of general government expenditure between 2004 and 2019, with wide variations as it passed from 5.3% (2011) to 2.4% (2013), according to national data. Health financing transition – Lower reliance on burdensome out-of-pocket payments for health has been achieved over the past two decades. The health financing transition refers to the process by which out-of-pocket health payments made by care users are progressively replaced by risk- pooling mechanisms. Looking back at the progress made since 2000, Mali has successfully started this transition. However, our findings have also highlighted the limitations of current mechanisms in fully protecting care users from financial hardship. Households still finance about a third of health expenditure and pooled prepayments schemes remain insufficient to provide a sizeable share of health financing. HEALTH SYSTEM PERFORMANCE Health spending efficiency – The returns on investments made in the health system in Mali can possibly be improved by more efficient distribution and tracking of health spending. Life expectancy at birth reached 59.7 years in 2020 in Mali but, when regressed against per capita investment made in health, the level appears comparatively below the general trend. Such global benchmarking, although one-dimensional (axis Y), suggests that Mali’s returns on its investment in health is sub-optimal. By increasing allocative efficiency in the distribution of available financial resources, prior studies conducted by WB and IMF experts indicate that incremental gains in health outcomes (e.g., between by 2.1 to 3.4 life years) could be reached in low-income economies like HFSA: Mali | Technical report vi The World Bank Mali. Alternatively, it can be assumed that UHC elevated to the 75th percentile in low-income economies would enable savings averaging about 3.4 years –without compromising resources in competing sectors. Recent evidence modeled up to 10 years of life lost in Mali due to persisting inefficiencies in public health spending. Some concordances can be highlighted in efficiency measurements, showing the importance of a better understanding ways to improve health spending efficiency. In regard with health service coverage (as expressed by the UHC index), the return on investment in health showed Mali’s health system performance below its expected potential. Similar scenarios for child and maternal mortality or for populations protected for vaccine-preventable diseases were explored, thereby reinforcing the need for generating additional resources by increased efficiency within the health sector. Public finance and health – Weak governance and public finance management directly impact budget execution and health financing performance of Mali’s health sector. Found with high-risk of resource leakages, Mali’s public finance system is no exception. Existing leakages undermined Mali’s health system performance. At country level, Mali scored 28% and ranked 137th out of 180 countries (2022), suggesting low capacity in monitoring and control systems. At the health system level, budgetary losses in MOH-managed funds were estimated at 18.7% of allocated budgets in 2021, overall. Losses induced by low budgetary efficiency ranged from 7.4% (health workforce resource) to 23.8% (other than workforce resource), on average. From another a management perspective, the participative management is a peculiarity of Mali’s health system that could have enabled more efficient administration of public health services. The model did not keep all its promises, especially due to weak capacities of the decentralized structures and local authorities. Mali’s situation in the health sector is not unique as data from other sectors and from peer countries has shown some similarities. Program budgeting (introduced by the public finance reform) provides options to better track, monitor and link health budget and spending to results and. Besides, auditing sub-sectors, programs or interventions identified with low efficiency can lead to short-term solutions. These are possible tools to be implemented at the central, regional and district levels. THE WAY FORWARD In a post-COVID-19 era, investing adequately in health is more likely seen efficient for human and economic developments. The multifaceted crises that the country has experienced since 2012 have hampered governance and narrowed health financing impact on public service delivery in Mali. Mali’s low level of health spending remains one of the key bottlenecks to converging towards UHC in 2030. It is also the result of a combination of factors comprising relatively low overall government revenue generation, lower budgetary prioritization on health than before. Induced by low domestic revenue mobilization for health, the health workforce and Mali’s health system infrastructure are below international norms and are a major obstacle to the provision of quality health services. In addition, the under-resourced health system is less resilient against external shocks and more vulnerable to Mali’s multifaceted crises. HFSA: Mali | Technical report vii The World Bank UHC in 2030 in Mali requires adequate financing and efficient health spending. Actions can be taken to improve the allocation, distribution and use of funds. Qualtiy primary health care service delivery is fundamental for UHC and must be prioritized and secured in budget trade-offs. Additional resources for health are needed to close the gaps and attain the 2030 targets for health- related sustainable development (e.g., UHC at 80%). New evidence from studies and surveys are key to drive substantial change and orient the policy dialogue around adequate financing for UHC in Mali. Moving forward, it is important to produce and use data and health financing indicators according to decision-making needs. Building on new evidence, including from other studies, the authors aimed at raising awareness on the role of health financing for UHC. We attempted shortlisting priority areas of action, while promoting result dissemination and appropriation. KEYWORDS Benchmarking, Data analytics, Health financing, Health infrastructure, Health outcomes, Health policy and reform, Health system strengthening, Health workforce, Informed decision-making, Mali, Primary health care, Public finance and health, Universal Health Coverage HFSA: Mali | Technical report viii The World Bank Contents EXECUTIVE SUMMARY ................................................................................................................................ I CONTENTS ................................................................................................................................................ IX LIST OF FIGURES, TABLES AND BOXES ....................................................................................................... XI ABBREVIATIONS AND ACRONYMS ..........................................................................................................XIV 1 INTRODUCTION AND BACKGROUND ................................................................................................. 1 2 COUNTRY CONTEXT .......................................................................................................................... 4 2.1 KEY CHALLENGES FROM THE GENERAL ENVIRONMENT ................................................................................. 4 2.1.1 Socio-political instability and its consequences ......................................................................... 4 2.1.1 Vulnerability to climate change and epidemics ......................................................................... 7 2.1.2 Demographic dynamics ............................................................................................................. 8 2.2 ECONOMIC GROWTH, POVERTY AND SHARED PROSPERITY .......................................................................... 11 2.2.1 Economic prospects and major obstacles to growth ............................................................... 11 2.2.2 National strategy for growth and sustainable development ................................................... 14 2.2.3 Human capital development and poverty trends .................................................................... 16 2.3 HEALTH SECTOR CONTEXT ................................................................................................................... 18 2.3.1 Health policy and program design ........................................................................................... 18 2.3.2 Main stakeholders and organizational model ......................................................................... 20 2.3.3 Key developments .................................................................................................................... 22 3 HEALTH SYSTEM OUTPUTS AND OUTCOMES .................................................................................. 25 3.1 POPULATION HEALTH INDICATORS......................................................................................................... 25 3.1.1 Life expectancy trend and long-run achievements .................................................................. 25 3.1.1 Mortality trends and long-run achievements .......................................................................... 26 3.2 SERVICE COVERAGE FOR HEALTH ........................................................................................................... 31 3.2.1 Access to essential health services .......................................................................................... 31 3.2.2 Access to primary healthcare services ..................................................................................... 36 3.2.3 Other basic amenities .............................................................................................................. 37 3.3 DISEASE BURDEN ............................................................................................................................... 37 4 HEALTH SYSTEM INPUTS ................................................................................................................. 40 4.1 HUMAN RESOURCES FOR HEALTH.......................................................................................................... 40 4.1.1 Policy goals and orientations ................................................................................................... 40 4.1.2 Health workforce needs and coverage .................................................................................... 41 4.1.3 Health workforce skill-mix ....................................................................................................... 43 4.1.4 Health workforce production ................................................................................................... 44 4.1.5 Health workers stock across occupation type.......................................................................... 45 4.2 HEALTHCARE INFRASTRUCTURE ............................................................................................................ 46 4.2.1 Healthcare organization .......................................................................................................... 46 4.2.2 Healthcare delivery model and status ..................................................................................... 48 4.2.3 Spatial distribution and population coverage.......................................................................... 53 4.2.4 Other inputs ............................................................................................................................. 61 4.3 HEALTH INFORMATION SYSTEMS........................................................................................................... 63 4.3.1 Architecture of health system information .............................................................................. 63 4.3.2 Informing health policy and performance budgeting .............................................................. 65 4.3.3 Decision-making lacking high-quality and on-time health financing information................... 66 HFSA: Mali | Technical report ix The World Bank 5 HEALTH FINANCING LANDSCAPE..................................................................................................... 70 5.1 OVERALL TRENDS IN HEALTH SPENDING .................................................................................................. 70 5.2 MAJOR DOMESTIC SCHEMES FOR HEALTH FINANCING................................................................................ 72 5.3 REVENUE SOURCES FOR HEALTH ........................................................................................................... 73 5.4 HEALTHCARE FUNCTIONS AND SPENDING LEVELS ...................................................................................... 75 5.5 PANDEMIC-RELATED FINANCING ........................................................................................................... 77 5.6 SPENDING ADEQUACY FOR UHC........................................................................................................... 78 5.6.1 Per capita health spending and gap ........................................................................................ 78 5.6.2 Income growth on health ........................................................................................................ 80 5.6.3 Prioritization on PHC spending ................................................................................................ 83 6 BUDGETARY EFFICIENCY, FRAGMENTATION AND MISSED RESOURCES FOR HEALTH ....................... 86 6.1 ASSESSING MOH BUDGETARY EFFICIENCY .............................................................................................. 86 6.1.1 Human resources for health .................................................................................................... 86 6.1.2 Health system (excluding human resources) ........................................................................... 87 6.2 BUDGETARY CHANNELS AND EXPENDITURE FRAGMENTATION ..................................................................... 88 6.3 COMPARATIVE PERFORMANCE OF SELECTED COMPETING SECTORS, PROGRAMS AND ACTIVITIES ......................... 90 6.4 REALITIES AROUND BUDGETING ADEQUATE RESOURCES FOR THE HEALTH SECTOR ........................................... 92 6.4.1 National mid-term budgetary forecasting ............................................................................... 92 6.4.2 Overview of health sub-sectors of priority actions for UHC ..................................................... 93 6.4.3 Estimated cost of vaccine-preventable diseases...................................................................... 96 7 PATTERNS AND DRIVERS IN DECISION-MAKING .............................................................................. 97 7.1 RESOURCE MOBILIZATION ................................................................................................................... 97 7.1.1 Domestic resource mobilization (DRM) ................................................................................... 97 7.1.2 External resource mobilization (ERM) ................................................................................... 102 7.1.3 Effects of the crises on development aid and effectiveness ................................................... 111 7.2 POOLING AND PURCHASING FUNCTIONS ............................................................................................... 114 7.2.1 Legal framework behind the reform ...................................................................................... 114 7.2.2 Effects of limited financial protection for health ................................................................... 117 7.2.3 Components of existing financial health protection .............................................................. 119 7.2.4 Strategic purchasing for enhanced PHC ................................................................................ 128 7.3 PERFORMANCE OF AVAILABLE RESOURCES ............................................................................................ 129 7.3.1 Returns on investment from allocative distribution .............................................................. 129 7.3.2 Technical and productive performance ................................................................................. 136 7.4 LINKS WITH PUBLIC FINANCE MANAGEMENT AND HEALTH ........................................................................ 142 7.4.1 Overall performance .............................................................................................................. 142 7.4.2 Strengthening public finance ................................................................................................. 143 8 THE WAY FORWARD ..................................................................................................................... 151 9 BIBLIOGRAPHY ............................................................................................................................. 154 HFSA: Mali | Technical report x The World Bank Figure 17: Key indicators of access to care in Mali and across regions, 2021 ..................... 57 Figure 18: Overview of the unified social register scope and indicators available at country-level, 2022 ...................................... 68 Figure 19: Trends in total and per capita List of Figures, Tables and Boxes expenditure on health in Mali, 2000-2020 . 71 Figure 20: Major health financing domestic Figure 1: Mapping insecurity threat and schemes in Mali, 2000-2020 ....................... 73 population displacements in Mali, 2022 ....... 7 Figure 21: Sources of revenue for health in Figure 2: Forecast of Mali’s population, 2000- Mali, 2000-2020 ........................................... 75 2030.............................................................. 11 Figure 22: Functional allocation of health Figure 3: Human capital index (HCI) in Mali spending in Mali, 2016-2019* ..................... 76 against focus countries and global averages, Figure 23: Per capita health spending in Mali 2017-2020 .................................................... 16 benchmarked to trend performance across Figure 4: Theory of change of the PRODESS income level, 2000-2020 ............................. 79 Health component, Mali .............................. 20 Figure 24: Health spending as a share of GDP Figure 5: Life expectancy at birth in Mali in Mali benchmarked to trend performance benchmarked to global trends, 1960-2020 . 25 across income level, 2000-2020 .................. 80 Figure 6: Adult mortality ratios in Mali against Figure 25: Fluctuations of annual health and global benchmarks, 1960-2020 ................... 27 public spending in Mali and its expected Figure 7: Child mortality trends in Mali convergence growth against benchmarks, against global benchmarks, 1960-2020....... 29 2000-2020 .................................................... 82 Figure 8: Maternal mortality ratio trend in Figure 26: PHC expenditure in Mali against Mali against benchmarks, 2000-2017 ......... 30 the global trends, 2019................................ 83 Figure 9: Trend in service coverage for Figure 27: Expenditure on immunization in essential health care services (UHC index) in Mali, 2016-2019 ........................................... 85 Mali, benchmarked globally, 2000-2019 ..... 32 Figure 28: MOH budget and expenditure on Figure 10: Service coverage (UHC index) human resources for health in Mali, 2021 .. 87 trend and performance in Mali benchmarked Figure 29: MOH budget and expenditure on internationally, 2000-2019 .......................... 33 health system (excluding human resources Figure 11: Trends in service coverage across for health) in Mali, 2021 .............................. 88 type of health service in Mali and related Figure 30: Health budget and expenditure of benchmarked achievements against peers the Ministry of National Defense ................ 90 and global averages, 2000-2019.................. 34 Figure 31: Budget execution of annual Figure 12: Regional disparities in child forecasts (CP) by function in Mali (as of mortality and major causes of death in Mali, December 31), 2019-2021 .......................... 91 2018.............................................................. 39 Figure 32: Variability of health budget Figure 13: Density of skilled health workers in execution across programs and activities, Mali, benchmarked to SSA countries and 2021 ............................................................. 91 norms, 2020 year or latest available ........... 43 Figure 33: Trends in adolescent fertility rate Figure 14: Architecture of the pyramid of in Mali, benchmarked to global trends for healthcare delivery and administration in comparable groups of countries, 1960-2020 Mali ............................................................... 48 ...................................................................... 94 Figure 15: Mapping of the public healthcare Figure 34: Trends in budget prioritization on supply in Mali with a heat map for population health in Mali (national estimates), 2004- density and for conflict-affected zones, 2022 2019 ............................................................. 99 ...................................................................... 54 Figure 35: Evolution of the budget Figure 16: Expansion of the PHC supply prioritization on health through MOH in Mali (CSCOMs) in Mali, 2000-2021 ...................... 55 (national estimates), 2004-2019 ............... 100 HFSA: Mali | Technical report xi The World Bank Figure 36: Budget prioritization on health in Table 6: Magnitude of foreseen health Mali against benchmarks, 2020 ................. 100 investments in Mali, 2023 ........................... 72 Figure 37: Overview of the distribution of Table 7: Increment in health spending as foreign aid active in health in Mali, 2019 .. 103 %GDP during the COVID-19 pandemic in Mali Figure 38: GFF resource mapping in health (in and benchmarks, 2020 ................................ 81 million US$ per stakeholder), 2020 ........... 103 Table 8: Mid-term budgetary framework for Figure 39: Percent shares in net ODA health in Mali, 2019-2023 ........................... 93 received (%GNI and % GOV) in Mali against Table 9: Overview of vaccine-preventable benchmarks, 2000-2020 ............................ 107 expenditure in Mali against comparators and Figure 40: Net ODA received on health (per regional LICs ................................................. 96 capita US$) in Mali against benchmarks, Table 10: Post-COVID-19 health spending 2000-2020 .................................................. 109 priorigzagon and breakdown allocagon to Figure 41: Total net ODA to medical research MOH in Mali, 2022-2023 ............................. 98 and basic health sector in Mali and against Table 11: Breakdown of grants modaliges to peers, 2000-2018 ....................................... 110 Mali, 2019-2021 ......................................... 106 Figure 42: Health financing transition over Table 12: Net ODA disbursements to Mali, past decades in Mali, 2000-2020 ............... 118 2018-2020 .................................................. 108 Figure 43: Estimated spending across major Table 13: Inpagent care use of the 2nd and “free” policy schemes in Mali, 2011-2022 127 3rd referral levels of service across payment Figure 44: Comparative returns on modaliges in Mali, 2021 ............................ 119 investment in healthcare for life expectancy Table 14: Avertable and amenable mortality in Mali against benchmarks, 1960- 2020 .. 130 in relagon to health system quality and use in Figure 45: Comparative returns on Mali and benchmarks, 2018 ...................... 133 investment in healthcare for selected health Table 15: Overview of unused public outcomes, 2019 ......................................... 132 resources managed by the ASACOs, 2020 145 Figure 46: Comparative returns on investment in healthcare for immunization, 2019............................................................ 137 Box 1: The four steps of the budget cycle Figure 47: Public Finance Management (MOF) ......................................................... 148 progress and current status according to Box 2: Tentagve takeaways for policy PEFA scores, 2018-2021 ............................ 142 implicagons in health financing for UHC in Figure 48: Overview of the decisional Mali ............................................................ 152 calendar for budget programming in Mali 148 Figure 49: Health budget execution across fiscal year quarters in 2021-2022 .............. 149 Table 1: Macro-economic and fiscal indicators: esgmates and WB Economic Update forecasts, 2018-2024 ...................... 13 Table 2: Budgetary framework of the nagonal strategy for acceleragng growth and sustainable development in Mali, 2019-2023 ...................................................................... 15 Table 3: Top 20 causes of disability-adjusted life years (DALYs) in Mali, benchmarked to low-income average, 2019 ........................... 38 Table 4: Health workforce status across occupagon and regions in Mali, 2021 ......... 46 Table 5: Healthcare providers across types and regions of Mali, 2021 ............................ 54 HFSA: Mali | Technical report xii The World Bank HFSA: Mali | Technical report xiii The World Bank Abbreviations and Acronyms I A IBRD International Board for Reconstruction and Development AE Autorisation d’Engagement IC Investment Case AFD French Development Agency IDA International Development Association AMO Assurance Maladie Obligatoire IDE State-diploma nurse (Infirmier Diplômé d’Etat) AMV see VHI (Assurance Maladie Volontaire) IHR International Health Regulation AN Nationa Assembly Assemblée nationale ILO International Labor Organization ANAM National medical insurance agency (ANAM - Agence Nationale d’Assurance Maladie) IMF International Monetary Fund ANEAS National agency for health evaluation and accreditation (Agence nationale d’évaluation et d’accréditation INFSS en santé) National institute of training in health sciences (Institut National de Formation en Sciences de la S ASACO Community health association (Association de Santé Communautaire) INPS National Institute of Social Welfare (INPS – Institut National de Prévoyance Sociale) B IO Obstetric nurse (Infirmière Obstétricienne) BOD Budget Orientation Debate IPC Infection Prevention and Control BSI Capital investment budget (“ Budget Spécifique d’Investissement”) IS Health nurse (Infirmier de Santé) C L CAMs Mutual assistance agreement (CAMs – Conventions d’Assistance Mutuelle) LGs Local governments CANAM National Health Insurance Fund (Caisse Nationale d’Assurance Maladie) LHIS Local health information (LHIS) or SLIS, sub-component of the national information system CARFIP Cellule d'Appui à la Réforme des Finances Publiques LHMIS Local Heath Management Information System (SLIS) CEPRIS Implementation Unit for Health Infrastructure Reinforcement Programs (Cellule d’Exécution des Programmes de Renforcement des Infrastructures Sanitaires) LMIC Lower-middle-income country CHW Community health workforce LNME National List of Essential Drugs (LNME) CMSS Malian Social Security Fund (CMSS – Caisse Malienne de Sécurité Sociale) LSMS Living Standards Measurement Survey CMU Universal health coverage (Couverture Maladie Universelle) CNC M National Coordination Committee for drugs monitoring and management (Comité National de Coordination et de suivi de la gestion des medicaments) CP M&E Monitoring and Evaluation MOH Ministry of Health Crédit de Paiement CPIA Country Policy and Institutional Assessment MAP Mali Action Plan CPN Prenatal consultation Consultation Prénatale MEF Ministry of Economy and Finance CPON Postnatal consultation Consultation Postnatale MMR Maternal Mortality Rate CPS Planning and Statistics Unit (Cellule de Planification et Statistique) MNCH+N Maternal, Newborn and Child Health + Nutrition CREDD Strategy for Accelerating Growth and Sustainable Development (Cadre Stratégique pour la RelanceMOH Economique et Ministry and Social Development of HealthDurable) le Développement CROPEC Regional Orientation, Coordination and Evaluation Committee for the PRODESS evaluation (Comité MPARégional d’Orientation, Multiphase Programmatic de Coordination Approach et d’Evaluation du PRODESS) CSCOMs Primary healthcare centers (Centres de Santé Communautaire) MTEF Medium Term Expenditure Framework CSCRP Strategic Framework for Growth and Poverty Reduction (Cadre Stratégique pour la Croissance Net la Réduction de la Pauvreté) CSLP NCD Strategic framework for the fight against poverty (Cadre stratégique de lutte contre la pauvreté) Noncommunicable disease CSOs Civil Society Organizations NHA Health Accounts CSREFs NIPs National Immunization Programs CTs Local Authorities (CTs – Collectivités territoriales) O D ODA Official development assistance DAH Development Assistance for Health ODHD l’Observatoire du Développement Humain Durable (ODHD) DALYs Disability-adjusted life years OOPS Out-of-pocket spending DFM MOH Directory for finance and equipment (Direction des Finances et du Matériel) P DGSHP MOH General Directory of health and public hygiene (Direction Générale de la Santé et de l’Hygiène Publique) PAA Plan Annuel d’Activités (Annual activity planning) DHIS District Health Information System PACSU Project for accelerated UHC (Projet Accélérer les Progrès vers la Couverture Sanitaire Universelle DHIS2 District Health Information Software 2 PAG Action Plan of the transitional Government (PAG - Plan d'action du gouvernement) DHS Demographic and Health Survey PAGAM-GFP Plan d’action gouvernemental pour l’amélioration et la modernisation de la gestion des finances DLI Disbursement Linked Indicator PAMORI Programme d’appui à la mobilisation des ressources intérieures DMOs Delegated Management Bodies (OGDs – Organismes de gestion déléguée) PANB Costed National Plan for Family Planning interventions for 2019-2023 (PANB – Plan d’Action Nat DPEBP Multi-year programmatic plan for economics and budget affairs (Document de programmation économique et budgétaire pluriannuelle) PAP Projet annuel de performance DPM Directorate of Pharmacy and Medicines (DPM – Direction de la Pharmacie et du Médicament) DRM PASA Programmatic Advisory Services and Analytics Domestic Resource Mobilization DRS Regional Health Directorate (Direction Régionale de la Santé) PBB Program-based budgeting DRUM Domestic Resource Use Mobilization PBF Performance-based financing E PDDSS Ten-year Health and Social Development Program Development Plan (Plan Décennal de Dévelop EBFs Extra-budgetary funds PDSC Five-Year Cercle Health Development Plan (PDSC – Plan de développement sanitaire de cercle) ECD Equipe Cadre de District PDSSD Plan de Développement Sanitaire et Sociale de District ECOWAS Economic Community of West African States PEFA Public Expenditure and Financial Accountability EDS Enquête Démographie et Santé PETS Public Expenditure Tracking Survey ENABEL Belgian Development Agency PMA Basic service package (PMA – Paquet Minimun d’Activités) ENV Enquête sur le Niveau de Vie des Ménages (Living Standards Measurement Survey) PNS National Health Policy (Politique Nationale de Santé) F PPM Pharmacie Populaire du Mali FCAS (or FCV) Fragile, Conflict-Affected and Violence Situations PPP Public private partnership FEMATH Malian Federation of Traditional Therapists and Herbalists (FEMATH – Fédération Malienne des Tradithérapeutes PRDSS et Herboristes), G PREM Public finance management national plan (Plan de réforme de la gestion des finances publiques au GAVI Global Alliance for Vaccines and Immunization PRODESS Health and Social Development Program Development Program (Programme de Développemen GDP Gross Domestic Product PRODESS Socio-Health Development Program (PRODESS – Programmes de Développement Socio-Sanitaire GFF Global Financing Facility for Women, Children and Adolescents R GFTAM Global Fund to Fight AIDS, Tuberculosis and Malaria RAMED Régime d’Assistance Médicale GNI Gross National Income RAMU Régime d'Assustance Maladie Universelle GOM Government of Mali RAP Annual Performance Report (Rapport Annuel de Performance) H RMNCAH+N Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition HAIs Health care associated infections RPM Reference Price Indicator (RPM “ratios des prix médians” HCI Human Capital Index S HeRAMS Essential Health Resources and Service Availability Monitoring System SCI Service Coverage Index HFSA Health Financing System Assessment HiAP SDA/ME Schéma d’Approvisionnement et de Distribution en Médicaments Essentiels Health in all policies approach HIPC Heavily Indebted Poor Countries SDAME Supply and Distribution of Essential Drugs (SDAME – Schéma national d’approvisionnement et de HIS Health Information System (HIS), sub-component of the national information system SDGs Sustainable development goals HMIS Health Management Information System (SNIS) SDI Service Delivery Indicator HNP Health, Nutrition, and Population SEC Essential Care in the Community (‘Soins Essentiels dans la Communauté – SEC’). HRH Human resources for health SIAPS Systems for Improving Access to Pharmaceutical products and Service (SIAPS – Systèmes pour l’ HTA Health Technology Assessments SIDS Social development (SIDS – Système d’information sur le développement social) HWF Health workforce SIES Social economy information subsystem (SIES – Système d’information en Economie Soliaire) SIGD-PRED Integrated system for the management of public expenditure (Système intégré de gestion des dé SIGHR Integrated Human Resources Management System for State and Local Government Public Servic SIGMAP Integrated system for the management of public markets (Système intégré de gestion des march HFSA: Mali | Technical report xiv The World Bank SIGTAS Integrated system for the management of taxation (Système intégré de gestion des taxes et assimilées) SIH System of Hospital Information (SIH) SIS Health information subsystem (SIS) SISo Social information subsystem SNAQSS National Strategy for Improving the Quality of Care and Services (SNAQSS – Stratégie nationale d’amélioration de la qualité des soins et services) SNEM National strategy for the expansion of mutual health organizations ( SNEM – Stratégie nationale d’extention des mutuelles de santé au Mali ) SNISI Integrated Digital Health Information System (SNISI – Système Numérique d'Information Sanitaire Intégré) SNISS National Health and Social Information System (“SNISS: système national d’information sanitaire et sociale”) T TWGs Technical Working Groups U UHC Universal health coverage UN United Nations UNACEM-AN Control and assessment unit at the National assembly for the general budget (Unité d’analyse, de contrôle et d’évaluation du Budget de l’Etat du Mali à l’Assemblée nationale) UNFPA United Nations Population Fund UNICEF United Nations Children's Fund UTGFS Management unit of the Malian social safety nets program (Unité Technique de Gestion Filets Sociaux) UTM Malian union of mutuals (Union Technique de la Mutualité Malienne) V VHI Voluntary health insurance VPDs Vaccine-preventable diseases W WAEMU West African Monetary Union WaSH Water, hygiene and sanitation WB World Bank WBG World Bank Group WFP World Food Programme WHO World Health Organization HFSA: Mali | Technical report xv The World Bank 1 Introduction and Background This Health Financing System Assessment (HFSA) is a tool to promote increased awareness and better use of an evidence-base for health financing reforms, especially in progress towards Universal Health Coverage (UHC). The 2030 goals for sustainable development and better health are seven years away. This type of exercise is internationally used to support health financing decisions, including in many low-income and peer countries, and was recently conducted in Niger (1). The Republic of Mali (Mali)’s HFSA attempts to provide relevant information, as comprehensive as possible while covering major issues to help rethink Mali’s health system financing in the frame of the sustainable goals. How can Mali’s HFSA contribute to health financing decision-making? Advancing Mali’s health financing agenda for UHC requires informed policymaking, which is why both health and other high-level authorities can learn from the evidence and lessons learnt by health financing analytics. Past G20 consultations on high-performing health financing for UHC have raised health policymakers’ interests to systematically assess the national health system resilience and sustainability threats. Embedded in the 2030 UN agenda for sustainable development, the UHC goal refers to providing access for all Malians to required health services of sufficient quality, and financial protection for health. The health financing transition for UHC inevitably requires greater budget space for health no matter which of the three dimensions of the UHC cube (WHO definition) should expand first. After 2015, many (14) African governments, Technical and Financial Partners and experts also acknowledged the urgent need for improved efficiency in health expenditure. Therefore, the government of Mali (GOM) should use the full knowledge of its national health financing system to progressively drive change while setting its own baseline data and targets. This should ultimately ensure all Malians have access to quality and affordable health services, without delaying the use of health services due to financial barriers and without suffering financial hardship. The latest joint research by the World Bank (WB) and the World Health Organization (WHO) recalled that, prior to COVID-19 pandemic, more than half a billion people were pushed or further pushed into extreme poverty because they had to pay for health services out of their own pockets (2). The Malian health system is no exception. The Malian health sector is under pressure as the country is reforming its national health financing system. Reaching vulnerable populations at scale with essential medical care is a huge challenge that GOM intends to address with its health reform. Within the context of the health sector reforms promulgated in February 2019, the GOM and its partners have recognized the need to examine all financial possibilities and options necessary to reconcile the Government’s health care goals and its available financial resources. Although the UHC reform presents several HFSA: Mali | Technical report 1 The World Bank opportunities to further pool existing resources, it is unlikely expected to cover universally by the end of the decade under the current budgeted plan. How major results will be disseminated? The report is accompanied by a short narrative (annotated Power Point presentation) that can be used for results dissemination. The short narrative is easily adaptable and can be updated if used in a near future. It aims to create shared knowledge across different stakeholders. Stakeholders may include GOM and other officials (MOH and MOF), parliamentarians, local authorities, operational teams, external technical and financial partners, civil society organizations (CSOs), and the private sector–especially those involved in supplying the country with pharmaceuticals. This list is obviously not exhaustive. Alternative outputs (e.g., short brief of the in-depth report) can be developed (such as data-driven policy notes) to support to the health financing for UHC policy dialogue in Mali. Niger peer experience can be highlighted as a series of three policy notes (state of health, health financing and immunization financing) were derived from a similar Niger HFSA (1) and WB health workstream. Regarding policy implications, a country workshop can be envisaged to discuss and refine concrete recommendations, agree on more specific priorities, and further design and plan the way forward to 2030. Authors hope Mali’s HFSA and linked studies will usefully inform and orient the policy dialogue around health-related SDGs as well as future health projects in Mali. What was the broad context of WB health studies? This report is part of a broader Advisory Services and Analytics program (PASA, P172823) of the WB that continues until 2023. Along with the implementation of a WB project “Accelerating Progress towards Universal Health Coverage” that was launched in 2019 towards 2023, the PASA promotes the generation of new evidence and provides technical assistance to the Malian government to implement its UHC policies and reform. Several linked studies were concurrently conducted by the World Bank in 2023 i.e., Mali Country Equity Diagnostic; Mali Service Delivery Indicators; Mali Human Resources for Health from the employees’ perspective (survey results); Mali Performance-based financing Situation Update and Roadmap; and a JLN Fiscal Narrative on Mali’s public health expenditure and domestic resource mobilization. Considering most recent evidence, HFSA aims at informing policymaking around three pillars: (i) health financing, (ii) frontline service delivery and human resources, and (iii) health system and expenditure performance measurements. How Mali’s HFSA was conducted and what were our methodological approaches? Mixed method data collection was used to generate data for analytics. Data was primarily collected from national and infra-national data sources and reporting. We screened the scientific and grey literature and considered an extensive range of ministerial reports, official documentation, laws and decrees, draft publications, press releases and national websites. We were heavily constrained by data scarcity in certain niches, which constitutes a methodological limitation. Main issues related to interrupted time series, unvalidated or missing values, disaggregated data scarcity, data discrepancy across data sources, and/or delayed/late data release. These limitations impacted HFSA: Mali | Technical report 2 The World Bank some analytics, and additionally required to update data and outputs on multiple occasions during the study process. In cases of data scarcity or requirements for standardization, we used data from global databases (WHO, WB, IMF, etc.). A benchmarking approach was used to highlight Mali’s situation against global, regional, sub- regional and income group averages. For the global-level comparative analyses, we referred to the standards using WHO regional and WB income group classifications of countries. Mostly, global data repositories were used to produce additional estimates and ease comparative analytics. Peer comparisons were key to assessing health financing in Mali, mainly to better reflect on national progress against several relevant subsets of countries. Understanding the relative performance of Mali against other comparator countries provided key insights into the nation’s successes and areas where the health system might be falling behind. Regarding country-to-country benchmarking, two subsets of structural and aspirational peers were defined using a macroeconomic, trade and investment method. Firstly, structural peers (referring to countries that are currently similar to Mali) were Afghanistan, Burkina Faso, Chad, Uganda and Zimbabwe. Secondly, aspirational peers (referring to countries that were similar to Mali in the past but grew much faster than Mali over time) were Tajikistan, Uzbekistan, the Lao People's Democratic Republic and Rwanda. For each subset of peers, a country ranking was made using criteria in several areas related to: i) the economy such as government expenditure as a share of GDP, per capita real GDP and GDP growth, dominance of the agriculture sector, the country being a commodity exporter (or not); ii) socio-demographic features such as the population count and growth, life expectancy; and iii) the geographical situation such as being a landlocked country (or not). The ranking resulted from analysis of the trends and/or averages in indicators observed over a 3-year period prior to date or to a decade ago. Based on the country ranking, selected peers were those closest to Mali’s rank. To avoid potential bias induced by the surge of the pandemic, all indicators referred to the pre-COVID- 19 situation. Additional comparators were explored to consider common use of country comparators as well as neighboring countries (Dem. Rep. of Congo, Niger, Nigeria, Senegal). HFSA: Mali | Technical report 3 The World Bank 2 Country context This first chapter investigates the many contextual factors that may influence health system and financing decisions. A complex crisis is affecting the entire country, with conflicts and insecurity triggering large-scale population displacement, socio-political instability, climatic shocks and epidemics and unprecedented levels of food and nutrition insecurity. This chapter describes the specific challenges brought by demographic dynamics, socio-economic and political uncertainty as well as the conditions of human development and related vulnerabilities and fragility. It also presents the policy developments in the health sector. 2.1 Key challenges from the general environment 2.1.1 Socio-political instability and its consequences The year of the 2012 coup marked a critical change in Mali’s socio-political environment. Despite significant difficulties since the establishment of democracy in 1991, Mali has maintained democratic principles and rules by organizing successive alternations through free elections in 1992, 1997, 2002 and 2007. But since then, the political landscape has successively changed as Mali has faced three coups d’état (March 2012, August 2020 and May 2021) over the past decade. The first coup on March 22, 2012 shook the democratic process and led to the establishment of transitional institutions. The deep socio-security and governance crises that the country has been going through since 2012 has led to profound institutional changes in the management of the State, with the establishment of a transition period during 2020 (PAG 2021). Social protection, as assessed by the CPIA index for instance, declined by 0.5 ahead of the 2012 coup. Political crises that occurred over the past decade have created instability in the country’s leadership and governance. Official sources of the Prime Minister1 report that, on August 19, 2020, his Excellency the President of the Republic, Mr. Assimi Goïta was appointed President of the National Committee for the Salvation of the People. He was one of the organizers of the 2020 coup deposing former President Ibrahim Boubacar Keïta (IBK). He later withdrew from his function as Chief of the Armed Forces, after which he was appointed Vice-President of the Transition on September 21, 2020 and took the oath of office four days later on September 25, 2020. Then, following the third coup d'état of May 24, 2021, the Prime Minister and the Minister of Defense were dismissed from their positions by Assimi Goïta who became interim President of the Transition. Since 24 August 2020, he has officiated as head of the State and, after taking the oath 1 https://primature.ml/?ova_dep=le-president-de-la-republique HFSA: Mali | Technical report 4 The World Bank at the Supreme Court, acting as head of the GOM since 7 June 2021. Following this investiture, the Prime Minister, Doctor Choguel Kokalla Maiga (7 June 2021), and the members of his government (11 June 2021) were appointed by decree. The Action Plan of the Transitional Government (PAG 2021-2022) comprises four priority areas, which are: (i) Strengthening of security throughout the national territory; ii) Policy and institutional reforms; (iii) Organization of general elections; iv) Promotion of good governance and adoption of a social stability pact. Mali’s socio-political and governance crises left the country subject to violence, attacks, and occupation by armed groups, which impacted livelihood conditions and the national economy. In 2012, the national economy suffered a significant decline in activities in the tertiary (-6.7%) and secondary (-2.9%) sectors (3). Rising inflation (5.6%) in 2012, which exceeded the West African Monetary Union (WAEMU) standard set at 3%, deteriorated household living conditions (3). Mali’s Economic Studies and Analysis Division attributed the numerous layoffs to the 2012 crisis, notably due to the suspension of international cooperation and the slowdown in business activity(3). The independence of the North of the country (Regions of Gao, Timbuktu, and Kidal) was declared unilaterally by an armed group in April 2012. Mali is experiencing a jihadist insurgency and a resurgence of abuses committed by armed groups and banditry, especially in the north of the country (4). About two-thirds of the territory is occupied by armed rebels and the population is impoverished. Needing to control these threats beyond its borders, Mali was part of a five-nation anti-jihadist task force (G5 Sahel Group) with Burkina Faso, Chad, Mauritania, and Niger, which was set up in 2014 for coordinated regional cooperation in development policies and security matters, but later announced its withdrawal in May of 2022. Violent attacks by armed groups affect most of the country. Current security threats are mapped in Figure 1Error! Reference source not found.. More recently, a USAID indicator of fragility scored Mali 99 out of 120 for the fiscal year 2023, classifying it among the group of countries at the most severe stage of State fragility (5). This calculation was based on Mali's ability to maintain stability and its vulnerability to conflict and collapse (comprising up to 12 indicators spanning across cohesion, political, economic, and social dimensions). Attacks on Mali’s healthcare that is monitored by WHO/Surveillance System for Attacks has counted multiple incidents since 2020, impacting the health workforce (15 people), transportation (8), facilities (8), supplies (8), patients (3), and warehouses (4). At the regional level for Africa, multiple incidents during 2022 impacted the health workforce (117 people), health transportation (77), healthcare facilities (63), patients (64), health supplies (26) and warehouses (14). The country is also bearing the brunt of tensions with the international community, which aggravates general instability. Mali’s political instability led to successive waves of sanctions that have severely disrupted Mali’s economic and financial environments. In 2017, the UN security council advised its member states to sanction Mali’s financial assets (6). Both the Economic Community of West African States (ECOWAS) and the African Union were quick to react after the latest crises, condemning the coup and calling for the return of a civilian government. In January 2022, ECOWAS imposed economic and financial sanctions against Mali, including the closure of land and air borders between Mali and ECOWAS countries, the suspension of all commercial transactions between Mali and countries in the region, the freezing of Mali's assets in ECOWAS central and commercial banks, and the suspension of Mali receiving aid from ECOWAS financial institutions. To HFSA: Mali | Technical report 5 The World Bank prevent a further humanitarian crisis, some products have been exempted from the 2022 sanctions such as essential consumer goods, pharmaceuticals, medical supplies/equipment (including equipment for the control of COVID-19), petroleum products and electricity. But the leaders of ECOWAS member states have recalled their ambassadors appointed to Mali. Mali’s land and air borders closure and the embargo on financial and commercial exchanges (except for essential goods) was part of prior sanctions imposed by ECOWAS after the 2020 coup. The September 15, 2020 ECOWAS summit required the appointment of a transitional government to lift the sanctions. ECOWAS later lifted several of its sanctions on Mali after the junta announced that a presidential election would be held in early 2024, but the impact on Mali's economy has been devastating. The country has experienced successive institutional changes, violence and war leading to a deficit of governance and generalized instability (7–9). After only nine months of operating in transition after the 2020 coup, the country experienced a new change with the 2021 coup (10). The economic context is characterized by a certain awareness of major structural dysfunctions present in the country, including corruption (8). Mid-2015 (April-June), the Algiers agreement for peace and reconciliation marked a return towards peace in Mali, leading to transition governance bodies in the region (11). But the situation remains volatile since the Algiers Peace Agreement signed in 2015 has not been fully implemented (12,13). The national election for the head of state expected shortly also adds to current instability linked to changes in the MOH (EIU 2022). Violence and insecurity has almost reached the entire territory (Figure 1). The north of the country is occupied by armed forces. Mali’s government lacks the military capacity to contain the growing threats from terrorist groups present in Mali, the emergence of self-defense groups in the center of the country and inter community conflicts. Armed conflicts and violence severely affect public delivery systems, transportation and access to healthcare and education. In 2023, more than 30% of CSCOMs in the Ménaka region have been destroyed or closed due to armed conflicts, affecting 70,000 people - equivalent to a third of the population living in these territories (14). Similarly, in 2023, almost 40% of the schools in the Gao and Ménaka region have closed due to repeated violent incursions (14). As a result of the security crisis, the Gao region has a higher rate of child malnutrition and coverage of assisted deliveries more than two times lower than the national average (14). Kidal, Ménaka and Gao recorded cases of measles. Food insecurity and human rights violations are also consequences observed in Mali, and more severely among displaced populations. Health staff activities are disrupted (e.g., with 6 aid workers killed and more than 140 attacks in 2022). In the north and center, about 20% of health centers were dysfunctional while the rest were only partially operational due to insecurity and a lack of personnel. During October 2022, about 1,726 schools closed, leaving nearly 520,000 children and 10,000 teachers without school and without access to national education. The situation in Ukraine creates an extra layer of fragility, notably affecting the market of wheat imports in Mali and other West African countries. Unlike the ECOWAS-UEMOA sanctions, the Ukrainian crisis does not have direct effects on all social sectors, but it does affect an entire sector of Mali's economy. The West African region, which has already been facing a major food crisis (since 2011), must now suffer the effects of the crisis in Ukraine. Russia and Ukraine are major exporters of agricultural products (i.e., 50.2% of world sunflower seed production, 12.4% of world wheat production) and non-agricultural products in the region. The war in Ukraine is a real concern for HFSA: Mali | Technical report 6 The World Bank several West African countries, including Mali, because of their heavy dependence on wheat imports. Indeed, according to FAO estimates, about 30% of wheat consumed in West Africa comes from Ukraine and Russia (10). Russia being the main exporter of wheat to West Africa makes the dependence on wheat imports particularly high in Mali (as it is in Mauritania, Senegal, Cameroon, and Benin), where over half of all wheat consumed comes from Russia. Following the outbreak of hostilities between the two countries, the price of wheat has risen to EUR 344 per ton, compared to an average of EUR 200 per ton in 2021 (10) - a price increase that will be passed on to the various importing countries, including Mali, at a time when food prices are already very high. Other agricultural products are also impacted by these situations (corn, rice, fertilizers essential to agricultural production, etc.) and other sectors such as the energy market (petroleum products) and other materials (cement, iron) that are inputs for infrastructure investments. The war in Ukraine is therefore an aggravating factor in an already complicated situation in Mali, with important economic and political consequences affecting energy and fuel prices worldwide. Figure 1: Mapping exacerbated fragility and conflict in Mali, 2022 Violence and insecurity, ACLED (February 2022) Displaced populations (returnees, refugees in Mali and Malians in neighboring countries), UNHCR (December 2022) Source: ACLED and UNHCR mapping 2.1.1 Vulnerability to climate change and epidemics Mali belongs to the group of fragile and conflict-affected states (FCS or FCAS). More generally, the Sahel region is a fragile zone due to different factors such as extreme poverty, weak state structures and climate change. Conflict and fragility adversely affect the lives of many Malians. In fragile contexts, rates of extreme poverty can increase as individuals are displaced, livelihoods are devastated, and opportunities for broader growth, development and prosperity are destroyed. Mali is also vulnerable to the effects of climate change but has a relatively low level of economic, governance and social readiness. In 2020, the country was the 7th most vulnerable to climate change and other global challenges, combined with much lower national readiness to improve resilience compared to other countries, as it ranks the 157th most ready country out of 182 (22). Using information from six life-supporting sectors (health, food, water, ecosystem services, human HFSA: Mali | Technical report 7 The World Bank habitat and infrastructure), Mali scored 34.7 out of 100 on climate-change preparedness. Climatic hazards were already a threat for Mali in 2013 (severity stage 4 out 5) (23). At least three major exports, which are gold, cotton and livestock (beef), are heavily influenced by climate effects and subsequent price fluctuations (24). With more than 80% of the population dependent on predominantly rainfed agriculture for their livelihood, crops damaged by heavy rains, droughts, floods, and locust invasions devastating the harvests are a public health threat. In 2022, up to 72,025 people were impacted by floods, according to OCHA estimates. The country is also experiencing ever more erratic and unpredictable rainfall patterns, less evenly distributed seasons, and extreme and changing temperatures (rising up to 50°C in the desert and projected to change annually by 0.9°C to 1.5°C by 2050, especially in the Southwest and Central regions) (25). In 2023, Mali’s satellite imagery mapped cropland losses, which are more pronounced in the Mopti and Ségou regions (26). Climate shocks also induce food insecurity and contribute to population displacement in Mali. Beyond the conflicts, climate change and irregular rainfall is another major cause of food insecurity and population movement. In 2023, WHO’s bulletin on outbreaks and other emergencies for Africa estimated about one Malian out of four (4.8 million people) is currently in food insecurity because of insecurity and the impacts of climate change. In 2022, during the lean season between harvests (June to August 2022), a staggering 1.8 million people were estimated to be acutely food insecure. In 2023, around 1.2 million Malians will need emergency food aid during the lean season, according to other estimates by the EU. Some 367,000 U5 children suffering from severe acute malnutrition also need emergency assistance, a headcount up by 16% compared to 2022. Mali’s MOH has tracked displaced populations across major events including climate shocks, showing that in 2022, a total of 32,455 individuals (equivalent to 6,931 households) were displaced due to climate shocks, with Biandiagara’s region bearing with about half of the burden (27). Over the past years, successive epidemics (H1N1, Ebola, COVID-19) have affected the country and the threats are growing. Linked to the country’s context, there is indeed a tangible risk of bioterrorism, possibly facilitated by the jihadism in Northern Mali. Awareness of these epidemics and conflict-related threats makes health authorities prioritize preparedness planning and health security agendas. The central role of PHC to COVID-19 recovery and reinforced health systems has been largely recognized (28). 2.1.2 Demographic dynamics Living conditions and purchasing power are deeply affected by the crisis in Mali, pushing a large share of the population towards humanitarian aid. According to EU estimates, an estimated 8.8 million people (42% of the population) are in need of humanitarian aid in 2023. This threat is growing as they were 5.9 million in 2021 and 7.5 million the following year. The loss of the economic and purchasing power of Malians is also a reality, which translates into increased poverty and social decline. Rising food costs result in more families depending on financial transfers from the diaspora, however these money transfers were blocked, making living conditions increasingly harder for the Malians. Living conditions in the conflict zones were profoundly impacted, resulting in additional displaced persons. The UN General Assembly also reports specific risks for children (15). HFSA: Mali | Technical report 8 The World Bank A growing segment of the population is affected by food insecurity. At the end of 2021, 6 areas were listed as being in the crisis phase for food insecurity (Ansongo, Ménaka, Bandiagara, Douentza, Koro and Niono), twelve areas were under pressure (Bourem, Gao, Nioro, Abeibara, Tin - Essako, Bankass, Djenné, Ténenkou, Goundam, Gourma Rharouss, Niafunké and Timbuktu) whereas 32 other areas and the District of Bamako were in minor threat of food insecurity. This translates into more people being in food emergency (57,543 people, equivalent to 0.27% of the total population), under pressure (1,187,363 people, equivalent to 5.47% of the total population), and under minor threat (3,585,989 people, equivalent to 16.53% of the total population) (16). According to a report from the Office for the Coordination of Humanitarian Affairs (OCHA) dated June 2022, food insecurity in Mali has reached an unprecedented level over the past decade (as evoked earlier while presenting the country context). The report indicates that more than 1.8 million people are in acute insecurity and in need of emergency food assistance. The report also suggests that more than 2.3 million people are specifically affected during the lean season (between June and August 2022), which is much higher than 2021’s headcount of 1.3 million during the same period. These results are the highest level recorded since 2014. Large-scale population displacements along with greater vulnerability are a consequence of the crisis, occurring both inside and outside the borders. About 1.5 million Malians (EU estimates) have fled their homes since 2012, and some on multiple occasions. In December 2022, more than 470,000 people were displaced, including refugees from neighboring countries, with little chance of returning. UNCHR further details the displacements, highlighting disruptive situations in all regions of the country in December 2022 (Figure 1). Overall, more than 723,000 people have returned to their homes and 85,000 have returned from abroad since the beginning of the conflict. In addition, nearly 198,000 Malians continue to live in neighboring countries. Displaced populations are all in a situation of extreme vulnerability. In 2023, it has been estimated that more than 3.9 million people need protection due to serious human rights violations, including sexual violence. Population growth also weighs heavily on social sectors, putting into question the real impact of current development efforts. Mali’s population growth is among the highest in the world which is complicated by uneven spatial distribution. Mali is a continental country and home to about 21 million people, of which most live in the South-Western territories. The district of Bamako is forecast to reach 5 million people by 2030, and 10 million by 2050 ceteris paribus. From about 14.5 million inhabitants in 2009, Mali’s headcount increased to 20 million people in 2019 and 21 million in 2021. Over the past decade (2010-2019), it grew annually by 3.6% (95% CI: 3.0–4.1), which is much faster than averages observed in the region. Respectively, the SSA and Western SSA averages are estimated at 2.6% (95% CI: 2.5–2.7) and 2.9% (95% CI: 2.8–3.0) (17). Mali’s population growth is too fast compared to its economic growth and some experts warn of a required 7% of economic growth to act on poverty reduction (18). Mali’s population is unevenly distributed across its territories. Mali is one of the least densely populated countries worldwide, counting about 11.7 inhabitants per square kilometer (7). This unequal distribution shows differing density rates within the country as well as rural/urban disparities, with a large majority (77.5%) living in rural areas, against 22.5% in urban areas. Disparities in density rates are shown in Figure 15. Mali has 13 national languages in addition to its official language and at least ten distinct ethnicities, which characterizes Malian society. HFSA: Mali | Technical report 9 The World Bank This demographic pressure and structure poses specific challenges for the provision of social and health services in Mali. The youth-skewed population of Mali and its projection for 2030 signal growing needs in sexual and reproductive health. Youths aged under 18 account for about 55% of the population and adolescents aged between 10 and 19 about half of the latter, whereas adults aged 65+ only represent 5% of Malians (19). Of all women of reproductive age, a quarter (24%) are teenage girls aged between 15 and 19, representing more than 1 million people (19). High fertility rates are a public health challenge in Mali. Its synthetic fertility index is estimated at 6 children per woman (19). Mali’s age-specific fertility among adolescents and other groups is higher than the SSA average (Figure 2). Moreover, accelerated urbanization and subsequent internal migrations impose additional distortions, exacerbating the gap between available resources and growing and diversified needs for health, as well as for food, education and housing. Social protection is too limited with regard to Mali’s demographic patterns. The ratio of economic support shows a gap of 43% between headcounts of effective workers and consumers, meaning that 43 people work to support 100 people. Like Niger and Chad, Mali has barely (if at all) begun its demographic transition, largely because of persisting high fertility rates (20). Authorities are well aware of the doubling of the population that is expected every 25 years (cf. national strategic plan ‘SPSR’ 2017-2018). This trend is explained by the combination of a sharp decline in mortality rates that has not yet been compensated by a decline in fertility rates. Mali will however experience a mid-transition stage in its demographic transition as its crude birth rate begins a sustained decline, after a period of decline in the crude death rate (17). Since the demographic dividend is not automatic or guaranteed, it is important for GOM to identify the most promising investments to capture it. In this regard, the African Union has encouraged the adoption of a roadmap to take advantage of the demographic dividend by 2063 (Assembly/AU/Dec.601 (XXVI), 2016), which is what GOM aspires to according to its Strategy for Accelerating Growth and Sustainable Development (CREDD). Efforts must be maintained, as increased budget effectiveness by strengthening the interrelationships between strategic planning (of the CREDD) and budget processes was recommended in 2020 for Mali (21). Human capital investments are instrumental in taking advantage of the demographic dividend in Mali. A recent impact analysis found that the largest effects of human capital development are recorded for health, security and social network functions (21). Therefore, it would be more profitable for Mali to invest additional resources in those sectors. Mali's performance in achieving the demographic dividend is intertwined with its trade-off in investments. The study findings also show that transfers and subsidies in the health sector have positive effects. It confirms the relevance of taking action to strengthen social protection, in particular both the compulsory health insurance and medical assistance scheme introduced by the government in recent years. HFSA: Mali | Technical report 10 The World Bank Figure 2: Forecast of Mali’s population, 2000-2030 Population pyramid Patterns among teenage girls 100+ 90% 90-94 80% Cumulative percent of girls who... 80-84 70% 70-74 60% Age group stratification 60-64 (at each age) 50% 50-54 (years) 40% 40-44 30-34 30% 20-24 20% 10-14 10% 0-4 0% 5.0 0.0 5.0 8 9 10 11 12 13 14 15 16 17 18 19 Millions Year of age Total 2020 Forecast 2030 Had sex Got married Gave birth Source: Survey data DHS 2018 and GFF country brief 2.2 Economic growth, poverty and shared prosperity 2.2.1 Economic prospects and major obstacles to growth In Mali, economic growth experienced a modest recovery after the shock of the global pandemic, but projections announce a resumption of growth of around 5% in 2023. As at the 1st of July 2022, based on the Atlas method, the Malian GNI per capita of US$ 870 ranks the country 176th poorest out of 195 (LICs: < US$ 1,085). With a real GDP that plunged to -1.2% in 2020, Mali entered a recession as a result of the COVID-19 pandemic, an unsuccessful cotton harvest, and institutional change in August 2020 (29). The limited recovery experienced in 2021 (3.1%) continued in 2022 (3.3%), underperforming initial forecasts of real GDP growth (29). On average, prior to COVID-19, real GDP growth stood at 5.4% over the period 2015-2018 (30). However, the short-term projections (for 2023 and 2024) seem to announce a recovery and annual growth close to past performances. IMF estimates for 2023 announced a projected real GDP growth of 5.3% and an inflation rate of around 3% (31). Like other G5 Sahel countries, the Malian economy is under-diversified, making it more vulnerable to shocks. The Malian economic base is predominantly rural and dependent on agricultural production (cotton, cereals, livestock, etc.). The 2021 rebound was mostly driven by the agriculture and service sectors (30). Both sectors are highly vulnerable to climate change, insecurity and commodity price volatility2. For instance, several factors influence agricultural under- 2 With only 14% of the land suitable for farming, the agriculture sector drives the economy despite its performance being undermined by the effects of climate change (32). Agricultural production contributed to the rebound observed in 2021, HFSA: Mali | Technical report 11 The World Bank performance in Mali, including reduced access to inputs attributed to trade disruptions, or growing insecurity that limited access to the fields and restricted the availability of inputs (30). In Mali, main exports rely on gold (about 30% of GDP) and cotton, whose production requires a significant amount of water and is therefore highly vulnerable to water availability. Many sectors of the Malian economy will increasingly face the impacts of climate change (i.e., agriculture, health, fishing, energy, water resources, livestock rearing, forest-fauna, biodiversity, transport, industry, and education were ranked by the Government from highest to lowest in terms of vulnerability – Zamudio, 2016). Rising inflation is also a threat to the economy. Growing insecurity and political instability accounted for about 23% of the GDP between 2012 and 2018, on average (29). Beyond insecurity, the slow recovery of the economy is also exacerbated by food price inflation, which disproportionately affects the poorer segments of the population. Economists suggested that the medium-term outlook will be subject to significant negative risks, coping with uncertainty over the political transition and regional sanctions and with slowly declining poverty due to limited per capita income growth (33). Domestic prices surged in 2021 in Mali, exacerbating the burden on poor and vulnerable groups of populations. Inflation is closely linked to the COVID-19 disruptions, international trade and insecurity. Economic forecasts suggest that inflation is expected to rise continuously, notably given the poor harvest resulting from the low rainfall that the country experienced in 2021. The inflation rate already accelerated to 4.0% in 2021, against 0.5% in 2020 and minus 2.9% in 2019). As reported in the Economic update 2022, elevated inflation observed in Mali is primarily due to rising prices of “food products, non-alcoholic beverages” (3.9%), knowing that the contribution of food to the overall price index was estimated at 76.9% in 2021 (30). For example, the price of the local rice increased by 6.2% during 2020-2021, after an increase of 3.8% during 2019-2020, according to country data by INSTAT. Another product, peanut oil, experienced a price increase of 15.7% in 2020-2021, compared to a deflation of 5.1% during the previous period of 2019-2020. Like insecurity, high food inflation disproportionately impacts the poor and vulnerable segments of the population, of which households spend almost half (46%) of their budget on food, compared with less than a third (31%) for the non-poor segment of the population (30). Inflation is also due to rising prices of health products (8.1%), other products that are related to communication (3.3%) and those of leisure and entertainment (21.5%). mostly led by cotton production when farmers shifted to cotton as a result of higher farmgate prices. Manufacturing shrank in 2021, mainly due to input shortages (30). This activity is concentrated in low-value added textiles and agri-food (33). The service sector also faces weaknesses as it lacks a skilled labor and infrastructure base to sustain growth, although it has expanded rapidly over the last decade (33). HFSA: Mali | Technical report 12 The World Bank Table 1: Macro-economic and fiscal indicators: estimates and WB Economic Update forecasts, 2018-2024 Sources: Country authorities, IMF and World Bank Staff estimates and projections The large size of the informal economy (97% of the job market) adds pressure and is critical to the Malian transition towards UHC – this is a challenge in many developing countries (34). The Malian labor market also has a high unemployment rate, especially among young adults despite half of them (44.2%) having a higher education diploma and about a third (31.8%) having a secondary school diploma (7). According to ILO estimates, it is suggested that, on average, every Malian household includes three paid workers, and produces its own consumption goods. It should however be reminded that informality is distinct from poverty. Not all informal workers belong to poor households and vice versa (ILO). In Mali a minimum wage was set by decree at XOF 247.1 per hour (Decree n°2015-0073) (35). Small and medium-sized enterprises (SMEs) were severely impacted by the COVID-19 pandemic. More than half of small and medium-sized enterprises saw a drop of more than 30% in their turnover, mainly due to lower sales and supply difficulties in all sectors (36). Private companies experienced numerous disruptions in the supply chain, including rising prices and costs of services. The effects of the COVID-19 crisis have been observed in all sectors and therefore also impacted the health sector, which includes numerous small and medium-sized enterprises. With respect to public finance, the country faces rising public debt, notably attributed to increased public expenditure and reduced donor support since August 2020. Public spending accounted for 26.7% of GDP in 2021 and 25.9% in 2020. The economic recession, COVID-19 related spending, and an increased wage bill are all factors that contributed to increased public spending in Mali (30). Public spending recently rose to contain the social and economic fallout of the COVID- 19 pandemic. Military spending also rose in the context of rising insecurity. Since 2012, it has HFSA: Mali | Technical report 13 The World Bank increased to 20% of total expenditure, against 8.4% prior to the security crisis of 2012 (29). The rise in current expenditure, combined with the reduction in donor spending since August 2020, means that capital spending, however, experienced a modest increase. As a consequence of the above, the public debt rose sharply in 2021 in Mali, representing up to 52.0% of GDP, compared to 36.1% of GDP in 2018. Mali has faced new sanctions imposed by ECOWAS on January 9th, 2022, including the freezing of Mali's assets in ECOWAS central and commercial banks, suspension of all assistance from ECOWAS financial institutions, suspension of all commercial transactions and closure of land and air borders. Following the 2022 embargo3 imposed by ECOWAS and the WAEMU, many projects were suspended, as reported by the CNCD-11.11.114. It exacerbates the situation as prior embargoes were detrimental to living conditions and imports of food and agricultural products, creating shortages in many sectors. It has aggravated social inequalities. The 2022 embargo has also affected the work of civil society given the suspension of monetary transactions between local and international banks. A partial lifting of sanctions took place at the end of July following the junta's commitment to hold elections between November 2023 and February 2024. Mali was eligible for the Debt Service Suspension Initiative (DSSI) in West Africa, allowing savings of up to 1% of its GDP. Between May 2020 and December 2021, Mali’s potential savings from the debt service was estimated at 1% of GDP (37). Savings as expressed in relative terms to GDP ranged from 0.2 to 2.5% among the eligible countries and was, for instance, 0.3% for Burkina Faso and 0.6% for Niger. These potential savings in Mali have increased the fiscal space by about US$ 168.1 million for spending on COVID-19 pandemic relief. 2.2.2 National strategy for growth and sustainable development A year before the pandemic, the GOM adopted a Five-Year Strategy for Accelerating Growth and Sustainable Development (CREDD/2019-2023), laying the foundations to achieve the Sustainable Development Goals (SDGs) by 2030. About 40% of budget expenditure (XOF 3440 billion) projected under the prior Strategy for Accelerating Growth and Sustainable Development (CREDD/2016- 2018) was directed to investments in basic social services (health, education, drinking water, electricity) and other infrastructure. The current costed plan also generated optimism for accelerated development (38). In line with the Head of State’s Society Project "Our great Mali is moving forward"5 (39), this macro-framework guides the design, implementation, and monitoring of a set of national and infra-national policies for development. In terms of volume, about a quarter (24%) of GDP is expected to be invested into five lines of action, of which one is human capital 3 https://www.lemonde.fr/afrique/article/2022/01/10/les-dirigeants-de-la-cedeao-placent-le-mali-sous-embargo-pour- sanctionner-le-maintien-de-la-junte-au-pouvoir_6108802_3212.html 4 https://www.cncd.be/Mali-l-embargo-de-la-CEDEAO?lang=fr 5 Described in a 2018-2023 national program. An engagement letter assigned to the Prime Minister articulated the program around five axes, namely (i) governance and political & institutional reforms, (ii) promotion of inclusive growth, (iii) human capital development and social inclusion, (iv) environment, climate change and sustainable development, (v) diplomacy, international cooperation and partnership. HFSA: Mali | Technical report 14 The World Bank development (i.e., health, demographic dividend, social protection, education). Meant to be aspirational for the next generation, the 2023 plan established a series of game-changing goals across sectors, although it was approached with pragmatism (focused on a results-based approach) and realism (awareness of the economic, security and other country challenges). The budgetary framework (May 2019) shows a forecasted budget for health according to two scenarios (Table 2). As the Head of State deploys national efforts to materialize his political project, the country now has to cope with the post-pandemic macro-economic environment. In light of the current economic prospects, the projected recession could severely affect non- priority public expenditure. Although the pandemic brought to the fore increased health needs and new health system strengthening challenges, the future of health financing is uncertain. Health is a sector that has seen its prioritization declining over the past two years (according to WB/HFGSG). In Mali as elsewhere, this risk is tangible given the global slowdown and growth prospects being revised downwards during this period. If there is a setback, ambitions for better health coverage for all in Mali could become only aspirational. For social services and certainly for the health system, the situation remains precarious in Mali, characterized by low health coverage, unequal access to care and maternal and child health indicators below expected goals. In health, emphasis will be placed on the governance of health facilities and staff responsiveness in all health structures, making it more inclusive and accessible. Table 2: Budgetary framework of the national strategy for accelerating growth and sustainable development in Mali, 2019-2023 Source: Data was extracted from Mali’s Strategy for Accelerating Growth and Sustainable Development (May 2019) HFSA: Mali | Technical report 15 The World Bank 2.2.3 Human capital development and poverty trends Human capital accumulation in Mali remains inferior to the averages observed in the region and among LICs, while coping with large inequalities. In 2020, the Human Capital Index (HCI) value for Mali is 0.32, meaning that a child born in Mali today could expect to achieve on average just 32 percent of her/his potential productivity as a future worker. This is lower than average for sub- Saharan Africa (0.40) and low-income countries (0.38) (Figure 3) (40). The country ranks third lowest against its peers and ranked 170th (out of 174) in the world classification for HCI (2020). With regard to national wealth (expressed by per capita real GDP), both adult and child survival rates remain insufficient in Mali when compared internationally. Moreover, the equity ratio (expressed as 20% wealthiest to 20% poorest) was 1.54 in 2020 in Mali, against a global average of 1.35 (range: 1.12-1.68). Figure 3: Human capital index (HCI) in Mali against focus countries and global averages, 2017-2020 Trend in Mali’s HCI Comparative results Changes since 2017 2020 0.3220 0.45 0.40 0.3210 Human Capital Index 0.35 0.3200 0.30 (scale 0-1) 0.3190 0.25 2017 0.3180 0.20 2018 0.15 0.3170 2020 0.10 0.3160 0.05 0.3150 0.00 0.3140 Ni i Af Ma l ri a o, w a LI v e d Ni m. in a an i Et aso Bu Ug n p. da ve ) A Ch r ) ga al gh law (a age ge e ng R opi rk nd a ta g M Re an De ge ne ra is Mali F a Cs r hi a Se (a SS Co Source: WB HCI (October 2020) More than four Malians in ten still battle with poverty conditions lower than the national threshold. Resulting from the country’s context and pandemic, the most recent data puts monetary poverty at 44.4% (29). During 2011-2019, the poverty rate only fell by 3% whereas the GDP growth increased by about 5% per year (41). Mali’s poverty headcount ratio at national poverty lines has declined, passing from 47% on average between 2012 and 2015 to 42% between 2019 and 2020, using WDI estimates. In 2012, a drought exacerbated poverty and cut short the downward trend in poverty reduction observed over 2001-2010. In 2017 and 2018, good harvests (e.g., +5% annual change in cereal production) explained most of the improvements in the fight against poverty in Mali. But the inability to meet basic nutritional needs still affects more than a fifth (22%) of the population. The poverty headcount and inequalities declined more rapidly in the past (during 2001- 2010), which was associated with the increase in cereal production, with increased remittances, HFSA: Mali | Technical report 16 The World Bank improved on and off farm employment opportunities (casual labor, artisanal gold mining) and improvements in road infrastructure (41). Based on the non-monetary dimensions of poverty, the 10% decrease in poverty observed during 2014-2018 was attributed to improvements in education and access to essential services (29). According to the 2018 poverty line estimated at XOF 181,201, equivalent to about XOF 496.5 per day, the incidence of monetary poverty was about 43.8% in 2018, against 44.9% in 2017 and 46.8% in 2016 as reported in national reports (7,30,38). Poverty depth is associated with the averaged collective deficit of expenditure of the poor compared to the poverty line for the whole population of XOF 480.9 billion (30). In 2018-2019, 43.8% of the population lived below the national poverty line (XOF 722 per person per day) (42). Against regional benchmarks, Mali’s results in poverty reduction appear too slow, hiding significant inequalities. In 2019, a greater share of Malians (43.8%) lived in poverty, compared to the WAEMU average (42.1%). In Mali, a 1% increase in GDP was associated with only 0.4 % decline in the poverty rate, revealing a growth elasticity of poverty in Mali (-0.4) lagging behind the SSA regional average (-1.9) (41). Income inequality steadily increased in Mali. Between 2011 and 2018/19, “annual income growth among households in the bottom 40% of the income distribution averaged 4.2%, well below the average of 5.0% for households in the top 60%”) (41). Moreover, the Gini coefficient used to highlight income inequalities fell from 0.42 in 2011 to 0.38 in 2019 in Mali but remains higher than the WAEMU average of 0.33 in 2019) (41). Poverty is predominant in rural Mali compared to Bamako and other urban centers, with uneven poverty reduction and inequality trends. The poverty rates in urban Mali (Bamako and other urban centers) nearly halved during 2011-2019, compared to broadly stagnant poverty rates in rural Mali (41). A large share of households depends on nomadic and transhumant pastoralism in the Northern regions, which are sparsely populated. Poverty is not homogeneous throughout the Northern territory, for instance, the poverty rate in Tombouctou (49.2%) is much higher than in Kidal (4.7%). Although the incidence of poverty varies widely across regions, poor populations are heavily concentrated in Central and Southern Mali. The highest poverty rates in the country were observed in Sikasso (67.6%), Mopti (56.6%), Koulikoro (54.1%) and Ségou (49.6%) (42), with all rates above the national average. As expressed by the share of the population living below the monetary threshold of $1.9 a day per person, the rate of extreme poverty was significantly higher in rural Mali (41.0%) compared to urban settings (6.0%) in 2019; also compared to the country bordering its Central-Southern border, Burkina Faso (31.8%), or compared to Chad (33.7%) (41). Regarding insecurity, poorer areas have more conflict-related fatalities. Regions experiencing the greatest number of fatalities had a poverty rate of 55% (equivalent to 1.3 million poor people) in 2018/19, about 13% higher than the average for Mali, which contrasts with a rate of 37.8% in low- intensity conflict areas (29). Aware of the territorial disparities, authorities developed a poverty reduction plan and invested to fight disparities. Mali invested XOF 480.9 billion, distributed in a large majority (93.6%) throughout rural areas, compared to Bamako (0.3%) (42). Receiving 88.8% of the total investment, the regions of Sikasso (34.3%), Koulikoro (20.9%), Mopti (17.1%) and Ségou (16.5%) must drastically reduce poverty having higher levels of poverty than the national average. The distribution of household expenditure or income is also unequal between the different segments of the population HFSA: Mali | Technical report 17 The World Bank and regions. Measured by the Gini coefficient, the level of inequality is estimated at 0.38 at the national level (with 1 as reference value for an equal society). Inequalities are less significant in Bamako (0.28), which contrasts with more marked inequalities in the rest of the country, in particular in Sikasso (0.45) where they are the largest. 2.3 Health sector context 2.3.1 Health policy and program design Embracing a sectoral approach to health, Mali's current national health policy6 dates from 1990 and combines the organization of the health system, social development, and more recently, the promotion of the family. Mali’s vision for health was built and developed alongside several commitments, which are the Health for All policy in 1977, the Primary Health Care (PHC) strategy (Alma-Ata) in 1978, the 3-phase development scenario (Lusaka) in 1985, the Bamako Initiative in 1987 and Health for All in the 21st Century (Geneva) in 1998. All these led to the liberalization of the medical and pharmaceutical sectors to allow private practice in the 1990s. As a result, in order to provide adequate responses to the many health problems that affect the well-being of the population, the GOM adopted a declaration of the Sectoral Health and Population Policy on 15 December 1990. This political will was translated into the adoption in 1998 of a first decennial (Ten- Year) Health and Social Development Plan (PDDSS – Plan Décennal de Développement Sanitaire et Social). Mali’s national health policy is guided by long-term vision, and the expansion of health coverage. The Health Framework Law was established in 2002 and revised in 2018 as part of the ongoing reform (43,44). Two successive PDDSS present the vision of GOM in terms of health and social development to achieve the Millennium Development Goals (MDGs), reduce poverty, and for the latter to meet the SDGs. It is aligned with the orientations of the Strategic Framework for Growth and Poverty Reduction (CSCRP – Cadre stratégique pour la croissance et la réduction de la pauvreté) 2012-2017. In 2002, Mali’s authorities enacted the extension of health coverage in Mali, an essential objective of the PDDSS (43), and thus reinforced the place of decentralization (embodied by the CSCOMs) in the health system. In 2018, Mali passed and enacted a law to extend health coverage to the informal and agricultural sectors under a new single-scheme health insurance, called the Universal Health Insurance Scheme (UHIS)7 (45). The implementation of this new UHIS was scheduled for 2022, supported by a decree of application (46). However, a lack of alignment between the ongoing reform and existing health policies was identified, notably due to the quantity of stakeholders involved (health and social protection) for whom emphasis is not put on the same element of the future UHIS (47). The PNS national policy is implemented through four successive Five-Year operational national plans complemented by decentralized plans. The implementation of the PDDSS is guided by the 6 PNS – Politique Nationale de Santé 7 “RAMU – Régime d’Assurance Maladie Universelle” HFSA: Mali | Technical report 18 The World Bank so-called Socio-Health Development Programs (PRODESS), which design Five-Year targets for the implementation of the PDDSS. The PRODESS have gone through four distinct phases as follows: PRODESS I (1998-2002), PRODESS II (2005-2009 extended in 2011 to align it with the period of the CSCRP 2007-2011), PRODESS III (2014-2018) and PRODESS IV (2019-2023). The country also has an implementation mechanism at the local level, which is the Five-Year Local Five-Year Cercle Health Development Plan (PDSC). The latter includes all the objectives, activities, and resources to be implemented at the most decentralized level. Mali is one of the few countries to have institutionalized the planning function in a health policy law (48). The entire planning process as well as monitoring the implementation of plans and programs is clearly described in the orientation law as well as in the PRODESS procedure manual. Health stakeholders’ engagement approach has been institutionalized to move away from technocratic planning procedures and get closer to a needs-based approach instructed by involved health stakeholders (such as health related ministries, civil society unions, etc.). Mali’s health authorities also developed guidance and regulations in pharmaceuticals, which are in line with the sectoral policy. In Mali, the pharmaceutical policy is an integral part of the sectoral health and population policy declared in 1990. Thus, the national drug and medicines policy was developed at the same time as the last Ten-Year health and social action plan. Its Five-Year and priority action plans are directly integrated into the PRODESS. This policy has an official document annexed to the PDDSS and the PRODESS. Since 2000, Mali’s health system has had a Directorate of Pharmacy and Medicines (DPM), which is a central service in charge of developing the elements of the national pharmaceutical policy. The Directorate of Pharmacy and Medicines ensures the implementation of the national policy, the coordination and the controlling of the services that contribute to the implementation of this policy (49). It is headed by a director appointed by decree by the Council of Ministers and is assisted by a Deputy. The list and prices of drugs and medicines are also regulated by decree. A 2017 decree mentions the creation of the order of pharmacists. A National Coordination Committee for drugs monitoring and management (CNC) was established in 2013, with clear terms of reference. This Committee was endorsed by the MOH and is chaired by a MoH Pharmaceutical Technical Advisor. Several sub-committees running as Technical Working Groups (TWGs) were created for malaria, family planning, maternal, neonatal, child and adolescent health, Tuberculosis, HIV-AIDS, and nutrition. Quality management is supported under the USAID- backed project to improve access to medicines (Systems for Improving Access to Pharmaceutical products and Service, SIAPS), which started in 2012. Finally, drawing on lessons learnt from the past, Mali’s health system has capitalized on its ability to prepare for future shocks and pandemics – even if the contexts that we have previously described still undermine its functioning. After the Ebola virus epidemic in Mali, the country built on its experience to better prepare and respond to the weaknesses of its system, such as the lack of mobilization of human resources and the unpreparedness of health services in the face of a shock. Especially post-COVID-19, preparing for and responding to similar threats is now a priority for the country, as well as for its partners. HFSA: Mali | Technical report 19 The World Bank Figure 4: Theory of change of the PRODESS Health component, Mali Source: adapted from the MOH/PRODESS and BVG (2021) 2.3.2 Main stakeholders and organizational model The organization of Mali's health policy and system has the unique specificity of being very decentralized. The implementation of Mali's decentralization policy is one of the country’s major projects. In that regard, Local Authorities (CTs – Collectivités territoriales) are the official entities responsible for implementing the PRODESS, and are regulated by law under the Decentralization of Local Affairs Acts. As such, these entities are entitled to mobilize the necessary resourcesto finance local health development plans. The transfer of power and expertise to the CTs has however experienced delays, slowing down the effective implementation of Mali’s decentralization policy. Other local entities enshrined by the communities also play an important role in Mali’s health policy and system. It should be noted that the operational details of this decentralization framework for HFSA: Mali | Technical report 20 The World Bank health will be further presented later in the report (cf. the chapter devoted to healthcare infrastructure). Mali’s government remains primarily responsible for the health policy and its PRODESS implementation, due to its obligation to guarantee health for every Malian. The State should provide a significant part of the financing for health by offering and producing services through the construction and equipment of health facilities, the provision of human resources for the supply of healthcare services, and the operation of the health administration according to a theory of change. In this perspective, the successive PRODESS emphasize capacity building and the expansion of health coverage in order to build up a supply of health and hygiene services through a participatory management mode. The combined effect of these different activities should enable the health structures to offer quality health services to the population in a sustainable manner. However, the achievement of the above objectives depends on a certain number of factors, including the real financial and technical capacities of health stakeholders, the availability of material and human resources, the population's confidence in the health system and its ability to pay for its care (Figure 4). Between 2012 and 2020, Mali has had five successive heads of MOH (50). In practice, the intervention of the State is implemented through several entities and technical services. First, the MOH planning and statistics unit (CPS/SS/DS/PF) is the entity that coordinates the technical secretariat of PRODESS as well as the sectoral support of partners. With the support of the CROCEP and the Management Councils, it is responsible for planning PRODESS activities for year N+1 and for reporting on those of the previous year. Second, the Directorate of Finance and Material for Health8 is responsible for mobilizing and making available the financial resources necessary for the implementation of PRODESS. To this end, it is represented at the regional level by accountants in the regional health directorates (DRS). Third, the Directorate for Human Resources for Health has the mission to develop, as far as the MOH is concerned, the elements of the national policy in the field of human resources management and development. Its mission is to ensure UHC through the efficient management of human resources in the health sector. Fourth, the Directorate of Pharmacy and Medicines (DPM) is essentially responsible for coordinating the drugs and medicines supply process, therefore centralizing all such needs. These needs are transmitted to the ‘Pharmacie Populaire du Mali’ (PPM), which then purchases and distributes them to the health facilities. Finally, there is also a Health Infrastructure Strengthening Program Implementation Unit9 in charge of providing technical services for the supervision, control and monitoring of health infrastructure strengthening programs. The latter monitors and coordinates the construction of health infrastructures so that they meet standards. Within the framework of the PRODESS, CEPRIS is the delegated project manager of the Department of Health. Providing technical assistance to the DFM, CEPRIS is responsible for monitoring the execution of the construction sites without being involved in the planning, studies and contracting operations of the PRODESS. 8 DFM/Santé – Direction des finances et du Matériel 9 CEPRIS - Cellule d’Exécution des Programmes de Renforcement des Infrastructures Sanitaires HFSA: Mali | Technical report 21 The World Bank External Technical and Financial Partners also support the PRODESS. Financing agreements with the Technical and Financial Partners are established according to various modalities (direct budgetary support, and general and sectoral budgetary support). Some partners use their own procedures to finance health at the central and/or operational level. Donor coordination is managed through Compact agreements for International Health Partnership (IHP+), with the first Compact signed in 2009. Similarly, the role and importance of the different Technical and Financial Partners in supporting Mali’s health system will also be further developed in the report. 2.3.3 Key developments The second and current PDDSS for 2014-2023 is steered by a newly Government-appointed team in the MOH, reflecting the Government’s efforts to renew sector leadership. Mali’s health policy priorities focus on human resources development, improvement in the quality of health services and care, and community contribution to health access and financing – all seen as the key steps for achieving the PDDSS objectives. With this new team, the country has committed to rebuilding donor confidence, given the increasing governance concerns around country leadership and systems. All development partners have been invited to participate in a comprehensive assessment and investigation by the internal audit branch for good governance ‘10, notably leading to an action plan to improve governance (51). “Donor coordination improved with the Compact for International Health Partnership (IHP+). The discussions to align with donors, highlighted substantial gaps, specifically in the coverage of reproductive health and family planning.” To advance the SDG 2030 agenda and establish UHC in Mali, GOM presented an ambitious health reform in 2019. Health is an ambitious project amply promoted by Mali’s State and its authorities aim to make Mali’s health reform a model on the continent (52). Under the leadership of the MOH, the ongoing reform constitutes an unprecedented opportunity to improve population health and invest in human capital and social protection for health. Revised in March 2020, the reform was elevated to a ‘Mali Action Plan’ designed for the decade (2020 to 2030) to strengthen Mali’s health system resilience (53). Within this ‘Mali Action Plan’, national authorities intend to strengthen the country’s health system resilience11., The country aspires to become one of the first to nationalize and implement the “Global Plan of Action for Healthy Lives and Wellbeing for All”, already endorsed by major development organizations (including World Bank and Global Financing Facility–GFF) and all UN member countries at the UN General Assembly (September 2019). Commitments for improved health in Mali are included in the high-level political and economic agenda, emphasizing the importance of primary healthcare as a key ingredient of the health 10 Mali’s general audit office (Bureau du vérificateur général) - http://www.bvg-mali.org/ 11 A national consultation was initially launched in 2019 to prepare a bold and ambitious health reform agenda to accelerate progress towards UHC. The proposed incremental reform program for the Malian health sector was elevated to a presidential initiative launched in Bamako on February 25, 2019. As part of the Strategic Economic Development Framework (CREDD) and the National Health Sector Strategic Plan (PRODESS), the reform seeks to expand high-impact interventions, give impulse to health innovations and strengthen both the management and financing of the national health system and governance. Focus was however on child and maternal health to reduce mortality rates while restructuring PHC as a key ingredient of the reform. HFSA: Mali | Technical report 22 The World Bank reform. Subsequent to a previous framework (2014-2018), the current Strategic Framework for Economic Recovery and Sustainable Development (CREDD/2019-2023) integrates both the SDGs and the ambitions of "Agenda 2063" of the African Union by making the targeted actions consistent under coherent intersectoral political and budgetary frameworks. Mali’s Strategy for Accelerating Growth and Sustainable Development promotes improved population health (national goal 5.1) and social protection/inclusion (national goal 5.7) under the umbrella of human development (38). The expansion of high-impact interventions is core to Mali’s political agenda along with a strong willingness to advance health innovations and improved governance. A major focus was notably on child and maternal health within the overarching goal of fighting mortality rates and leveraging health outcomes through restructured PHC. The health system reform is also built on past commitments in the health sector, regulated by a legal framework. The 1990 sectoral health and population policy marked a major step forward in health development, deviating from project-based approaches. It was translated into an orientation law in 2002, which enshrined the program-based approach (43). Health is one of the areas in which the central State has transferred its prerogatives to local authorities, anchored in the municipalities and cercles (2002 Decree n°02-314) (8). Since the 2002 decree, domestic financial resources have been granted to local authorities. By placing decentralization at the heart of its development process 30 years ago, the country took a decisive turn. Mali has 703 communes, 49 cercles and 8 regions, which are all decentralized powers (8). One year to go before the end of the current Ten-year health and social development plan is time for reflecting. The current Ten-Year plan for 2014-2023 envisions health and social developments within the framework of the SDGs (54). This health plan was developed within an intersectoral perspective, under joint leadership of the three ministries (health, social affairs and population). They set, among others, the strategic objective of developing a financing system allowing better mobilization and use of financial resources for health. Over the past ten years, the health authorities have been productive and moved forward with establishing transparent management, while encouraging providers and users to be more efficient. The MOH adopted several health policies, among which a national policy for pharmaceuticals (2012), a nutrition policy (2013), a health financing for UHC strategy (cited in PRODESS IV), and a national strategic plan for securing reproductive health products (2017-2021). A national plan for human resources for health (2019- 2023) envisions a critical mass of competent, committed, and motivated human resources that will gradually be put in place in the health sector, and social development and the promotion of family by 2030. Building on this framework, the country demonstrated its political will to move forward with strategic and operational planning for UHC. Reinventing health systems to achieve UHC requires leadership and strong political commitment from the country, and in Mali this leadership mobilized society as a whole. Integrating Community Health was key in Mali, which has its own cycle of reform (55). Since 2011, Mali has developed a coherent strategy for Essential Care in the Community (SEC – Soins Essentiels dans la Communauté), most recently with a SEC plan for 2016-2020. With the adoption in 2018 of the UHIS Act, the country institutionalized a future deployment of professional community health workers (CHWs) nationwide. The Mali Action Plan reform for 2023 provides for a national framework for professional and paid community health workers (CHWs). Transformational progress in support of HFSA: Mali | Technical report 23 The World Bank UHC goals is expected for the next few years in Mali but, as it has been shown, recent events are delaying the reform process. In this sense, the country is imposing a strong vision for a national health system, further institutionalizing the community, but its political will still has to be implemented. Incentive payments have been introduced under Mali’s health financing strategy, establishing a performance-based mechanism to purchase healthcare and support PHC delivery of care. Healthcare is purchased under two health benefit packages, respectively the minimum package of activities at the frontline PHC providers, and a complementary package at the 1st referral level. The overarching aim is to improve results in reproductive, maternal, neonatal, child and adolescent health and nutritional care, as well as to reinforce community health. To take into account the specificities of Mali’s health system, such as its high degree of decentralization, the performance- based mechanism features civil society (through CGIC) (8), involving the communities (through ASACOs). For instance, tripartite contracts are signed between the CSCOMs, community-based organizations and the mayors (or Cercle Council in the case of CSRef). The latter is not mainstream elsewhere. Currently effective in four regions, the way forward for more strategic health purchasing envisions the expansion of performance-based financing. Expanding the scope of performance-based financing in Mali is a a strategic priority of the GOM, which is part of the prior operational health program (PRODESS III). The rationale for Mali’s performance-based financing scaling-up was to address the critical impediments undermining the delivery of PHC services, including the low-quality dimension. Major challenges at the frontline service delivery of care included: (i) shortage of funds that made meeting operating expenses problematic for the providers; (ii) lack of autonomy in managing health facility financial resources, which is hastily needed to procure drugs and attract/motivate qualified human resources; (iii) absence or lack of focus on the results and limited use of performance data at all levels (health facility, district, regional and national); (iv) lack of accountability and transparency of the health system; and (v) weak managerial capacity at all levels (175). The future of Mali’s performance-based financing is expected to represent a greater funding stream for PHC. Moving away from pure input- based financing, PBF scaling-up was endorsed in the ‘Mali Action Plan’ for 2030. A State-owned company no longer has the monopoly - a major evolution in Mali’s pharmaceutics policy The system has evolved into an industrial and commercial company facing stiff competition from private wholesalers and distributors. Those private stakeholders now generate 80% of turnover at the transfer price and cover 50% of the needs of public structures12 (56). This situation is likely to penalize the national structure (PPM – Pharmacie populaire du Mali), which is unable to meet the delivery deadlines agreed upon with the health structures due to the cumbersome contracting procedures to which it is subject (56). 12 Il existe au Mali une “rude concurrence des sociétés grossistes répartiteurs privés qui réalisent 80% du Chiffre d’Affaires au prix de cession et couvrent 50% des besoins des structures publiques. Cette situation est de nature à pénaliser la PPM qui n’arrive pas à respecter les délais de livraison convenus avec les structures de santé du fait de la lourdeur des procédures de passation des marchés auxquelles elle est assujettie.” HFSA: Mali | Technical report 24 The World Bank 3 Health system outputs and outcomes This third chapter shows the extent to which the supply of health services in Mali is responsive to key outcomes. We questioned the capacity of the Malian health system to deliver improved outcomes and greater service coverage over the past decades and against global performance. 3.1 Population health indicators 3.1.1 Life expectancy trend and long-run achievements Despite significant progress, life expectancy at birth (58.6 years in 2020) in Mali is lower than global averages. Comparative trends of life expectancy at birth in Mali against global averages for low-income countries, sub-Saharan Africa and the group of fragile countries are presented are Figure 5. When adjusted for health, life expectancy in Mali only reached 54.6 years in 2019 (Figure 5), which improved by 9.1 years from 45.6 years in 2000. It however remain inferior to the global averages for SSA countries (57.4), Western SSA (57.5) or global (63.7 years old) (17). Besides, a strong correlation between the socio-demographic index and health adjusted life expectancy (17) suggests up to 2 years less for the sub-groups with low socio-economic levels. This indicates that acting on socio-demographic indicators would help Mali’s healthy life expectancy increasing to the level observed in Malawi (Figure 5). Figure 5: Life expectancy at birth in Mali benchmarked to global trends, 1960-2020 Average number of years a newborn is expected to live if mortality patterns at the time of its birth remain constant in the future 70 65 Life expectancy at birth, total 60 55 50 45 40 (years) 35 30 25 20 15 10 5 0 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 Mali Low income Fragile and conflict-affected situations Sub-Saharan Africa (excl. high income) HFSA: Mali | Technical report 25 The World Bank When adjusted for health, average number of years that a person could expect to live in "full health" Healthy Life Expectancy (HALE) at birth 56 (years), 2019 54.6 Healthy Life Expectancy (HALE) Uzbekistan 54 53.0 Tajikistan 52 51.3 Rwanda at birth (years) Ethiopia 50 Senegal Uganda 48 Malawi 45.6 46 Niger Burkina Faso 44 Mali Nigeria 42 Congo Dem. Rep. 40 Afghanistan 2000 2010 2015 2019 Zimbabwe Chad Mali 0 10 20 30 40 50 60 70 Source: WDI (for LE) and WHO-GHO (for HALE) The gender gap is a public health concern. Mali’s high gender-based disadvantages were assessed by the United Nations across three dimensions (reproductive health, empowerment and the labor market). It even grew slightly, up to 67% after 2012, against a desired 0% value for gender equality, and is much higher than the global average (57). Overall, Mali’s women, business and the law index scored 63.8 out of 100 in 2023 whereas the regional average across sub-Saharan Africa is higher (estimated at 73) (58). Mali’s gender gap is also reported within the health sector at various levels (education and staff training and health workforce occupation), which calls for gender-sensitive planning in health (59). Regarding child development, WHO reports that 61.6% of the U5 children were developmentally on track for health, learning and psychosocial well-being (in 2015, according to country overview for Mali’s triple billion targets monitoring). 3.1.1 Mortality trends and long-run achievements Adult mortality has significantly reduced over the past two decades, but Mali’s achievements lag behind the averages of low-income countries. Adult mortality rate is the probability of a 15-year- old adult dying before reaching age 60. In Mali, the probability of male and female adults dying too early was estimated at 312.2 and 257.2 per 1,000 adults in 2020 (Figure 6). Mali’s efforts in the past century succeeded to significantly reduce adult mortality, even surpassing achievements of low- income countries for several years. However, in 2020, the ratios are higher than the average of low- income countries, which were respectively estimated at 291.9 (male adults) and 209.3 (female adults) per 1,000 adults. Persisting mortality in young age groups in Mali, which is illustrated later, significantly lowers the life expectancy at birth. Overall mortality indicators (infants, children and adults) are important indicators of health status, often used to identify vulnerable populations and to compare socioeconomic development across countries. HFSA: Mali | Technical report 26 The World Bank Figure 6: Adult mortality ratios in Mali against global benchmarks, 1960-2020 Female adults dying between the ages of 15 and 60 in a given year 550 500 450 Mortality Rate, Female 400 (per 1,000 adults) 350 300 250 200 150 100 50 0 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 Mali Low income Fragile and conflict affected situations Sub-Saharan Africa (excluding high income) Male adults dying between the ages of 15 and 60 in a given year 550 500 450 Mortality Rate, Male 400 (per 1,000 adults) 350 300 250 200 150 100 50 0 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 Mali Low income Fragile and conflict affected situations Sub-Saharan Africa (excluding high income) Source: UN World Population and The Human Mortality Database Child mortality has halved over the past two decades, but its reduction must be sustained to converge towards benchmarks and meet the desired sustainable development goal by 2030. Significant progress has been made in Mali to reduce death among under-five children, reaching 97.1 per 100,000 live births in 2021 compared to a much higher threat in 1990 (231.4 per 100,000 live births), according to UN-IGME estimates (60). The under-five mortality rate has also halved over HFSA: Mali | Technical report 27 The World Bank the past twenty years, as it used to be around 187.7 per 100,000 live births in 2000. The average pace of reduction was estimated at 3.1% annually between 1900 and 2020, which remains insufficient as the current level of under-five mortality is higher in Mali than the average for the sub-Saharan Africa region (74 per 100,000 live births in 2020). This means that Mali is unlikely to achieve the SDG target on under-five child mortality (25 per 100,000 live births by 2030) without renewed efforts to accelerate its progress. Despite Mali’s efforts to reduce mortality among younger children, its achievements remain below the regional and LICs achievements. Mali’s infant and neonatal mortality rates have steadily declined, down to 33.4 and 61.6 respectively per 100,000 live births in 2021Error! Reference source n ot found.. Mali managed to reduce child mortality among infants and newborns while reducing the gap between its achievements and the averages for sub-Saharan Africa and low-income countries. However, Mali’s infant and neonatal mortality represented about 47 thousand deaths among children under 12 months of age and 26 thousand newborns in 2020 (60). Similarly, Mali’s neonatal (newborn) mortality is largely higher than the benchmarks for the SSA region (27.1) and income group (26.7); and the SDG target of at least as low as 12 per 100,000 live births by 2030 implies accelerating the pace. Child mortality in Mali is uneven across infra-national administrative territories. Mali is one of the countries with the highest inequality range in under-five mortality. In 2020, the lowest mortality rates were found in Kidal (32.7 per 1,000 live births) against the highest rates at almost twice the national average observed in Timbuktu (174.9 per 1,000 live births), with 94.2 per 1,000 live births as the national average. In 2021, disparities in under-five mortality rate persisted, ranging from 1 to 4 depending on the region. Mali’s under-five mortality rate remains largely above the WHO alert threshold (10 deaths per 1,000 per day) in all regions of the country, the District of Bamako included (16). The odds of survival remain lower in Mali than region and income group comparators. Currently, children born in Mali continue to face steeper odds of survival than in most low-income countries in 2020 (Figure 7). HFSA: Mali | Technical report 28 The World Bank Figure 7: Child mortality trends in Mali against global benchmarks, 1960-2020 Children dying before reaching five years of age in a given year (SDG 3.2.1.) 450 Under-Five Mortality Rate 400 (per 1,000 live birthss) 350 300 250 200 150 100 50 0 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 Mali (IGME) Low income Fragile and conflict affected situations Sub-Saharan Africa (excluding high income) Infants dying before reaching one year of age in a given year 250 225 (per 1,000 live births) Infant Mortality Rate 200 175 150 125 100 75 50 25 0 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 Mali (IGME) LICs (IGME) Fragile and conflict affected situations Sub-Saharan Africa (excluding high income) Neonatal deaths during the first 28 completed days of life in a given year 120 Neonatal Mortality Rate (per 1,000 live births) 100 80 60 40 20 0 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 Mali Low Income Fragile and conflict affected situations Sub-Saharan Africa (including high income) HFSA: Mali | Technical report 29 The World Bank Source: IGME (Gender Portal) Regarding the maternal mortality, it has reduced since 2000 but, in 2020, Mali’s ratio remains higher (562.0 per 100,000 live births) than the average among low-income countries (453.0 per 100,000 live births) (Figure 8). Maternal mortality in Mali is among the steepest compared to most of its peers, except for Afghanistan and Chad, which represents a higher risk associated with each pregnancy in Mali. This indicator is part of the sustainable development agenda (SDG 3.1.1) for monitoring maternal health. Thanks to efforts to reduce the number of women dying from pregnancy-related causes, the maternal mortality ratio has halved over a generation as it dropped from 1,010 per 100,000 live births in 1990 to 562.0 per 100,000 live births in 2017. The annual rate of reduction in maternal mortality is estimated at 2.3 in Mali, on average (Figure 8), which had been slower than in sub-Saharan Africa (2.8), among landlocked developing countries (3.9) or least developed countries (3.6) – whereas the greatest sub-regional rate of reduction was observed in Southern Asia (5.3) (61). Maternal mortality, monitored by the GFF among core reproductive, maternal, neonatal, child and adolescent health and nutritional care impact indicators, indicated a lower ratio at 325 per 100,000 live births based on survey data (DHS 2018) (19), which remains insufficient to meet the 2018 PRODESS target (230 per 100,000 live births). Mali’s indicator is also above the 2018 average of the GFF group of countries with low or moderate rates (297 per 100,000 live births). Figure 8: Maternal mortality ratio trend in Mali against benchmarks, 2000-2017 Number of women dying from pregnancy-related causes while pregnant or within 42 days of pregnancy termination 1000 900 Maternatl Mortality Ratio (per 100,000 live births) 800 700 600 500 400 300 200 100 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Mali Low income Fragile and conflict-affected situations Sub-Saharan Africa (excl. high income) Source: Gender data Portal The SDG indicator (Goal 3.1.1) for monitoring maternal health by 2030 has a target set at 70 per 100,000 live births, appearing very ambitious in light of current Mali’s progress. Progressive HFSA: Mali | Technical report 30 The World Bank objectives toward the 2030 target must be found in Mali. Reproductive health is a product of Mali’s reproductive system and its functions, processes and financing. Means of achieving improved reproductive health include the delivery of quality services during pregnancy and childbirth, safe and effective contraception, and prevention and treatment of sexually transmitted diseases. It should be highlighted that complications of pregnancy and childbirth are the leading cause of death and disability among women of reproductive age in developing countries. Hence, to end preventable maternal mortality by 2030 in Mali, a more realistic goal for Mali would be to reduce its rate to below 140 deaths per 100,000 live births, equivalent to twice the initial target. This reaffirms that efforts should not only be maintained but strengthened to fight maternal deaths in Mali. According to projected scenarios, the stillbirth rate, if maintaining the observed path, should reach 16.0 by 2030. The 2030 target of the ‘Every Newborn Action Plan (ENAP)’, that has been set at 12 stillbirths or fewer per 1,000 total births, could only be met in 2046 with no acceleration in the annual reduction rate. To meet this ENAP target, the required annual reduction rate for 2020- 2030 should transition from the projected 1.9% (maintaining current trend) to a required reduction rate of 4.5% (based on desirable progress). 3.2 Service coverage for health 3.2.1 Access to essential health services Despite recognized successes, there is a sense that the health supply has not yet fulfilled its potential in terms of service coverage in Mali. Service coverage has improved in Mali, increasing from 21.2 in 2000 to 41.5 in 2019, doing as well as half of the low-income countries (Figure 9). Mali also lags behind the average level reached by its comparators and most of its peers, disposing Mali’s achievements below the general trend when compared globally across income level. On average, Mali’s UHC index was estimated at 39.6 between 2015 and 2019, placing the country in a median position compared to low-income countries also estimated at 39.6 (Min/Max range: 26.1–58.2). In other words, it can be said that half of the low-income countries have reached higher service coverage for health than Mali. HFSA: Mali | Technical report 31 The World Bank Figure 9: Trend in service coverage for essential health care services (UHC index) in Mali, benchmarked globally, 2000-2019 Comparative trends in progress made between 2000 and 2019 Overall service coverage (UHC index) 80 70 60 Service coverage (scale 0-100) 50 39.4 41.5 40 36.2 37.8 30 21.2 20 10 0 2000 2010 2015 2017 2019 Mali LICs Avg score LICs Median LICs Lowest score LICs Highest score Latest achievement against selected comparators Latest achievement across income level Essential care (UHC), 2019 100 90 Service coverage (UHC index, scale 0 to 100) HICS (OECD) HICS (non OECD) 80 Uzbekistan 70 UZB Tajikistan TJK LoMICs 60 Zimbabwe RWA ZWE Rwanda 50 UGA SEN Uganda NGA Service coverage BFA 40 (scale 0 - 100) Senegal AFG Mali Peers (sample) 30 SSA region TCD Nigeria 20 LICs 10 Burkina Faso Mali 0 Low Income Lower Middle Income Upper Middle Income High Income Congo, Dem. Rep. 280 600 2,030 4,410 10,390 16,500 30,330 53,010 117,740 Niger GNI per capita, Atlas method (current US$) Afghanistan X axis Source. WHO expressed isGlobal in log Health Expenditure Database, 2019. scale. Axis X: Income (GNI per capita, Chad Axis X is expressed on a log scale. Focus country is compared to study sample (dark blue) and sub-Saharan countries (light blue). US$); Axis Y: Service coverage (UHC index, scale 1-100) 0 20 40 60 80 100 Source: UHC service coverage index (Global monitoring report) Mali’s achievements for UHC are halfway to the 2030 sustainable development goal (Target 3.8.) set at 80, which is equivalent to the current highest score achieved in Europe and Northern America (81) (62). This reflects the extend of additional efforts needed in Mali on fourteen tracer indicators of essential health services defining the average coverage of essential services. These can be further improved acting on the tracer interventions for reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access among the general and the most disadvantaged populations. Focusing on PHC-relevant services, the National Immunization Program has significant deficiencies in service delivery. In 2018, WHO assessed the maturity of immunization programs HFSA: Mali | Technical report 32 The World Bank across Africa to highlight additional efforts required to achieve robust immunization systems all over the continent. Based on this WHO assessment, Mali’s national immunization program was characterized as having persistent deficiencies in multiple areas, attributed to the weak national health system and the intermediary capabilities on immunization service delivery (63). Recently, other findings have shown how public health emergencies can threaten an already disrupted national immunization program by maintaining suboptimal immunization coverage rates (64). Since the pandemic, the continuity of essential care services is even more challenged, increasing the risk of halting the progress made in coverage expansion in Mali. If Mali had reached a 2.7% average percentage change rate in the past (1990-2010), it significantly decreased to 1.5% during the following decades (2010-2019). Benchmarked to global progress made since the 2000s, Mali showed lagging progress in expanding service coverage for essential care (Figure 10). Globally there is growing concern around financial protection for health even in countries that have significantly improved service coverage (2). Distance to access health and primary care services, resource mobilization for health, quality of care and the purchasing power of the population continue to challenge UHC performance (8). Factors linked to the population environment and health financing are key to maintaining progress towards UHC. Aware of this situation, the Government has fostered multiple initiatives, as part of the PDDS, to improve the quality of care and the use of health services and to facilitate, in particular, financial access to care. Figure 10: Service coverage (UHC index) trend and performance in Mali benchmarked internationally, 2000- 2019 Trend in convergence rates between 2000 and 2019 Latest achievement (2019) across income level 100 90 Service coverage (UHC index, scale 0 to 100) 80 70 UZB TJK 60 ZWE RWA 50 UGA SEN NGA BFA 40 AFG Mali 30 TCD 20 10 Low Income Lower Middle Upper Middle High Income 0 Income Income 280 600 2,030 4,410 10,390 16,500 30,330 53,010 117,740 GNI per capita, Atlas method (current US$) Source. WHO Global Health Expenditure Database, 2019. Axis X is expressed on a log scale. Focus country is compared to study sample (dark blue) and sub-Saharan countries (light blue). Axis X is expressed in log scale. Axis X: Income (GNI per capita, US$); Axis Y: Service coverage for health (UHX index, scale 1-100). Focus country is benchmarked against peers (dark blue) and SSA (light blue). Source: UHC service coverage index (Global monitoring report) In Mali, major advances were made in the fight against infectious diseases despite capacity and access slowing down progress in improving service coverage. Noticeable improvements in service coverage were made between 2005 and 2010 on infectious diseases, whereas Mali shows lagging HFSA: Mali | Technical report 33 The World Bank performance on other effective coverage indicators. From a global perspective, low overall UHC effective coverage index performance (i.e., <40) often leads to low performance across most effective coverage indicators, except in very specific areas such as vaccine coverage or diarrhea treatment (65). Scoring below 20 for service coverage categorizes the country into the group having the lowest performing health systems. It therefore categorized Mali among the lowest performers for capacity and access index (16.2 in 2019), despite Mali evolving as expected compared to the general trendline. With respect to non-communicable diseases, service coverage has tended to stagnate over time, although it is the sub-component holding the highest level of performance. Maternal, newborn, and child health also improved over time but less than expected compared to general trends, and apparently the Malian health system is not keeping pace with the increasing burden. Figure 11: Trends in service coverage across type of health service in Mali and related benchmarked achievements against peers and global averages, 2000-2019 Trends of the four sub- categories of the UHC service coverage index Mali 80 70 60 Service coverage (scale 0-100) 50 40 30 20 10 0 2000 2005 2010 2015 2017 2019 Service capacity and access Reproductive, maternal, newborn and child health (RMNCH) Noncommunicable diseases (NCDs) Infectious diseases (IDs) HFSA: Mali | Technical report 34 The World Bank Capacity and access Reproductive health Service capacity and access, 2019 Reproductive, maternal, newborn and child health (RMNCH), 2019 HICS (OECD) HICS (OECD) Tajikistan Uzbekistan Uzbekistan HICS (non OECD) HICS (non OECD) Zimbabwe LoMICs Tajikistan Zimbabwe LoMICs Peers (sample) Uganda Nigeria Rwanda Service coverage Service coverage (scale 0 - 100) (scale 0 - 100) Rwanda Senegal SSA region Burkina Faso Uganda SSA region LICs Peers (sample) Afghanistan Niger Senegal LICs Congo, Dem. Rep. Mali Burkina Faso Nigeria Mali Afghanistan Niger Congo, Dem. Rep. Chad Chad 0 20 40 60 80 100 0 20 40 60 80 100 Infectious diseases Noncommunicable diseases Infectious diseases Noncommunicable diseases (IDs), 2019 (NCDs), 2019 HICS (OECD) Uganda HICS (non OECD) Rwanda Tajikistan Burkina Faso Uzbekistan Mali Senegal Congo, Dem. Rep. Rwanda Nigeria LoMICs Chad Mali Service coverage LICs (scale 0 - 100) Service coverage Zimbabwe (scale 0 - 100) SSA region Peers (sample) Uganda Peers (sample) SSA region Niger Burkina Faso Senegal LICs Zimbabwe Congo, Dem. Rep. HICS (OECD) Niger LoMICs Nigeria Afghanistan Afghanistan HICS (non OECD) Chad Uzbekistan Tajikistan 0 20 40 60 80 100 0 20 40 60 80 100 Source: UHC service coverage index (Global monitoring report) Other indicators of Mali’s achievements in reproductive health suggest that it has resisted recent shocks well, although with uneven results. Several key indicators of reproductive health have evolved favorably (10). But continuity of care remains insufficient, especially regarding antenatal care for which the rate of four antenatal consultations (recommended) was estimated at 24.4% in 2020 against 27.6% in 2021. There is however greater awareness of the need to improve healthcare use in reproductive health. As for basic emergency obstetric and neonatal care (SONUB), the achievements fell slightly, from 669 structures offering SONUB services in 2020 to 619 in 2021. This slight drop was explained by the mobility of personnel trained in SONUB, but also the lack of SONUB equipment in some health structures. HFSA: Mali | Technical report 35 The World Bank 3.2.2 Access to primary healthcare services In Mali, half of the population with health needs did not resort to outpatient care, with a higher burden in some regions and socio-economic groups. According to survey data (EHCVM 2018), nearly a third (29.7%) of Malians needed outpatient services for an illness or injury, as reported over the recall period prior to the survey. Across regions, this proportion varied between 21% to 37%, with four regions (Mopti, Tombouctou, Bamako and Koulikoro) reporting proportions below the national average (29.7%). Across the different wealth-related quintiles of the population, more than one in five of the 20% poorest had reported health needs, against about one in three of the 20% wealthier. A result confirmed by the literature, wealthier individuals tend to report more injuries or illnesses than poorer ones, which is not necessarily due to a larger exposure to health shocks for the wealthiest and rather reflects a possible reporting bias (66). For all, about half of the reported health needs were incapacitating (meaning that individuals were not able to conduct their normal daily activities due to health needs), with a stable proportion across the wealth quintiles and most regions (i.e., except for the Taoudenit region where the proportion fell below 10%). Forgone care was spotted for half of the Malians who reported health needs (50.9%), leaving six regions behind with a higher coverage gap due to unmet needs than the national average (Min/Max for regions: 39–59%). Overall, the share of the 20% poorest Malians reporting health needs without following-up with outpatient service contact was larger (over half, estimated at 59%) than the national average and above the level of the 20% wealthier (41%). Underuse of healthcare services is linked to self-medication behaviors and financial barriers to accessing care, while distance was only reported as an issue by less than 1% of Malians. The primary reason for forgone outpatient care was attributed to self-medication by individuals with health needs, possibly caused by the financial trade-off and/or distance to care. Such behavior was found to be consistent across all wealth-related groups and regions, except in Gao and Tombouctou. Financial barriers mattered regardless of wealth or regional affiliations and was the primary reason for forgone outpatient care in Gao. The third reason reported was the distance, but this did not seem to constitute an important factor driving forgone care, except in three regions where it affected above 5% and up to 20% of the population (mostly Taoudenit and Ménaka but also Kidal) against below 1% elsewhere. For those seeking care in the formal healthcare sector, the majority resorted to public sector providers. Private sector use was closely associated with wealthier socio-economic status (Wealthiest–poorest gap: 20.0%–2.2%). Only 14.2% of Malians using outpatient services reported service satisfaction (Wealthiest–poorest gap: 21%– 9%%), with a consistently higher level of satisfaction for care sought within the public sector than the private sector for all socio-economic groups. The primary issue put forward by care users in terms of service satisfaction was the high cost at the point-of-service, reported for all socioeconomic groups and in six regions (especially Gao and Koulikoro). Long waiting times were also reported and constituted the second most cited reason for all groups, although mostly put forward by the better offs. In two regions (Ménaka and Kidal), drug stockouts were the most cited reasons for service use dissatisfaction. The population- based survey (2019 EMOP) further reported the pattern of care use by the poor (42). HFSA: Mali | Technical report 36 The World Bank Monitoring the performance of the PHC system in Mali will be essential to catalyze efforts and accelerate progress towards effective UHC. Recent literature highlighted the crucial need to prioritize research efforts and reverse current lacking or fragmented evidence on PHC in LMICs (67). Future rigorous measurement of the PHC system should help Mali to catalyze the necessary improvements while strengthening its national commitment around PHC. 3.2.3 Other basic amenities The supply of drinking water and hygiene and environmental sanitation needs additional effort in Mali. According to the results of the Permanent Modular Household Survey (EMOP 2020), 85.2% of Malian households have access to drinking water, and 92.5% use latrines. The Mali humanitarian response plan developed for 2020 (National Response Plan 2020) estimated that approximately 2.3 million people had unmet needs for drinking water, hygiene and sanitation. In view of the results obtained, the ambitious national goal of reaching 100% coverage by 2030, which was set by Mali’s Strategy for Accelerating Growth and Sustainable Development, is far from being achieved, as it is for the objectives set in terms of access to drinking water through the SDGs. Exacerbated by food insecurity, inadequate access to health services and water, hygiene and sanitation (WaSH), malnutrition remains a major public health concern for Mali’s authorities. According to a national survey, the rate of global acute malnutrition was estimated at 10.0% in 2021 (against 10.7% in 2016, according to a prior survey), and that of severe acute malnutrition was about 1.8% in 2021 (against 2.6% in 2016) (16). Disparities across regions persist in malnutrition, with observed values at both extremes for the rates of global acute malnutrition and severe acute malnutrition in Sikasso (respectively at 6.1% and 0.6% in 2021) compared to Ménaka respectively at (17.9% and 3.9% in 2021). The malnutrition rates in Mali remain above the emergency threshold set by WHO (greater than or equal to 10% for global acute malnutrition and greater than or equal to 2% for severe acute malnutrition) (16). 3.3 Disease burden Limited or low quality of care in LMICs has been found to be an important driver of amenable mortality across conditions. Poor quality of care amongst those who accessed care remains a main factor in global mortality that spanned many conditions including cardiovascular disease, vaccine preventable diseases, neonatal conditions, road injuries, maternal mortality, tuberculosis (TB), HIV- AIDS, and other infectious diseases. For instance, cardiovascular diseases (84%), vaccine preventable diseases (VPDs) (81%) and neonatal conditions (61%) are attributable to low quality care; so are half of the deaths from maternal causes, road injury, tuberculosis, HIV-AIDS, and other infectious diseases (68). Averting deaths from cancer, congenital defects, mental health, and chronic respiratory conditions will require additional and substantial increases in the quality of service and usage rates. The following paragraph can provide some insights about potential policy directions for Mali’s health decision-makers. Communicable, maternal, neonatal and nutritional diseases remain in the top five threats since 2019, causing major death and disability in Mali. In terms of the number of Years of Life Lost (YLLs) HFSA: Mali | Technical report 37 The World Bank due to premature death in Mali, neonatal disorders, malaria, lower respiratory infections, protein- energy malnutrition and diarrheal diseases were the highest-ranking causes in 2009, all confirmed in 2019. Air pollution and sanitation (WaSH), and malnutrition (childhood underweight) remains the primary risk factor driving death and disability in Mali since 2009. Mali stands among the countries with the largest disease burden, totaling about 54,936 disability adjusted life years (DALYs) per 100,000 population lost in 2019. This is higher than the average for low-income countries (46,887 per 100,000 population) (Table 3). The top 20 causes of disability- adjusted life years represent 80% of the total burden in the country. In Mali, communicable, maternal, perinatal and nutritional conditions cause almost three quarters (73%) of the overall burden, and half of the total burden is due to neonatal conditions, lower respiratory infections, malaria and diarrheal diseases. Non-communicable diseases represent a rising concern in Mali. Causes are presented against major causes in low-income countries. Regarding trend over the past 10 years for death causes in Mali, stroke (27.4% increase over 2009- 2019), ischemic heart diseases (32.6% increase over 2009-2019) and congenital defects (29.2% increase over 2009-2019) substantially increased and all three indicators ranked in the top 10 classification of the most important causes. Along with behavioral risk linked to malnutrition (14.1% increase over 2009-2019), two environmental and occupational risks linked to air pollution (11.7% increase over 2009-2019) and WaSH (17.4% decrease over 2009-2019) remained in the top three risks factors driving death in Mali since 2009. Metabolic risks like blood pressure or high-body mass index increased respectively by 35.5% and 57.2% over 2009-2019. Table 3: Top 20 causes of disability-adjusted life years (DALYs) in Mali, benchmarked to low-income average, 2019 Mali Low-income Rank Cause Share of total Cumulative DALYs per 100,000 Rank Cause Share of total Cumulative DALYs per 100,000 DALYs (%) % population DALYs (%) % population 0 All Causes 100.0 54,936 0 All Causes 100.0 46,587 1 Neonatal conditions 19.6 19.6 10,749 1 Neonatal conditions 15.5 15.5 7,222 2 Lower respiratory infections 10.8 30.4 5,922 2 Lower respiratory infections 8.4 23.9 3,918 3 Malaria 9.5 39.9 5,220 3 Diarrhoeal diseases 5.8 29.7 2,679 4 Diarrhoeal diseases 8.6 48.5 4,701 4 Malaria 5.1 34.8 2,393 5 Protein-energy malnutrition 4.0 52.5 2,218 5 Road injury 3.7 38.5 1,724 6 HIV/AIDS 3.4 55.9 1,887 6 HIV/AIDS 3.2 41.7 1,513 7 Congenital anomalies 3.3 59.2 1,813 7 Congenital anomalies 3.2 44.9 1,473 8 Meningitis 3.2 62.4 1,738 8 Tuberculosis 3.1 48.0 1,440 9 Road injury 2.8 65.2 1,564 9 Ischaemic heart disease 3.0 51.0 1,382 10 Iron-deficiency anaemia 2.3 67.5 1,243 10 Stroke 2.9 53.9 1,364 11 Stroke 1.7 69.2 959 11 Measles 2.8 56.7 1,322 12 Maternal conditions 1.6 70.8 904 12 Meningitis 1.8 58.5 836 13 Interpersonal violence 1.3 72.1 702 13 Protein-energy malnutrition 1.5 60.0 681 14 Measles 1.3 73.4 690 14 Collective violence and legal intervention 1.4 61.4 674 15 Ischaemic heart disease 1.2 74.6 686 15 Maternal conditions 1.4 62.8 648 16 Sickle cell disorders and trait 1.2 75.8 669 16 Depressive disorders 1.4 64.2 631 17 Cirrhosis of the liver 1.0 76.8 543 17 Cirrhosis of the liver 1.3 65.5 597 18 Kidney diseases 0.9 77.7 479 18 Diabetes mellitus 1.3 66.8 595 19 Tuberculosis 0.9 78.6 470 19 Iron-deficiency anaemia 1.2 68.0 566 20 Diabetes mellitus 0.8 79.4 462 20 Interpersonal violence 1.2 69.2 549 Source: WHO-GHO and author’s calculation for percentages HFSA: Mali | Technical report 38 The World Bank With respect to child mortality or causes of deaths, disparities across regions persist in Mali. At national level, the highest causes of death among children relate to neonatal conditions and prematurity. Despite progress made on reducing mortality rates, the pace of decline is too slow to meet the national PDDSS targets for 2023. On average, about 160,000 women and children under the age of 5 die every year. None of the 2018 PRODESS III targets were met. This poor performance was attributed, to a large extent, to the political and security contexts that the country has experienced since 2012 (7). Figure 12: Regional disparities in child mortality and major causes of death in Mali, 2018 Child mortality rates across region Causes of U5 mortality across region 160 100% 140 120 80% Child mortality rates 100 60% 80 40% 60 20% 40 20 0% Tombouctou Mopti Taoudenit Menaka Koulikoro Segou Sikasso Kayes Mali Kidal Bamako Gao 0 Tombouctou Mopti Taoudenit Menaka Koulikoro Segou Sikasso Kayes Mali Kidal Bamako Gao Causes of U5MR: Neonatal Causes of U5MR: Others Causes of U5MR: Pertussis Neonatal mortality rate (NNMR) Causes of U5MR: Meningitis Infant Mortality Rate (IMR) Causes of U5MR: Injuries Under-five mortality rate (U5MR) Causes of U5MR: AIDS Causes of U5MR: pneumonia Causes of U5MR: Measles Causes of U5MR: Malaria Causes of U5MR: Diarrhoea Source: IHME Local Burden of Disease Data (2017) HFSA: Mali | Technical report 39 The World Bank 4 Health system inputs 4.1 Human resources for health 4.1.1 Policy goals and orientations Strengthening health workforce (HWF) capacities in line with the national strategy to improve quality care and services was elevated as an overarching priority for MOH and its partners. According to the planned targets (PRODESS IV), Mali set its national target at 7 health professionals per 10,000 inhabitants by 2023. To achieve this objective, Mali would have to recruit 14,917 health professionals according to national calculations (from the Mali/DRH-SS DS), since the 2021 ratio was estimated at 5 health professionals per 10,000 inhabitants in the latest health statistics yearbook released in February 2023. Complete and effective implementation of the ongoing health reform (PRODESS IV 2019-2023) would have been crucial to meet its national goals. HWF is key to establishing greater productivity and well-being nationwide and, at community level, to contribute to improved access to quality PHC and reduced maternal and infant mortality. The operational plan (PRODESS IV) reminds us that a national strategy for human resources has long been adopted by GOM (2009). Mali still struggles at: (i) providing competent and quality resources, available at all levels of the health system, with a specific focus on vulnerable groups living in poor and ‘difficult’ areas, (ii) developing performance among human resources for health with the intention to obtain higher productivity and better-quality work within the missions already assigned. Under HRH 2030’s national program for 2018-2020 designed to strengthen HRH management, Mali hoped to accelerate the path towards improved quality of service delivery throughout the health system. GOM received external support and used technical assistance (notably with USAID) for the implementation of the HRH 2030. Aims were threefold: 1) tackling ‘unfinished business’, from prior commitments such as well-defined supervision patterns and qualitative coaching processes; 2) reinforcing normative documents to support regional- and district-level managers and; 3) increasing the use of evidence in HR decision-making (69). Moreover, greater effectiveness and efficiency of maternal, neonatal, child and adolescent health and nutritional care and family planning services were sought, as well as the strengthening of health providers’ training – at all levels of the health system, and both the strengthening and the application of HR policies, guidelines, and good practices. In a broad collaborative approach (involving other ministries, regional powers, and community-level associations), the HRH2030 technical team delivered a community development plan targeting a sub-set of five regions (Bamako excluded). HFSA: Mali | Technical report 40 The World Bank 4.1.2 Health workforce needs and coverage Functioning with health workforce shortages imposes many constraints on Mali’s health system, including limited access to care and poor service quality– despite long being recognized and increasingly monitored. It is critical for Mali to reduce the shortage as the low density of health workers (doctors, nurses and midwives) in Africa was proven to be strongly and positively correlated with maternal, child and infant mortality (70). Over the years, the lack of qualified health workers has undermined the PHC system, creating instability and uneven distribution. These weaknesses have compromised Mali’s ability to guarantee minimum standards of quality care. Assessing PHC financing and determining how it can leverage Mali’s health workforce is therefore highly needed. Recent findings from a scoping review highlighted the need to better understand the potential of hybrid PHC financing while already showing some benefits induced by financing choices (67). In March 2019, a ‘Monitoring System for Essential Health Resources and Service Availability (HeRAMS)’ was launched in Mali, resulting in the publication of a resource map of HRH (released in January 2021 based on 2,399 surveyed health facilities) (71). The study showed that failures to meet essential needs encompassed issues of fast-growing populations and urbanization. Health decision-makers seem unanimous in recognizing that Mali’s health workforce represents the backbone of its national health system, but Mali’s potential in this regard is under-realized. The shortages of skilled and motivated health workers have been recognized as severely undermining Mali’s health system (72). In the past, between 2009 and 2014, Mali’s qualified health workforce (doctors, nurses and midwives) increased by more than 25%. But despite existing efforts to recruit additional staff (civil service, collectivity, community), the availability of qualified health workers remains critical to building the health system blocks. They remain insufficient to cover the workload, needs and specificities of the health sector. Since 2015, both national and regional directorates have used specific tools for the management of human resources13, which augurs enhanced planning and operations using needs-based health workforce data. It should also contribute to taking into account priority areas for their deployment. However, the existing assets and systems are insufficiently exploited or not up-to-date, including the organic frameworks (“cadres organiques”) intended to rationalize assignment decisions. Past and current density requirements for a skilled health workforce are not met in Mali, whose health workforce faces critical shortages according to WHO definitions. This critical shortage is not new, as WHO formerly defined shortages as health systems with fewer than 2.3 health workers per 1,000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. Mali’s density of skilled health workers is currently estimated at 0.57 per 1,000 people. This means that almost twenty years after being characterized in critical shortage in the 2006 WHR, the country continues to provide barely a quarter (26.1%) of the former threshold required for PHC revitalization. That latter threshold, although outdated, is still often taken as a key reference by health decision-makers. In 2016, the WHO norm was elevated to 4.45 per 1,000 population, which 13 SI-GRH ‘Système d’Information – Gestion des Ressources Humaines’ HFSA: Mali | Technical report 41 The World Bank is aspirational for Mali. The rationale for this updated norm is found by broadening the scope to reflect on twelve SDGs-related indicators, instead of five indicators used in the prior WHO definition. Several alternative thresholds challenge Mali’s target to tackle the critical health workforce shortage and reaffirm the urgent need to be translated into progressive goals towards UHC. The ILO for social norms has been set at 4.1 per 1,000 population to comply with the social protection threshold norm (2015) that was developed as an alternative method for vulnerable countries. The ILO norm has been recognized and cited by WHO (2016). In addition, other more ambitious thresholds exist. For instance, the value of 5.9 was advanced as the workforce requirement for the Ending Preventable Maternal Deaths initiative, which entails reducing global maternal deaths to 50 per 100,000 live births by 2035. As a result, if Mali aims to advance the health-related SDGs, the country must shift its paradigm for HRH and reflect the broader range of services that should be targeted by 2030. Mali’s health system is among the lowest staffed, which enables greater advocacy for increased investments in health workers. Mali’s skilled health worker density (0.57) lags behind averages for LICs (0.86) and is almost three times lower than the average level attained in sub-Saharan Africa (1.52) (Figure 13). Shortages in doctors, nurses and midwives constitute persisting bottlenecks preventing effective delivery of good-quality health services in Mali, as they do for several other peers. In 2015 it was found that a small proportion of the CSCOMs were staffed with at least ‘one midwife or one doctor’ (1). More generally, it is interesting to recall that most European countries function with a health workforce employed in the sector of human health and social activities constituting between 2.5% and 5.5% of the general population, which suggests that WHO European region health systems are considerably better staffed (73). On the other hand, countries like Mali deal with a much lower percentage of the population employed in human health and social activities, which falls as low as 1% for most African countries and low-income countries, and 0.07% in Burundi which appears to be functioning with the lowest staffing levels in the world. Mali however counts other categories of PHC workers, whose stock matters and should be better monitored. Authorities agree that, to enable progressive achievements in UHC and PHC, the health workforce should be substantially strengthened in Mali. Reaching a level of coverage at 70% of the UHC targets in the Africa region would require a progression of the staff density up to 13.4 health workers per 1,000 population (comprising 13 categories of health staff but excluding health managers and support staff) whereas the average for the region was estimated at 2.9 in 2018 (70). The latter was based on a smaller sample that did not comprise Mali and may not be fully representative of the whole Africa region. The requirement threshold for Africa was projected at 10.9 health workers when excluding the community health workers category. Disaggregated data for health workforce densities by occupation is available at the regional level; these can be used to benchmark Mali’s progression towards a desirable 70% coverage level of UHC. At the regional level for Africa, in 2018, the density per 1,000 population averaged 0.43 for administrative and support staff and additionally 0.40 for other technicians and health executives (70). Similarly in Africa, lab technicians averaged a density of 0.35 per 1,000 population. Pharmacists and assimilated staff averaged a density of 0.09 per 1,000 population. Other types of occupation HFSA: Mali | Technical report 42 The World Bank like dentists and technicians or environmental and public health staff are much less represented, averaging respectively densities per 1,000 population of 0.05 and 0.04. Figure 13: Density of skilled health workers in Mali, benchmarked to SSA countries and norms, 2020 year or latest available Divergence across sub-Saharan Africa Source: GHO (December 2022) In Mali, community health may be particularly highly staffed in appearance, but its data is poorly reported in global data repositories. According to the latest WHO inventory for Africa, the density of Mali’s community health workforce of 0.6 per 100,000 population is highly inferior to the regional average for Africa (4.57) (70). According to an alternative data source from the Community Health Roadmap, Mali’s community health workforce could increase to an estimated density of 1.37 including the so-called community health workers (Rcoms: Relais communautaires) and 1.0 for other community workers (cadres communautaires), which are much higher estimates than those reported to WHO. Extending preventive, promotive, and curative health services into communities is recognized as being a critical aspect of ensuring access to high-quality PHC. In 2015, with the implementation of the then new ‘SEC’ strategic plan, Mali intended to scale up the stock of community health workers deployed in the country to 5,000 by 2020. Community health additional workforces are therefore numerous in Mali, compared to other countries. In spite of this, they certainly represent forward-looking standards to be considered in future decision-making in Mali and across Africa. 4.1.3 Health workforce skill-mix Mali’s skill-mix ratio of nurse/midwife to doctor is comparatively low against benchmarks and the regional average. In Mali, the health system has about 2.9 nurses or midwives for 1 doctor, which ranks the country among the systems with the lowest ratio of nurse/midwife to doctor. At the regional level for Africa, this ratio averaged 3.9 (70). The ratio varies greatly across countries, HFSA: Mali | Technical report 43 The World Bank with Zimbabwe (13.6), Burkina Faso (10.4), Rwanda (8.0), Chad (6) or Niger (4.2) showing the highest values; and Uganda (1.4) with one of the lowest ratios. Similarly, Mali’s skill-mix ratio of community health worker to nurse/midwife is comparatively low against benchmarks and the regional average. In Mali, the health system has about 0.14 community health workers for 1 nurse (or midwife), but the WHO estimate for Mali under- estimates this workforce, as evoked previously (70). The average for Africa is estimated at a ratio of 0.37, above Mali’s ratio if accurate. According to WHO, Mali’s community health would therefore rank among the systems with lowest ratio of community health workers to nurse/midwife. Mali's share of health managers as a percent of the total health workforce is the lowest in Africa, highlighting a distinctive skill mix in Mali. Regarding the percentage of health managers as a proportion of total health workers, Mali’s estimate of 0.09% is the lowest in Africa, according to WHO estimates (70). In relative terms, its workforce is ten times lower than the regional average for Africa (0.86%). Mali’s percentage is also below Zimbabwe (0.65%) and Malawi (0.76%) percentages that, like Mali, are also below the regional average (70). 4.1.4 Health workforce production Mali has opted for the harmonization of training between the public and private sectors and for authorization to train students in paramedical fields (74). The country has implemented the harmonized curriculum of the West African Health Organization (WAHO) (74) and trains its HRH across 85 health training institutions. Mali’s public training for HRH comprises five public institutes for health sciences and three faculties (medicine, odonto-stomato and pharmacy) (75). The public system is based on a single selection of candidates through a national entrance examination for public schools (74). The liberalization of HRH training has been achieved through the opening of private training sites, about 77 private schools and 2 faculties (medicine and pharmacy). In practice, the private sector training structures, especially for paramedics, have grown without strong planning and to the detriment of the quality of training (74). The quality monitoring of training in Mali is however framed by a strategy of health worker supervision. The training of doctors, pharmacists and odonto-stomatologists is provided by the faculties of medicine and odonto- stomatology and the faculties of pharmacy. As for paramedics, they are trained in public and private schools or institutes, the number of which is around one hundred, with a large number of establishments that had opening permits in 2016 (75). The level of production of health personnel training institutions is perceived as relatively high by MOH (Human Resources directorate) but may not be sufficient to cover the gap. Domestically trained health staff are mainly nurses and midwives. Between 2010 and 2015, a total of 3,954 senior health technicians (such as midwives and nurses), 3,652 health technicians (such as public health and maternal health nurses) and 462 medical assistants (mainly in anesthesia, operating room and public health) were trained in Mali, which are part of the paramedical staff (75). If we compare those headcounts to the earlier mentioned gap of 14,917 health personnel needed to meet the PRODESS IV target, Mali’s production may appear largely insufficient. Among the 12 teaching streams for senior health technician training in Mali, 82.7% are trained as state midwives and nurses and 8.8% in medical biology, with areas such as mental health, medical imaging or ENT and HFSA: Mali | Technical report 44 The World Bank ophthalmology less popular. With regard to health technicians, the two main sectors are public health nurses (55.7%) and the other mother and child health nurses (40.9%). The basic salaries of health personnel are fixed by the general statutes of civil servants of the State and the CTs. The method of fixing the basic salaries of health personnel falls within the general framework of the administration defined by Law No. 02-053 of December 16, 2002 on the general status of civil servants. In general, the salary is not indexed. For example, the gross salary of a category B1 nurse is XOF 127,800 at the start of a career and that of a medical specialist is XOF 288,800. Mali also implemented incentive-based mechanisms, job openings by direct competition and student grants for a better distribution of HRH in remote areas (74). 4.1.5 Health workers stock across occupation type Although still limited, Mali’s health worker stock has improved over time, reaching minimum requirements for some occupations. The largest increase over 2014-2018 was observed among midwives with increases of 92.8%, followed by doctors (75.8%) (76). The WHO norm set at one doctor per 10,000 inhabitants was passed during the period from 2014 to 2018 as, on average, Mali’s health workforce supplied one doctor per 7,967 inhabitants in 2018, against one per 12,372 inhabitants in 2014. Similarly, Mali’s health workforce supplied one nurse for about 3,368 inhabitants in 2018, against one per 4,376 in 2014. This has also passed the WHO minimum supply requirement of 1 nurse per 5,000 inhabitants. In contrast, Mali’s health workforce only supplied one midwife for about 5,988 inhabitants in 2018, against 10,194 inhabitants in 2014. This means that the WHO minimum requirement of 1 midwife per 5,000 inhabitants is not quite, but almost reached at national level. Improvements in the national stock of health workers in Mali seem effective but remain challenged by Mali’s population growth. It is interesting to contrast Mali’s doctor and midwife supply against those in African countries, to show that Mali remains among the lowest resourced in Africa. A comparative study focusing on the lowest and highest resourced systems in Africa, with regard to human resources, classified the continent into five quintiles (77). When adjusted for population, the most under-resourced African countries had, on average, a doctor density of 0.39 and nurse density of 2.39 per 10,000 population. This bottom group of countries totaled 02.78 for both occupations, which is only 6% of WHO requirements (2016). In comparison, the wealthier resourced system in Africa (Quintile 1) had a doctor density of 11.84 and nurse density of 32.68 per 10,000 population, which at 44.52 met the minimum global threshold of 44.5. The uneven distribution of the health workforce creates sharp regional disparities, to the detriment of rural Mali compared to Bamako. Despite efforts to recruit staff and attract and retain staff in remote areas, qualified health personnel are concentrated in Bamako. Consequently, in the most underprivileged regions, many PHC centers (CSCOMs) do not have qualified staff (doctor, nurse) and are manned by health auxiliaries. Retention of the health workforce is a major challenge for political and administrative authorities at the highest level, with particular challenges in the Northern region because of several inherent difficulties (linked to geographical accessibility, climatic conditions, and lack of adequate infrastructure) (78). Moreover, some hospitals do not yet have all the specialists needed to provide quality care and services. Thus, the gaps in the distribution HFSA: Mali | Technical report 45 The World Bank of health personnel contribute to the reduction of equity of access to medical services in the country. The lack of health staff availability persisted in most regions: In 2014, Bamako and Kidal were the only regions to reach at least 1 doctor per 10,000 residents (according to PER). In 2018, half of the regions (5 out of the 11) met the bottom WHO threshold. However, there were stil a number of regions with substantial shortages of doctors and midwives, although the number of nurses appeared to provide adequate coverage for the population. Under-staffing in the health sector is not only problematic for the delivery of care, it is also a constraint directly affecting quality decision-making. Staff and capacity limitations at the National Statistics System’s data production and quality indirectly affect policy-making. Limited access to reliable and updated data is affecting the use of statistics for informed policy-making, monitoring, and research. According to prior work with a WB project (2017/P160977), inadequate HR quality was reported in all units within INSTAT, which is the body in charge of societal statistics. More precisely, fewer than 15% of staff were trained statisticians. INSTAT used to be unable to hire its own staff and the hired staff were not managed in a performance based manner or effectively trained to improve the needed capacity. Besides: “Even though the official remuneration scheme (negotiated through the “Accord d’Etablissement) is likely to attract and retain some of the best- skilled individuals, the presence of ample per diem opportunities for field work, training and report writing will continue to create a culture of favoritism and skews incentives towards large scale, low quality data collection operations as opposed to high quality, nimble data operations using administrative data.” Table 4: Health workforce status across occupation and regions in Mali, 2021 Health workforce occupation: (headcount) Staff density per 1,000 Population Region Doctor Midwife IO AM TSS/TS Total population Kayes 192 121 219 98 488 1.118 0,39 2.896.977 Koulikoro 255 210 286 110 584 1.445 0,41 3.519.001 Sikasso 226 213 232 158 673 1.502 0,39 3.840.785 Ségou 203 169 141 136 431 1.080 0,32 3.397.919 Mopti 128 91 113 70 375 777 0,26 2.959.002 Tombouctou 66 26 25 14 124 255 0,26 981.000 Gao 64 34 60 12 199 369 0,52 708.906 Kidal 19 24 13 2 68 126 1,28 98.433 Taoudénit 10 5 7 1 38 61 0,31 198.073 Menaka 10 4 7 10 85 116 1,47 79.130 Bamako 1.057 654 373 676 1.008 3.768 1,43 2.630.549 Sub-total, excluding Bamako 1.173 897 1.103 1.287 4.073 8.533 0,46 18.679.226 National (Public) 2.230 1.551 1.476 1.287 4.073 10.617 0,50 21.309.775 National (Private) 904 31 103 1.038 0,05 21.309.775 National (Total) 3.134 1.582 1.476 1.287 4.176 11.655 0,55 21.309.775 Source: Health yearbook (SNISS) 2021, and author’s calculations for density indicator 4.2 Healthcare infrastructure 4.2.1 Healthcare organization The MOH is a ministerial department whose responsibilities are set by decree. The agency responsible for health sector policy is the MOH, which is responsible for developing national health HFSA: Mali | Technical report 46 The World Bank policy, coordination, resource mobilization, budget planning, investment decisions, and research. It prepares and implements the national policy on health and public hygiene. As such, it is competent, among others, for: i) the extension of health coverage and the improvement of accessibility to health centers and institutions; ii) the reinforcement of the technical platform of health centers and establishments; iii) increasing the supply, improving the quality and reducing the cost of health care iv) the development and support of community health structures and the control of their management, the reinforcement of the autonomy and responsibility of hospital establishments; v) the development and control of the application of rules relating to the practice of medical, paramedical and pharmaceutical professions. Mali's health sector policy is built on a pyramidal structure that is administrated across a three- tiered pyramid of healthcare and community services broken down into four levels of care services. The system encompasses decentralized entities located at the regional level. The district of Bamako is part of the decentralized entities. They are responsible for the provision of technical support, coordination, and monitoring of the operational level. The Malian healthcare system is regulated by law (79). Public administration of healthcare delivery is as follows: i) a central administration, ii) a regional/intermediate level, and iii) district and operational levels. The national territory has the following administrative division, with the regions of Gao, Kayes, Kati, Kidal, Koulikoro, Mopti, Ségou, Sikasso, Timbuktu, and Bamako (Figure 14). - At the top of the pyramid, the central administration is responsible for the definition of the strategic orientations, determination of the investments and the functioning of the health system as well as financial resource mobilization from public and external funds. It also defines criteria for efficiency, equity and sustainability. It ensures the application of norms and standards. Also at the top of the pyramid, the central tertiary referral level (third-line service delivery) consists of five national hospitals and six public scientific and technical institutes. Service provision at this level deals with serious cases in need of specialized interventions or cases of clinical relapses. - At the bottom of the pyramid is the network of about 60 health districts, which are divided into catchment areas. These catchment areas are the principal administrative units spanning between 5,000 to 15,000 inhabitants within a 15-kilometer radius. Each catchment area has a frontline care provider, which is the community health center (CSCom – Centre de Santé Communautaire) (80). The national policy for PHC prominently features in prenatal care, disease prevention and health promotion for the entire population in general and the most vulnerable groups in particular. The operational level has 2 echelons. In addition to the CSCOMs, the cercle reference health centers (CSRefs – Centres de Santé de Référence) that make up the first referral level. Priority health needs are taken care of through a Minimum Package of Activities (PMA – Paquet Minimum d'Activités) by these 2 echelons, delivering curative, preventive, reproductive health, nutrition, hygiene, epidemiological surveillance and promotional activities. The CSREfs provide a technical platform to ensure the management of emergency surgical and gyneco-obstetric care such as caesareans as well as the management of cases of severe acute malnutrition with complications in the recovery and intensive nutritional educational units (URENI). HFSA: Mali | Technical report 47 The World Bank - In between, there is a second layer that is provided by a few second-line public hospitals (second referral level) located in the regions. This intermediate level mainly provides technical support to the operational level in relation to district-based executive teams (ECDs – Equipes Cadre de District). The private sector plays a particular role in Mali’s system as it has invested in areas that are traditionally reserved exclusively for the public sector, such as PHC, district hospitals and pharmacy management. According to the Mali Action Plan for 2030, the country is ideally placed to lead the way in public-private partnerships (PPPs) in the health sector. Mali’s authorities therefore call for supporting multisectoral efforts to engage constructively with the private sector. Figure 14: Architecture of the pyramid of healthcare delivery and administration in Mali Health System Stakeholders Type of Care sup ate ply sup blic v ply Pri n • Ministry Of Health and soial development, Pu tio national health directorate Na National • Other minsitries in charge of health Surgery care hospitals • FENASCOM (national) (3rd referral) & trauma medicine CHUs on • Regional health directorates (DRS) General and gi Regional hospitals • FERASCOM (regional) specialized medicine, Hospitals Clinics, Re (2 referral) nd • Steering committees surgery care polyclinics • Health district office (DHMT) District hospitals • FELASCOM (local) General medicine CSREFs Medical cabinets (CSREFs, 1st referral) (incl. c-sections) • Coordination committee for districts (ECDs) t tric D is Childbirth, PHC health centers • Health zones teams and ASACOs CSCOMs, Nursing cabinets, immunization, (CSComs, frontline care), • Community health associations (ASCs) nursing care Dispensaire Tradi-therapists community sites and associations • Village health (GSAN) & community relays Source: Author’s presentation 4.2.2 Healthcare delivery model and status Mali health system comprises several corporations that have developed in order to attempt to improve the national health system. Uniting several local associations, the FENASCOM (Fédération Nationale des Associations de Santé Communautaire) represents the union for the country, FERASCOM for the region and FELASCOM for the local level. As part of the implementation of the sectoral policy, the health system administration has a high degree of devolution. Each Commune is expected to create its health center (CSCOMs), which is created and managed by a Community Health Association (ASACO) (80,81). These state-and- community partnerships are private civil society entities and act as the main vehicles for community participation in health. The State-community partnership is supported by a mutual assistance agreement (CAM – Convention d’Assistance Mutuelle) between the MOH and the CSCOMs. It serves as a conduit for contingent subsidies from the State to the communities. It aims to cover the investment costs and part of the recurrent costs of community health centers, but also serves as an instrument for coordinating State interventions and community initiatives in health. Originally emerging as an urban phenomenon, the movement to create CSCOMs gradually spread to rural settings with specific challenges caused by both supply-side (low-attractivity of public HFSA: Mali | Technical report 48 The World Bank service) and demand-side (low-resource users). Starting with urban areas, Mali's public health authorities went on to adopt the CSCOMs’ model as the cornerstone of the national health policy. In rural areas, in general, community health remains difficult because it is primarily aimed at the poor. Another challenge is the lack of attraction for doctors in rural areas, particularly in comparison to the attractiveness of public or private clinics in urban areas or universities. In 2004, Mali adopted a plan to transfer health sector roles and responsibilities to the decentralized entities, setting up a MOH unit for Decentralization and De-concentration Support (i.e., the CADD – Cellule d'Appui de Décentralisation et Déconcentration). Before decentralization, the frontline care providers (CSCOMs) were private non-profit entities under the management of Community Health Associations (i.e., the ASACOs – Association Communautaires de Gestion des CSCOMs). These ASACOs worked directly with the MOH to set up a CSCom. Under the decentralization framework, local government replaced the MOH in partnering with ASACOs. Other local stakeholders such as the local federation for community health associations (FELASCOM - Fédération locale des associations de santé communautaire) accompany the ASACOs, local authorities and communal services in the management of community health. They encourage the different parties to sign the above cited CAM agreement by increasing awareness and capacity building. This CAM agreement aims to formalize and frame the collaboration between the mayor of the village (maire) and the president of the ASACO for matters related to health. Practice has shown that the agreement appears to be more of an administrative act than a real pact on health issues between two entities (82). FELASCOM also participates in the renewal of the ASACOs and advocates for the CSCOMs. Since 2012, Mali’s health system decentralization has been organized around 20 district-level administrations (4 new), including the district of Bamako, 64 cercles (‘Cercles’), and 703 communes (30). If the administrative division is effective, the decentralization process is still struggling to function, and four regions (Gao, Timbuktu, Taoudeni and Ménaka) are operating with interim authorities (9). The CTs14 have the mission of designing, programming and implementing economic, social and cultural development actions of regional or local interest. The districts of Bamako and Sikasso have been audited, and the results confirmed weak governance capacity at the district-level (83). These aspects are discussed further in the chapter on the use of public expenditure. The chief physicians of the CSRefs are pivotal in the process. They provide planning and technical management support to the CSCOMs on all points. They receive the operational programs and annual reports from the CSCOMs, which they process and forward to the central level for health management from the community level to the regional and national levels. They plan and supervise national immunization days (NIDs) and other health programs in the event of epidemics. They provide technical support to the CSCOMs for evacuations when necessary. They participate in the technical management of health agents in the CSCOMs. They train health workers and participate 14 Decree of 2002: “Décret no02-314/P-RM du 4 Juin 2002 – fixant les détails des compétences transférées de l’état aux collectivités territoriales des niveaux commune en matière de santé”; Loi consolidée relative aux ressources fiscales des CTS (Novembre 2019) HFSA: Mali | Technical report 49 The World Bank in the recruitment of the technical director. They supervise the CSCOMs and assist them in the event of epidemics. They donate materials (delivery tables, chairs, scissors, mattresses, beds, etc.). Mali has migrated to a digital health map for health facilities mapping, which should progressively include the coordinates of all health facilities across the entire territory. The digital data is based on the Integrated Digital Health Information System (SNISI), which is itself a group of several projects. Among the main projects, we have identified the following three entities: 1°) PNLP/MEASURE Evaluation: Monthly Malaria Routine in all centers in the regions of Ségou and Mopti as well as in the districts of Commune 4 and Commune 5 of Bamako; 2°) UNFPA: Community data recording (births, deaths, stocks) for reproductive health in two districts of Ségou and two districts of Koulikoro; and 3°) PNLC/SightSavers: Trichiasis trachoma surgery missions throughout the Koulikoro region. The country already had a historical map, produced and managed by the National Health Direction (DNS/CPS – Direction nationale de santé, Cellule de planification sectorielle). The digital map is intended to replace the historical health facility inventory, which had several limitations, including the impossibility of aggregating certain community-level data (at the village level) with health data. A new entity ANTIM was created in 2012 to replace the pre-existing paper-based system. However, to our knowledge, the most recent digital data (CNS – Carte sanitaire digitale) dates from 2017 and fails to cover the entire territory. CNS is calling on the community to complete the data15. As evoked previously, the public healthcare system (public and not-for-profit assimilated facilities) is based on a three-tier level of care delivery organized around four types of structures, which is fully described within the operational plan of the MOH (PRODESS IV). As at February 2019, the WHO spatial database of health facilities managed by the public sector in sub-Saharan Africa listed a total 1,478 structures providing public healthcare services in Mali. These structures are categorized across seven generic categories (clinic, community health center, hospital, polyclinic, referral health center, regional hospital and university hospital), each of these being listed with facility name, region, type of care and GPS coordinates. The main public supply comprised the 1,294 community health centers (88% of the total) and 94 clinics (6%). The country data breakdown of public supply for healthcare services is further described below, showing availability of service and functionality status across levels of care. ¨ According to the national information system (SNISS 2021), frontline care services are delivered through a total of 1,534 functional PHC centers (CSCOMs), of which 48 were newly created in 2021. Some villages in the health areas have rural maternity wards run by matrons. ¨ The first referral system is the second echelon of frontline care, (the CSrefs) comprising 65 functional structures in 2021 (SNISS 2021), often located in the administrative center of the regions. These structures act as first referral hospitals in their respective health districts. ¨ The second referral system is made up of 8 regional hospitals, of which 7 public hospitals (EPH – Établissements Publics Hospitaliers régionaux) located in the regions of Kayes, Kati, Sikasso, 15 https://ident.sante.gov.ml/map HFSA: Mali | Technical report 50 The World Bank Ségou, Mopti, Gao and Timbuktu; and the Luxembourg mother and child non-for-profit private hospital (recognized as being of public utility) in the Bamako district. ¨ The third referral system includes 6 structures, of which 4 public hospitals with a technical platform (CHU “Point G”, Gabriel Touré hospital, Hospital of Mali, Kati EPH – all already in activity in 2016) and 2 specialized hospitals (IOTA – Institut d'Ophtalmologie Tropicale d'Afrique; CNOS – Centre National d’Odonto-Stomatologie). The Kati EPH as the third level of referral is explained by the existence of the center of excellence for orthopedic traumatology. The supply also consists of army health services, consisting of medical stations, infirmaries, garrison maternity wards and hospital-infirmaries (PRODESS IV). Finally, in line with the African health development strategy, the health district is the operational unit for planning, corresponding in Mali to the cercles or Communes. In addition to the public supply, the private sector has been legally authorized since 1985, but its real size is hard to estimate. As of 2020, it may comprise about 850 health facilities, including 628 medical practices and 176 clinics and polyclinics - noting that clinics and polyclinics were assimilated to public facilities in the above cited WHO inventory. An inventory dating from 2017, which covered all types of establishments belonging to this private for-profit sector, evoked figures ranging from 22 to 1,679 structures depending on the data source (84). This confirms that there is indeed a private for-profit health sector in Mali, but also suggests that this sub-sector might be underestimated. Poor reporting of private structures to the public sector limits analysis and makes the estimation of its real size difficult to calculate, as well as making the appreciation of its interactions and its evolution particularly difficult. Two major types of structures make up the private for-profit sector, which are mostly concentrated in urban and peri-urban settings. According to the 2017 inventory, consultation and care surgeries (717 in number) and pharmacies (567) are the two most common types of private for-profit structures operating in Mali. The private for-profit sector exists in the form of sole or groups of owners. It collaborates with the State through the professional health orders (for doctors, midwives and pharmacists). Regarding pharmaceuticals, it includes pharmaceutical establishments in the form of pharmacies or private drug depots, establishments importing and wholesaling pharmaceutical products, establishments manufacturing pharmaceutical products and analysis laboratories (according to the 2015-2019 strategic plan for health information). The District of Bamako is the region which records the greatest concentration with 56.0% of the private sector, equivalent to 940 all-combined structures. It should be noted that all the medical analysis laboratories (14 in total) have been located in the District of Bamako. However, it should also be raised that many medical and surgical practices, clinics and polyclinics have their own laboratories – but only one pharmaceutical production company seems to have a business license. Next in volume, the Koulikoro region accounts for about 12.5% of the structures (210 structures) and is characterized by peri-urban settings. About 10.3% of the sector is situated in the region of Sikasso (173 structures), which is recognized as being economically the second most important region of the country. The regions of Taoudéni and Ménaka in northern Mali are almost devoid of private for- profit structures, only counting one depot for pharmaceutical products in Ménaka. HFSA: Mali | Technical report 51 The World Bank Mali’s private for-profit health sector is volatile, and poorly classified and/or tracked, missing opportunities for public-private relationships or partnerships. Despite its expansion, especially in large cities, the private for-profit sector is undergoing less controlled development and its data is insufficiently taken into account by the health information system, as reported in 2014 by the MOH (and highlighted in the 2015-2019 strategic plan for health information). The data inaccuracies seemed to stem in particular from the difficulty in classifying certain establishments and from high mobility within this sector. The above cited study (84) was able to show that, from one year to the next, a new facility could be created while another could be closed; and similarly, a structure classified as a pharmaceutical depot or a medical clinic in one database/source of information was considered a pharmacy or medical office in another database/source. Each entity providing data on this sub-sector was proven to use the information for its own purpose, without links or alignment with other data sources. The 2017 inventory study thus called for the creation of a consolidated database for this private sub-sector, which still does not exist or at least is not referenced in the various documents presenting the public sector. This for-profit private sector deserves to be further mapped, in particular because it constitutes an essential element for good planning and management of the public sector. Mali’s private non-profit system, which is assimilated to the public system, is managed at community-level, and regulated by public conventions. Firstly, the CSCOMs’ frontline care providers are run by the ASACOs’ community-level management associations, which are under the oversight of Commune governments. The ASACOs own the CSCOMs and manage the latter in direct collaboration with the CSCOMs’ technical head. The CSCOMs are therefore private non-profit entities, partially subsidized by the public authorities (76). They rely on cost recovery, implying contributions from the community (user fees) and a significant level of contributions from non- governmental organizations (NGOs), especially in rural areas. CSCOMs account for most of the direct contacts with patients, which can be estimated at about 0.43 contacts per person per year (2018). CSCOMs provide a basic service package (PMA – Paquet Minimun d’Activités), constituting the frontline care providers of PHC. They however operate alongside other health structures such as private clinics, polyclinics, medical laboratories, and pharmacies as well as traditional healers. These play the dual role of being a decentralized outpost of the MOH as well as a decentralized health service provider with oversight from cercle (county) governments. Secondly, regarding the regulation, ASACOs sign a mutual assistance agreement (CAMs – Conventions d’Assistance Mutuelle) with the municipal government at the commune level (76). The CAMs determine the package of services the CSCOM will offer and establish the mutual contractual responsibilities (both financial and technical) for health service provision between the commune and the ASACO. The frontline operational levels, in conjunction with local authorities, are responsible for the planning and management of the health budget at the local level. Local governments—at the Commune, cercle, and regional levels—are in charge of formulating policies for the creation and management of CSCOMs, maternity clinics, CSRéfs, and regional hospitals. Pilot CSCOMs with extended functions, such as innovative partnerships with universities co-exist in Mali. More generally, it also appears that, in practice, some CSCOMs have a more extended scope of activities, especially in the most rural settings. In addition, the University of Sherbrooke, through Canadian cooperation, has supported the development of CSCOMs-U. This collaboration is based on the idea of developing a pilot network of CSCSOMs with a university vocation. Those so-called HFSA: Mali | Technical report 52 The World Bank CSCOMs-U aim to carry out innovation within the framework of a project for training health professionals, currently involving five CSCOMs in four regions of the country – including a first one in Banconi since 199616. Health infrastructure data is monitored through annual Health yearbooks, notably showing the number of structures that have signed a convention with the CANAM National Health Insurance Fund. In 2021, 2,022 healthcare providers were under a convention with the CANAM, against 1,918 in 2020, according to SISo 2021 (also reported in SNISS 2021). They comprise most of the main structures, as 1,007 CSCOMs, 71 CSREFs and 13 hospitals are under convention with the CANAM. They also comprise other structures including 635 pharmacies, 201 health practices such as cabinet and private clinics and 95 other structures like infirmaries, inter-company medical centers and labs. The health sector also includes army health services. This sub-sector comprises medical posts, infirmaries, garrison maternity wards and two hospital infirmaries which are the Kati Hospital- Infirmary (IHK) and Bamako Hospital-Infirmary (IHB) (75). Lastly, the above is supplemented by NGOs acting in reproductive health and the fight against STIs and HIV/AIDS such as ‘Groupe Pivot Santé’ and several associations for population support (ASDAP - Association de Soutien aux Activités de Population), HIV/AIDS (ARCAD SIDA - Association de Recherche, de Communication et d’Accompagnement à Domicile des personnes vivants avec le VIH- SIDA), ENDA MALI, AGIR NGO, Save the Children, Red Cross, IAMANEH (11). In addition, the health sector also comprises para-public structures and traditional healers. These are distributed across 70 garrison facilities, 34 faith-based facilities, and 19 medical centers (inter- company). Traditional medicine practices are present in all the districts and villages and have, since 2002, their own consortium (FEMATH, Malian Federation of Traditional Therapists and Herbalists), which is mentioned in the PDDSS. These often constitute the first recourse to care needs – possibly perceived as an entry point in the health system for the majority of the population (75). Self- medication is also very common as in 31% of cases, the patients went to pick plants for treatment instead of using healthcare providers or traditional medicine (PRODESS IV). 4.2.3 Spatial distribution and population coverage 4.2.3.1 Overview Our mapping of healthcare supply across regions and districts indicates that care providers are predominantly located in the most populated areas of the country, therefore leaving Northern Mali with much less access to healthcare services (Figure 15). 16 Declic project of the university of Sherbrooke university (UDS), Canada (ACDI-backed, 2010-2018) HFSA: Mali | Technical report 53 The World Bank Figure 15: Mapping of the public healthcare supply in Mali with a heat map for population density and for conflict-affected zones, 2022 National Bamako Source: Author’s mapping using country and global data Table 5: Healthcare providers across types and regions of Mali, 2021 Medical Scientific/ Health Faith- CSCOM CSREF (1st Community Functional providers "MR" Clinic center (inter- Polyclinic Hospital Infirmary technological practive Total based (Frontline) referral) site (ASC) company) institute (cabinet) Kayes 8 26 14 2 271 3 1 2 0 10 142 282 761 Koulikoro 3 22 46 1 271 0 1 7 0 10 349 733 1443 Sikasso 3 202 30 5 271 0 1 14 0 10 183 707 1426 Ségou 15 20 11 3 219 0 1 15 0 8 69 686 1047 Mopti 4 6 1 1 182 0 1 2 0 8 28 409 642 Tombouctou 1 0 6 0 111 0 1 5 0 5 8 25 162 Gao 0 0 5 1 106 1 1 3 0 3 1 123 244 Kidal 0 0 0 0 23 0 0 0 0 4 2 36 65 Taoudenit 0 1 0 0 20 0 0 0 0 0 0 0 21 Menaka 0 0 0 0 71 0 0 3 0 1 1 10 86 Bamako 4 0 134 7 64 10 6 9 3 6 364 1 608 National, excluding Bamako34 277 113 13 1545 4 7 51 0 59 783 3011 5897 National (total) 38 277 247 20 1609 14 13 60 3 65 1147 3012 6505 Average 3 25 22 2 146 1 1 5 0 6 104 274 591 Source: Health yearbook (SNISS) 2021 using DHIS2 data HFSA: Mali | Technical report 54 The World Bank 4.2.3.2 Frontline care services (PHC centers) Regional disparities in access to frontline PHC providers persist in Mali, according to data from the health yearbook (SNISS 2021). On average, in 2021, the supply in CSCOMs corresponded to 3.3 units per cluster of 15,000 population. It ranged from 0.1 to 15.8 depending on the region. Regarding the distance to access PHC centers, on average 58.4% of the population lived within a 5 km radius of a PHC center, similarly, 88.2% were within a 15 km radius and 11.8% beyond a 15km radius. Depending on the region, those percentages varied widely. In the Bamako region where geographical access is high, almost the entire population (99.9%) lived within a 5km radius. In contrast, Taoudenit is the lowest covered region in term of geographical access as only 14.1% of its population lives within a 5 km radius and 15.3% within a 15 km radius. Taoudenit is however one of the least populated regions (0.9% of Mali’s population). While nearly half of the Bamako population lives within a 30-minute walk of PHC facilities, the access times to so-called “modern” health infrastructures vary across neighborhoods (86). In addition, the supply of care is largely dominated by the private sector, which mainly employs public personnel in the form of shifts, which raises the question of human resources but also of the quality of the care provided. Figure 16: Expansion of the PHC supply (CSCOMs) in Mali, 2000-2021 Cumulative number of providers (since 2000) Regional disparities Source: Health yearbook (SNISS 2021) and author’s calculations to compute the unit per cluster The private sector is developing very rapidly in Mali, consequently monitoring by the public health authorities remains very limited, as if this sector is not yet fully part of the health system. Private structures are unequally distributed over the territory and are poorly connected with the public sector, hampering their ability to contribute optimally to the achievement of public health objectives (48). Mali’s poor distribution of private medicine limits its absorptive capacity of the market. Historically, nearly three-quarters (70%) of private doctors are based in Bamako, while Bamako only represents 40% of the population living in an urban area (87). The country has therefore functioned for years with over-capacity in areas providing medical services (essentially Bamako) and under-capacity in others (regional towns). HFSA: Mali | Technical report 55 The World Bank The transformation of CSCOMs into medicalized structures with at least one doctor is a long-term process. Availability of at least one physician working within the PHC centers (CSCOMs) remains relatively rare beyond Bamako. In 2021 (SNISS 2021), the proportion of medicalized CSCOMs averaged 26% at the national level, ranging from 6% in Gao to 26% in Kidal, and 100% in Bamako. This means that, except in Bamako, many structures operate without the presence of a doctor. Legally, Mali’s PHC centers must include at least a dispensary, a maternity ward and a depot for essential drugs. In the PHC centers, all types of care (curative, preventive and promotional) that should be, in theory, provided by health staff are often led by doctors, in urban areas and increasingly in rural areas. Part of this transformational process, CSCOM-Us have been created to serve as a place of internships as part of the initial training of health workers. The health financing reform seems unable to sustainably improve attendance at health facilities, as the number of contacts per person per year remains low. In 2019, a study reported progress, passing from 0.16 contacts in 1999 to 0.23 contacts per person per year in 2003 in the CSCOMs (88). Similarly, the proportion of assisted births remains insufficient even though it increased from 29% in 1998 to 42% in 2003 (88). The report notes the non-implementation of the equity component of the Bamako Initiative and recalls the major obstacle represented by persisting OOPs for PHC. Some isolated initiatives (through mutual health organizations) had however already shown the positive impact of the presence of financial protection mechanisms on the attendance at health centers, which could double the rate for use. Depending on the region, the proportion of medicalized PHC centers vary from 9% in Ménaka to 34% in Koulikoro, against 100% in the Bamako region (SLIS 2020). It is essential to specify that almost one in three PHC centers is located outside cities (with “countryside doctors”), nevertheless evolving in a network (“un cercle”) placed under the supervision of a head physician. Health staff divide their workload between activities carried out in fixed health centers and in advanced activities carried out within the villages of each health area. In addition, the PHC centers benefit from the permanent support of community health workers, who reside in these localities. The CSCOMs transformation requires regular monitoring to prevent possible deviations from the place of these health structures in the health pyramid (48). Mali’s health reform aims to further rehabilitate medicalized CSCOMs (with at least 10 health officers), which will require the monitoring of specific indicators for future decisions. Overall, at the regional level, PHC center distribution remains constant across the regions with a density estimated at 0.7 per 10,000 inhabitants, below the WHO norm. To meet the WHO norm of one health center per 10,000 inhabitants, one prefectural hospital (equivalent to a CSRéf) per 250,000 inhabitants, and one regional hospital per 2.4 million inhabitants, Mali will need to expand its health infrastructure. According to the consolidated health orientation law (2018-049), the PHC centers are situated at the bottom level of the health areas (covering 5,000 inhabitants) and are administered by community health associations (ASACOs) made up of representatives of the population (35). The distribution of PHC facilities ranged from 0.7 to 3.3 per population depending on the region and 0.2 per population in the Bamako region (in 2018, according to PER 2021). At the national level, the number of PHC centers rose by 13.6% between 2014 and 2018, matching the estimated population growth. The number of PHC centers with at least one doctor increased by 18% between 2014 and 2018. HFSA: Mali | Technical report 56 The World Bank Despite limited resources for PHC, the implementation of the PHC health policy has made it possible to achieve two additional major advances. Firstly, the country reinforced the Minimum Activity Package at all levels, through the implementation of new management and control strategies developed by national programs (vaccination, malaria, IMCI, HIV/AIDS, micronutrients such as vitamin A, iodine, zinc and iron), and managed to medicalize nearly 30% of its PHC supply. Secondly, the country reinforced the promotion of community health care through the establishment of a vast network of community health agents and relays at the village level, to facilitate the management of simple cases of certain common pathologies and the early use of Essential Care in the Community (SEC). The pandemic impacted the capacity of the Malian healthcare system to deliver services as expected. Overall in 2020, partially attributed to COVID-19, it was found that only 69% of the services expected to be available within health facilities were fully available (71). The main reasons for non-availability of services in all sectors were lack of training (30%), followed by lack of medical inputs (24%), lack of personnel (20%), lack of medical equipment (18%) and finally lack of financial resources (8%). However, the situation greatly differed by location, level of care (community, primary, secondary, or tertiary), and by care service. The services most affected were general emergency services, child health and nutrition, communicable diseases, STIs and HIV/AIDS, maternal and neonatal health, sexual violence, non-communicable diseases, and mental health. The implementation of the HeRAMS resource mapping system highlighted and confirmed the hypothesis of a significant impact of the COVID-19 crisis on the capacity of the Malian health system to provide essential health services. Geographical access to care within a certain distance has been challenged over time and is uneven across regions in Mali. On average, in 2021, respectively 49.0% and 76.5% of the population accessed essential health services within a 5 km or 15 km radius (SNISS 2021). Excluding Bamako, these were estimated at 43.9% and 74.1% in 2021. These findings suggest that accessibility to care services has deteriorated in Mali. Indeed, the coverage as assessed by the percentage share of the population with access to care was higher in the past, as these estimates were respectively 57.5% and 87.5% between 2010 and 2015. Coverage has remained relatively stable in the recent past, as the rates were respectively 56.5% and 86% in 2018 and 57.9% and 88% in 2020. Yet, the 2018 national target for improved access to PHC services set at 61.0% was not met at the time and remains unmet, although coverage has greatly increased over the past two decades as it was around 29% in 1998. Similarly, against a target set at 42% for utilization rates in curative consultation in 2018, performance was lower than expected and tended to stagnate as it was 38% in 2014 and remained at 39% in 2017. Figure 17: Key indicators of access to care in Mali and across regions, 2021 HFSA: Mali | Technical report 57 The World Bank Key indicators Overview on regional disparities Within 5 km Within 15 km Beyond 15 km Bamako Kayes Ségou Sikasso Coverage (%) radius radius radius Koulikoro Mopti Tombouctou Gao Kayes 59,5% 85,7% 14,0% Koulikoro 52,7% 89,2% 10,8% Sikasso 54,2% 87,4% 12,6% Ségou 56,0% 94,2% 60,0% Within 15 km radius Mopti 48,4% 85,5% 14,5% Tombouctou 45,1% 73,7% 26,3% Gao 41,4% 83,2% 16,8% Kidal 38,0% 48,4% 51,6% Taoudenit 14,1% 25,3% 74,7% Within 5 km radius Menaka 29,9% 68,5% 32,0% Bamako 99,9% 99,9% - Subtotal, excluding Bamako 43,9% 74,1% 31,3% National (total) 49,0% 76,5% 31,3% 0% 50% 100% Coverage (Percent share of population) Source: Health yearbook (SNISS 2021) Territorial inequities in access to care persist in Mali, including for essential care services. CSCOMs structures provide public health services in a health area (aire de santé) and are distributed to cover approximately 10,000 inhabitants. Due to the geography of the country, some of them cover a much larger population (several tens of thousands of inhabitants) and others much smaller (less than 5,000) and in a larger territory (located for the most part in the northern zone which has a low population density). The proportion of the population having access to the basic package of healthcare services (PMA) within a 5 km radius differs widely across the regions and across the districts within the regions. Disparities persist as it ranges from 14.2% (Ménaka) to 94.2% (Ségou). Similar discrepancies can be reported for service coverage within a 15 km radius. Overall, the Bamako region remains the best serviced in Mali, with all residents having access within 5km and almost all (98.8%) within 15km. Overall, recent HeRAMs’ survey findings confirm variable performance of Mali’s health system capacity to provide essential health services, highlighting very marked geographical disparities, several shortcomings, and dysfunctions for several types of essential services. Since 2019, the Monitoring System for Essential Health Resources and Service Availability – HeRAMs’ survey series, which are tailored for fragile states, represent valuable guidance for decision-makers and partners helping them to quickly apprehend where and to which extent each type of service is available or not. In Mali, a baseline report in 2020 and two status update reports (April and July 2022), focusing on the operational capacity of the health system to deliver care in Mali, provide a plethora of mapping and indicators underlying regional and level of care disparities. The findings confirmed the wide disparities in operability and availability of care equipment and medical material, effective functioning of and access to health structures, and availability in hospital beds for intensive care and maternity services. According to Mali’s HeRAMS’ baseline report, for instance, some health structures were less operational than others depending on their location, with operating rates for care equipment ranging from 36% to 98% across regions. At the national level, the factors explaining the poor state of equipment available in health facilities were the lack of maintenance (76%), unidentified factors HFSA: Mali | Technical report 58 The World Bank (17%), natural catastrophe (14%), conflicts and looting (13%), or man-made catastrophe (5%). The survey findings showed that at least half of the structures were partially or fully impacted by up to four threats in Menaka and Taoudenit, more than a third in Tombouctou or a fifth in Sikasso, and less than a fifth in the rest of the country. Major causes of supply disruption were health workforce shortage (57%), lack of medical material or equipment (43%), lack of financial resources (32%), insecurity (23%), and lack of physical access (7%) but overall, they had little impact on real supply disruptions in most regions except in Timbuktu, Kidal and Menaka (for which over 10% of the structures were reported as being fully or partially unfunctional). The analysis of the extent of disruptions to the health system following the crisis also shows that, on average, at the national level only 69% of health services are fully available, but the situation differs greatly according to location and to the level and type of care. At the community level, for instance, availability of general clinic and emergency services is extremely low in Menaka (0%), Taoudenit and Timbuktu (about 20%) against the highest availability rates in Sikasso (79%). Lack of access to affordable and quality care renders the right to the enjoyment of the highest possible standard of physical and mental health unattainable for far too many people in Mali. Beyond geographical barriers to accessing essential health services, increased quality of care and adequate financing are very important to removing inequities in health. It should be remembered that half of the population still forgo necessary healthcare, with an even greater proportion among the poorest 20% of the population (76). According to PRODESS IV, an emphasis should be placed on strengthening the quality of the services offered to improve coverage, and on additional indicators to better capture healthcare coverage. Healthcare coverage by the multipurpose mobile teams (who offer the PMA) seem to not be monitored and evaluated, although it is a strategy implemented by the management teams in the north of the country. According to a Strength, Weakness, Opportunity, and Threat (SWOT) analysis of PHC accessibility, which was conducted along with the PRODESS IV, the lack of financial resources and poor governance for health coverage expansion were pointed out as key contributing factors to address. The findings suggest that effective provision of basic healthcare services cannot only be considered through the healthcare supply, although it matters. 4.2.3.3 Referral care services (hospitals) About 2% of the population resort to the 2nd and 3rd referral hospital care services in Mali. In 2021, the hospital utilization rate in Mali was approximately 2.6% according to our calculations based on the latest statistical yearbook (SIH 2021, Feb. 2023 release), with 1.6% for 3rd referral hospitals and 1.0% for 2nd referral hospitals. The 2021 utilization rate ranges from 0.4% to 2.8% depending on the health structure. In 2021, the majority of consultants came from the municipalities where the hospitals were located. On average, for the 2nd referral, most patients (57.6%) who accessed hospital care services came from the Commune where the structure was located. Regarding the 3rd referral, the proportion is 23.9%. Respectively, 0.7% and 1.4% of the users came from abroad. On average, emergency care accounted for about 9.6% and 12.1% of total hospitalizations, respectively for the 2nd and 3rd referral. In each level of referral, the hospitals receiving the highest proportion of emergency care patients were the GHU/GT (3rd referral) with 26.3% and CHU/BSS-Kati (2nd) with 15.4%. According to prior data collection (SIH and SLIS 2020), 225,189 patients were hospitalized in 2020, of which 60.1% at the 1st referral frontline care HFSA: Mali | Technical report 59 The World Bank (district), 19.5% at the 2nd referral hospital care (region) (7), and 20.3% in the 3rd referral hospital care (national) (8). In 2020, Malian hospital care infrastructure counted a total of 7,283 beds, respectively at 66.3%, 15.6% and 18.1% in the 1st, 2d and 3rd levels of hospital care. Except for the CHU-CNOS where 100% of hospitalized patients are referred, about a third of the patients (30.6%) hospitalized in hospital care facilities of the 3rd reference are referred from the 2nd level reference, in which the rate averages 25.6% (equivalent to a quarter of the patients). On average, the occupancy rate of hospital beds in Mali was estimated at 51.8% in 2021 against 31.9% in 2020. The 2021 rates varied according to the level of care, with an average estimate at 45.8% (Min-Max range: 30.7% - 76.8%) for the 2nd referral and 54.9% (Min-Max range: 34.5% - 78.0%) for the 3rd referral. In 2021, the average length of stay (LOS) was 5.6 days at the national level, and 4.8 and 6.3 days respectively at the 2nd and 3rd level referral level; which appears divergent from the 2020 estimates. In 2020, the length of stay (LOS) averaged 3.8 days and varied between 2.9 days (1st referral) to 5.8 days (3rd referral). In 2021, about 1,287 (3rd referral) and 11,197 beds (2nd referral) were functional or available for patients, making a total of 12,484. Wide geographical and level of care disparities exist in hospital bed accessibility and availability. According to survey data reported in the HeRAMS’ July 2022 status update, the density of acute care beds in hospitals per 100,000 population varied from 1 in Mopti to 78.4 in Ménaka, revealing significant disparities both in bed density and availability of service across regions. A similar result was found for maternity beds, which were assessed at 1.7 per 100,000 population in Kidal to 11.1 in Ménaka. The per 100,000 population density of other types of hospital beds also ranged from 1.6 in Kidal to 7.2 in Bamako. Across the level of care supply, on average, acute care beds were available at 47% in the CSREFs and 81% in hospitals. Similarly, maternity beds and other types of beds were respectively available at 89% and 47% in the CSREFs and 76% and 81% in hospitals, on average. At national level, the major reasons for unavailability of hospital beds were lack of equipment (89%), lack of financial resources (37%), lack of health workforce (18%), lack of medical products (17%) and low training capacity (8%). On average, inpatient care service capacity in regional hospitals can be estimated at about 1 bed per 20,000 population in Mali. In 2021, inpatient care service capacity at the 2nd referral hospitals increased (1,190 beds) compared to 1,135 beds the previous year. On average, hospital care bed density was estimated at 0.5 per 10,000 population (Min-Max range: 0.4-1.9) in 2021. Regarding inpatient care use, the density of the hospitalizations was estimated at 21.8 per 10,000 population (Min-Max range: 10.5-48.8) in 2021. According to another data source, which is based on WHO projections to estimate the COVID-19 impact in Mali, the UHC tracer indicator of hospital bed density is expected to reach 11.2 beds available per 10,000 population in 2023, compared to baseline data of 14.7 beds available per 10,000 population in 2018. The latter was reported in the health yearbook 2018. The density level has improved since 2010, which was estimated at 1 bed per 10,000 population (WDI). This estimate could however be nuanced, as the same dataset showed a density level of 6 beds per 10,000 population in Mali in 2008, which average the upper level reached since 2000. Roughly one in ten Malian patients still die while hospitalized in the regional or national hospitals for inpatient care service. The in-hospital mortality rate has appeared relatively stable since 2019, HFSA: Mali | Technical report 60 The World Bank with estimates at 12.6%, 12.3% and 11.9% respectively over 2019-2021 (SIH 2021). The highest mortality rates were recorded for inpatients admitted to the CHU/GT, estimated at 22.7% in 2021 against 23.2% in 2019. Evidently, the mortality rates varied a lot depending on the structure and the severity of the inpatient care delivered (Min-Max: 1.0% - 22.7% in 2021). Yet, it remains a concern for health authorities. 4.2.4 Other inputs 4.2.4.1 Drug pricing, supply and procurement The price of drugs remains an important parameter to be closely monitored in Mali in order to reduce the cost-burden of disease. The Reference Price Indicator (median, RPM) shows that in Mali the local price is 1.8 times the reference price for half of drug consumers. This is more than twice (2.1) for a quarter of the consumers, as joint reported by UTM and MOH17. Prices of generic drugs in the private sector were estimated to rise to eight times the prices charged in the public sector or in the faith-based sector. Overall, in Mali, the availability of medical products is not satisfactory, and the shortage of drugs is glaring, for instance for chronic diseases. Consequently, the unavailability of medicines in the public & private non-profit sector has a direct impact on the incidence of catastrophic expenditure and patient impoverishment. According to experts, Mali’s free pricing policy and its application should be reviewed for essential medicines. While the public sector benefits from competitive purchase prices, the prices paid in the private sector can vary widely. In the private sector, drugs are considered very expensive, including generic drugs. The market mechanisms and free competition therefore do not bring the expected results in the pricing of drugs in Mali, which was reported by WHO in 2015 (89). Generic drugs, even if more available in the private sector, are sold at a high price. Maintaining high prices poses the problem of financial access to care, particularly given the low purchasing power of the majority of the population. At community level, it was found that median prices also remained high, but it is above all established that a wide variation in prices persists. This means that even in the sectors where the price should be regulated and therefore should be stable, it is not. The availability of medicines is also not satisfactory at the local level, especially in regions far from the capital. Among the explanations put forward by WHO in its 2015 study in Mali, the price structure is defined in theory (indicating the percentage of the various margins, taxes and other costs) but it is not systematically respected. Considerable discrepancies between the margins have for instance been reported by wholesalers and retailers from the field. The current situation is less bleak than five years ago, as Mali’s hospital pharmacy system provides a good service overall in regional and national hospitals. In 2021, about 93.3% of life- saving drugs appeared to be available in the network of hospital care facilities (2nd and 3rd referral levels), according to the national yearbook (SIH 2021). The lowest availability rates for life-saving drugs were observed at the CHU/Point G (68.8%) and in the hospital of Mali (84.4%), both belonging to the 3rd referral system. On average, it was estimated at 85% among the 3rd referral network and 17 DPM Direction de la Pharmacie et du Médicaments HFSA: Mali | Technical report 61 The World Bank at 98% among the 2nd referral network. MSH is reporting projects to address the frequent stock- outs of lifesaving medicines and poor visibility in the pharmaceutical supply chain. Drug supply and procurement is publicly regulated through directives, which appear not fully effective. A national plan for the Supply and Distribution of Essential Drugs (SDAME) has existed since 1996, establishing the stakeholders’ roles and prerogatives in the supply chain. In practice, a great diversity of sources of supply of essential drugs is observed, suggesting a certain degree of non-compliance with the SDAME directives. Sales regulation for drugs and medicines is organized but illicit markets and counterfeit drugs exist in Mali. The fact that the regularly updated National List of Essential Drugs (LNME) of 566 drugs is not available or communicated throughout the country does not help. Its under-use is apparently linked to a lack of financial resources for its printing and distribution. Improving the financing and procurement mechanisms for pharmaceutical products is an objective of the PDDSS for 2023. The safety and quality control of imported goods such as drugs and medicines, as well as other health-related goods (like food, water and beverages), are key for public health although insufficiently guaranteed in Mali. In general, the products available on the market in Mali, whether manufactured locally or imported, lack systematic and rigorous controls related to safety and quality, despite the existence of quality certificates at least for imported goods. In Mali, the Laboratoire National de la Santé (LNS) is accountable for these controls, both for food products and drugs. Despite operating with annual budgetary allocations estimated at XOF 1 million on average over 2019-2021, its means were inadequate (staff and financing) and the challenges ahead growing (90). Globally, the development of industry and commerce has changed consumption habits. In Mali, industrial units have multiplied in the food sector with insufficient safety control systems and guarantees, which is also reported in the medical sector. According to some experts, unsafe food is the cause of approximately 200 illnesses ranging from simple diarrhea to much more severe diseases such as cancer. Given its continental location, the country imports huge quantities of products from various countries, which include medicines as well as foodstuffs and food additives. According to MOF, food imports accounted for XOF 393.6 billion in 2020 and represented about 15.9% of total imports, against 11.7% in 2019. The increased share of food-related imports was due to sugar (8.3%), beverages (28.0%), milk (8.0%), cereals (22.4%), tea and coffee (9.1%) and flour and cereal preparations (9.4%). Imports of medicines and medical products were estimated at XOF 40.7 billion in 2020, which gives an idea of the financial magnitude of this sector compared to food (90). 4.2.4.2 Cold chain, waste management and other basic amenities More than half of Mali’s care supply lacks cold chain equipment. According to recent HeRAMS’ survey data, cold chain equipment is only available and sufficient for almost half (47%) of health facilities, and a quarter (25%) of health facilities function without cold chain at all. The absence of cold chain equipment is particularly acute in Ménaka (71%), Bamako (52%), Koulikoro (32%) and Gao (27%) (71). Previously (WB 2011), cold chain equipment storage capacity was reported as being insufficient and highly dependent on immunization campaigns and the introduction of new vaccines. Cold rooms did not have automatic temperature recorders, nor a reliable alarm system in the event of a power cut. In 2011, capacity was reported to be insufficient in 12% of health districts HFSA: Mali | Technical report 62 The World Bank and in some CSCOMs. A renewal plan for cold chain equipment by level, drawn up in 2005, was being implemented only in 2011. Apparent comprehensive coverage in structural amenities hides severe territorial inequities in Malian health facilities. With regard to structural amenities (such as access to water and energy), only 4% of health facilities seem to be deficient, although large inequities persist across territories (71). In 2020, the proportion of health facilities without access to water was estimated at 47% in Taoudéni, 36% in Ménaka, 11% in Kidal, 9% in Gao and 6% in Timbuktu. Similarly, the lack of energy coverage in health facilities was estimated at 68% in Kidal, 58% in Ménaka, 53% in Taoudéni, 14% in Gao and 9% in Timbuktu. Solar energy was the main source of energy in most regions (60%). Health facilities remain uneven regarding waste management and sanitation requirements. Regarding waste management (71), about 4% of health facilities did not separate waste. Again, national estimates hide considerable variability as the percentage was up to 47% in Taoudéni and 36% in Ménaka compared to 11% in Kidal, 9% in Gao and 6% in Timbuktu. Infectious waste disposal was unavailable in 8% of the health facilities, but in 47% in Kidal, 40% in Taoudéni and 18% in Mopti (71). Overall, 7% of all health facilities did not dispose of sharps (“évacuation des objets tranchants”) while the proportion reached higher levels in Kidal (63%) and Taoudéni (40%) compared to Mopti (20%), Ménaka (16%), Timbuktu (12%) and Sikasso (11%) (71). Regarding sanitation (71), about half (56%) of health facilities have available and sufficient toilets and a few (1% of health facilities) have no toilets available. The proportion of health facilities lacking sanitation varies across territories, with a higher proportion in Taoudéni (40% of health facilities having no toilet available) compared to Ménaka (9%), Kidal and Gao (5%). Overall, pit latrines were the most common (55%), followed by flush toilets (29%) and uncovered pit latrines (22%). Overall, about a tenth (12%) of health facilities lack any communication system. However, access to communication systems was very uneven in 2020, with a greater lack of access in Taoudéni (87%), Ménaka (64%), Kidal (42%) and Kayes (24%) (71). To our knowledge (WB 2011), it used to be reported, a decade ago, that the central level had dilapidated logistical resources (owning two trucks, of which one in poor condition), for supplying regional depots with vaccines and consumables and for supervision activities. There was no policy to ensure maintenance, regular monitoring and renewal. At the regional/district level, the problem encountered was that of the availability of timely transportation means when supply, supervision and immunization services were scheduled. However, 81% of the CSCOMs had functional means of transport, mainly motorcycles. 4.3 Health information systems 4.3.1 Architecture of health system information Mali has had a master plan for the national health and social information system (SD-SNISS – Schéma Directeur du Système National d’Information Sanitaire et Sociale) since 1998. The information and indicators produced by the SNISS make it possible to measure the performance, process or impact of the PDDSS and PRODESS implementation programs. The SNISS aims to provide information in a timely manner and suitable form for program needs elaboration and steering HFSA: Mali | Technical report 63 The World Bank decisions. In its current form, four sub-systems coexist and are coordinated by the Planning and Statistics Unit (MOH/CPS): 1) health information subsystem (SIS); 2) social information subsystem (SISo); 3) subsystem for research, studies and surveys information (SIREE); and 4) subsystem of administrative and financial information (SIAF). The fragmentation of these different information channels is presented in the following paragraphs. Mali’s SNISS is itself structured on several levels to inform most indicators (35) for the PRODESS monitoring and evaluation framework. The SNISS is based on three major elements that produce statistical yearbooks through distinct channels. It comprises the local health information system (SLIS) managed by the DNS, the epidemiological surveillance and alert system (SAE) piloted by the DNS, and the hospital information system (SIH) piloted by the CPS/SSDSPF. Since 2000, the SLIS has been collecting, storing, processing, analyzing and disseminating district level data from CSCOMs, CSRefs, garrison infirmaries as well as certain private structures, but without exhaustivity for the latter. Since 2003, the SIH has been collecting, storing, processing, analyzing and distributing data from regional health hospitals (EPH). The SAE, for its part operational since 1998, collects, stores, processes, analyzes and disseminates data related to the epidemiological situations. Independently from the SNISS, Mali’s SISo informs additional indicators (15) for the PRODESS monitoring and evaluation framework, but it remains incomplete. Since 2005, it has collected, stored, processed, analyzed and disseminated information in three technical sub-domains that can be assimilated to sub-systems. The breakdown is as follows: i) strengthening solidarity and the fight against exclusion; (ii) the fight against poverty; (iii) strengthening social protection. These three technical areas are complemented by the transversal aspect of finance. The SISo is coordinated by two national directorates (DNDS and DNPSES), which is supported by SISo regional and local officers. With respect to UEOMA or OHADA recommendations for data collection, Mali’s SISo is incomplete (48). The lack of information on the AMO and RAMED and “free” policy schemes has important consequences on the quality of the PRODESS planning, the management of the programs and interventions planned and the quality of service provided. It comprises two subsystems of information for social development (SIDS) and social economy (SIES) (75). Mali’s SIREE is the system in charge of Health Accounts, routine surveys and other studies. It collects, stores, analyzes and disseminates data on studies and surveys such as the DHS, MICS, Health Accounts, study reports and publications. Under this umbrella, about 12 entities operate for different purposes, including the ODHD or the CNAM. Finally, and lastly, Mali’s SIAF also processes health information. Since 1987, it has related to legislation and regulations and has provided information on health inputs (human, material and financial resources) and the interventions of partners in the field of socio-health development. The development of a strategic plan (2015-2019) represented real progress in guiding the implementation of the actions necessary to strengthen the SNISS (91). To our knowledge, there is no platform for collaboration and information sharing between the various components of the health information system. Besides, each of the SNISS subsystems has been and still is confronted with various problems, including those of the regularity of publications and the validation and HFSA: Mali | Technical report 64 The World Bank consistency of the data produced. Strengthening the coordination of these stakeholders within each information subsystems and providing offices with the necessary means is a priority for Mali. 4.3.2 Informing health policy and performance budgeting Mali’s MOH recently innovated by providing technical guidance tailored to health workers, researchers or partners to better inform their practice. In 2017 the MOH developed this powerful tool to support workers and researchers in health, social development, and family promotion who, in their daily practice and at all levels, need to: i) describe the health status of the population of the catchment area in which they work, ii) monitor the evolution of this state, iii) assess the impact of public health interventions in which they are asked to participate, iv) interpret survey or analysis documents. This indicator guide was revised in 2021 (add citation). It covers the so-called “classic” indicators that any professional in the sector should master, and a set of additional indicators selected for the monitoring of the implementation program for health and social development (PRODESS IV, 2019-2023) and of the health component of the Poverty Reduction Strategy Paper (PRSP). However, this initiative does not aim to replace the official monitoring approach. It rather aims to provide a technical handbook to help the health, social development and family promotion professional to make adequate use of indicators of the sector for his personal practice. In 2018, GOM initiated a reform to move to programmatic and performance-based budgeting (PBB). Government agencies and health authorities committed to achieving pre-defined strategic objectives in return for budget commitments. In line with the recommendations from the Systematic Country Diagnostics (SCD), Mali built several centers of excellence, including the National Institute of Statistics (INSTAT) and the Observatory of Sustainable Human Development (ODHD) with the intention to improve data quality and strengthen capacity building in health and social data management. PBB arrangements as a means to improve data quality in health financing was implemented by INSTAT. At the central level (of the State), the strengthening of statistics in support of decision-making is part of the 13th CREDD priorities for 2023. The monitoring of the 38 ambitious strategic objectives of the Strategy for Accelerating Growth and Sustainable Development announced timely and recurrent statistics across different sectors, including the social sectors. In the health sector, the health development plan (PDDSS 2014-2023) conveys the need to support the development of the sector in the production, analysis, dissemination and use of reliable health information, which stands as a specific objective (54). The plan is calling for better use of timely and disaggregated information on the determinants of health, the performance of the health system and health status. Despite efforts to create a center of excellence to promote the use of high-quality data in health, further inter-center collaboration and greater data availability are still needed. For instance, as at 1st of July 2022, the INSTAT data portal18 does not report on any health or health financing data, which limits our capacity for PBB analysis. A weak collaborative working approach, notably regarding INSTAT, was mentioned as undermining data production and the proper functioning of activities (92). Capacity strengthening at INSTAT is ongoing and supported by external funders (XOF 18 https://mali.opendataforafrica.org/data/#menu=topic HFSA: Mali | Technical report 65 The World Bank 15.2M funded by the Swiss Agency for Development and Cooperation and technical support from AFRISTAT) (93). Last May 2022, an integrated system for human resources management19 was launched with a primary intention to enhance accountability in the sector. 4.3.3 Decision-making lacking high-quality and on-time health financing information Although the political and institutional environments are conducive to the paradigm shift for result-oriented policies, the availability of information based on quality and timely data remains a huge challenge in Mali. During the preparation of the PDDSS 2013-2024, the lack of health financing data and information was raised as an issue (88). The lack of data and reliable indicators was also noted during the preparation of the Universal Health Insurance Plan (UHIP or RAMU in French) reform. We also found several limitations in our data collection over this HFSA process. Health policies require health decision-makers to be well informed, which obviously requires measurements of the progress made to achieving the strategic objectives in health and other sectors, including health financing. Improved health financing data and improved data use for decision-making is needed to better administrate Mali’s health system and related policies. Mali’s data use for policy and action was qualified as nascent capacity in Mali, and more than half (57%) of indicators lack data availability to secure effective monitoring of the health-related SDGs (WHO score) (94). An assessment of the progress made between 2013 and 2018 revealed an improvement in data use in health decision-making at all levels of the health pyramid, although data use scores at peripheral and regional levels remain significantly lower than at district and central levels. The conclusions of an USAID study highlighted the need to strengthen the health information system (SLIS) by seeking a better system for archiving and storing quality data that is made available for necessary audits (95,96). For example, at the district level, the timeliness of delivery of health information reports remained very low, regardless of the method used (e.g., paper reports: 27%, electronic system reports: 51%). Targeted support at the peripheral level clearly needed to be strengthened. By improving the quality of data and creating the conditions for rigorous analysis and use of data, Mali can in turn improve its health decision-making and the quality-of-service delivery. To achieve significant improvement, the study argued that promoting information literacy alone is not enough to change behaviors and that close monitoring would be vital to effectively build staff capacity to work with the information tools and promote willingness to use them regularly. 4.3.3.1 Health Accounts The Malian Health Accounts are indispensable tools for health financing, but delayed release hinders timely policymaking. Health accounts enable decision-makers to assess the flows and use of financial resources for health and should help them to timely correct imbalances in health system financing. Mali was among the pioneer SSA countries establishing Health Accounts, and the first 19 Integrated Human Resources Management System for State and Local Government Public Services (SIGRH); source: https://koulouba.ml/fonction-publique-lancement-dun-projet-pour-la-gestion-transparente-des-ressources-humaines/ HFSA: Mali | Technical report 66 The World Bank edition dates from 1999, to our knowledge. The latest release during the study was in March 2022, referring to the fiscal year 2019. A prior edition was released in December 2020 for 2018. Recent publications were made with two- or three-year delays, limiting their use for short-term decision- making. Poor access to data and/or limited dissemination of Health Accounts results also undermine the use of health financing information in policymaking. For instance, in 2018, primary data was collected for all regions with the exception of the Northern region, due to country context. About 45 NGOs were interviewed on the occasion and 94 companies (out of the 347 identified) provided health information. Statistical yearbooks (SLIS and SIH) along with budget reports and household survey data were used to feed the report, as a secondary source of data. At least five major shortcomings were highlighted, which were non-conformity of the umbrella organizations' data structure with the Health Accounts classifications, reluctance of data transmission, insufficiency of disaggregated data, lack of an updated database for the private sector (NGOs, insurance companies and businesses), and fragmented data preventing data extrapolation. These are not unique to the health sector as, at State-level, the structural basis of the National accounts was outdated and missing multiple source data, affecting the quality of macroeconomic aggregates. The exhaustiveness of data reporting for Health Accounts remains a challenge for Mali. Staff turnover also contributed to disruptions in their publication. For instance, “in 2002, when the report was finalized and was to be presented to the MOH, the government changed and the involved staff at the MOH were replaced. This resulted in no Health Accounts being initiated in Mali” (97). 4.3.3.2 Other channels for accessing health financing data Irregular NHA publication prevents attempts to assess effective health expenditure against budget expenditure (as costed in the development plan). Regarding open budget data, Mali has been preparing an annual citizens' budget since 2011, a source of publicly available information to support informed decision-making. The MOF provides public finance data that is highly relevant for health decision-making. Both alternative sources of data were searched and used in this HFSA. Access to public health literature is organized by law (2019) in Mali, with the Institute for Public Health accountable for it. The Institute for Public Health is the result of merging former MOH research structures, including the National Institute of Public Health Research (INRSP), the Research, Study and Documentation Center for Child Survival (CREDOS), the National Agency for Food Safety (ANSSA) and the National Center for Disease Control Support (CNAM). To our knowledge, the website does not provide access to NHA or related health financing reports. In 2022, however, several communiqués were made available online regarding monitoring and evaluation in the context of COVID-19 prevention. Global repositories on health financing data lack timely transmission of country-validated data. It is interesting that the major global data repositories are as a result outdated for Mali. As at 17 June 2022, for instance, IHME used outdated NHA data (98). As at 1 September 2022, WHO-GHED only reported up to 2019 (at least for key health financing indicators), with 2019 added during the second semester of 2022. Similarly, the Boost public expenditure was last updated in July 2020 but only reported on the period from 2014 to 2017. HFSA: Mali | Technical report 67 The World Bank When statistics do exist, the right combination of data and indicators to support decision-making is poor and remains challenged by a lack of technical resources. In spring 2019, an evaluation by Measure Health concluded the inability to produce annual statistical yearbooks on time until 2018, which was addressed in 2019 for the first time (99). In 2019, “Mali successfully produced validated records of the prior year’s health data before April 30”. Main weaknesses were attributed to unsecured financial resources, the need to harmonize data from multiple health structures, and developing three yearbooks: for the LHIS, SIH, and the national statistical yearbook. In Mali, the National Health and Social Information System (SNISS) is made up of four components that are the Health Information System (HIS), the local health information (LHIS), the System of Hospital Information (SIH), and a fourth one on the epidemiological alert system. The timely production of the annual statistical yearbooks should allow health facility and hospital managers, policy makers, the various implementing partners and all stakeholders to use, in time, reliable data for decision- making. The digitalization of health statistics should help improve quality data checks and data transmission for tailored feedback. Since November 2019, Mali has had a Unified Social Register (RSU), which is an information system housing a national database on beneficiaries of social protection. Hosted by the Ministry of Health and Social Affairs, it was developed in partnership with the World Bank, International Development, UNICEF and DJIGISEMEDIRI. Social protection for health indicators are generated and available through a website (100). This web platform is an asset, making digital information on social coverage publicly available in Mali. Currently, in health, it highlights the number of people with disability (10,133) and with chronic affections (7,310) registered in the RSU, as well as two other indicators such as the headcount of pregnant women who gave birth at CSIs (15,639) or who were followed after childbirth at CSIs (12,318) and the headcount of immunized children (1,548). The web platform also stores major documents. Figure 18: Overview of the unified social register scope and indicators available at country-level, 2022 Overview of RSU website Source: RSU website HFSA: Mali | Technical report 68 The World Bank In practice, health system information lacks robustness and/or completeness, therefore preventing optimal use by the care providers or users. In 2020, the health information system was unavailable in nearly a quarter (26%) of health facilities (71). The proportion of unavailable reports was higher in Bamako (i.e. 57% for weekly epidemiology reports, 40% for monthly activity reports and 38% for the local health information system), followed by the Koulikoro region (i.e. 34%, 21% and 18% respectively). In Mali, routine data collection and mass campaigns are operationalized via the DHIS2 regional platform (USAID 2017), with information presented in annual yearbooks. On the demand side, GOM implements health campaigns to educate citizens about common diseases and their prevention, and to raise awareness about public health risks such as epidemics. However, the impact of these campaigns on the population is not very visible due to the irregularities that punctuate the process, as reported by a MOH informant (22 August 2022, Africa Integrity). Citizens can find health information about the most common illnesses, treatment and prevention but the information may be incomplete, or presented in a way that makes it difficult to understand. Mali scored 50 out of 100 as assessed by the Africa Integrity Indicator on health campaigns to educate citizens on the most common diseases and affections, which is a lower performance than most of the comparator countries (e.g., Burkina Faso and Chad scored 75 and 100 in 2022). HFSA: Mali | Technical report 69 The World Bank 5 Health financing landscape Chapter 5 focuses on describing the landscape of the health financing system in Mali, looking at the long-term trends and growth rates of national health spending, the main sources of revenue for the sector, and the distribution of available financing linked to the functions and schemes of the national health system. To accelerate progress toward UHC, Mali, like the other low-income countries and many others, will need to invest additional financial resources into their national health system if they expect to converge towards UHC over this decade. In this chapter, authors explore ways in which lessons can be learned from the past. We attempt to answer the following questions: Who’s been paying for health in Mali? How much was raised over time? Who’s bearing the highest share of the financing system? and Where does the money invested go? 5.1 Overall trends in health spending In Mali, total expenditure on health has risen over past decades, up to 150% compared to an arbitrary baseline level set for post-2012. Total expenditure on health includes all expenditure on activities whose main objective is to restore, improve and maintain the health of the population and individuals for a given period, which can be partly managed outside of the MOH budget expenditure. It is the sum of both public (domestic and external financing) and private health expenditure (including out-of-pocket payments), encompassing all-ministry expenditure on health. According to Health Accounts, the 2019 total health expenditure accounted for XOF 420.7 bn, against XOF 362 bn in 2018 and XOF 350.0 bn in 2017, equivalent to an annual increase of 16.1%, which is not representative of past annual increases estimated at 1.9% over 2016-2018 (the prior to 2019 3-year period) and 0.0% since 2013. For instance, 2018 saw a substantially smaller annual increase of 3.5% compared to 2017 (XOF 350.5 bn). In Mali, capital expenditure on health accounted for about 7.8% (XOF 3.3 bn) of the total spent on health in 2019, against 1.4% (XOF 4.9 bn) in 2018. For the latter, the data series was incomplete, which might be potentially partially explained by Mali’s general financing architecture. Mali’s context partially explains the health sector setbacks and underfunding. The premises of and the 2012 crisis itself had dramatic short-term consequences on the financing of the health sector. For example, government-funded health financing passed from XOF 96 to 54 bn in one year between 2011 and 2012, cutting almost half of the vital financial resources on health (all ministries combined). In 2015, government-funded health financing still barely reached pre-crisis levels. Since then, health financing has seen both improvements and new setbacks as shown below. The sector’s funding setbacks are also directly induced by the effects of political instability, the withdrawal of Technical and Financial Partners’ financial support and by a net reduction in their funding support. The analysis of resource mobilization by these stakeholders will be further described later. HFSA: Mali | Technical report 70 The World Bank Per capita, the growth in health spending follows a relatively similar trend, with a sharp decline before a recovery and then a plateau. Broadly, the large increase seen over the most recent period did not translate to the same magnitude when expressed in amounts spent per person (Figure 19). In 2019, current expenditure on health accounted for 92.2% (XOF 357.3 bn) of the total expenditure on health, against 98.6% (XOF 357.3 bn) in 2018. Since 2013, the trend in current health expenditure in Mali appears idling. Annual growth in current expenditure on health averaged 7.5% in absolute terms but loses impetus when expressed per inhabitant (2.8%) (Figure 19). In 2019, compared to 2018, the annual increase was estimated at 11.6% in absolute terms while only reaching 2.6% per inhabitant. Similarly, on average over the past period (since 2013), annual increase in current expenditure on health averaged 7.5% and 2.8% respectively in absolute volume and per inhabitant. Figure 19: Trends in total and per capita expenditure on health in Mali, 2000-2020 Total trends Per capita trends Source: GHED Mali’s MOH health investments account for a small share of total investments made nationally, including those directed to health and social affairs purposes. At the national level, the country has a capital investment budget (BSI) that includes all-sector budgets. The National Directorate of Planning for Development of the MOF lists all-purposes projects planned by sectors (a total of 388 projects and programs in 2023), including those under the leadership of the MOH (23 in 2023). According to the 2023 Finance Act, MOH investments for 2023 will account for XOF 19.4 billion, entirely sourced from internal funding (Table 6). This 2023 budget represents the first installment of a three-year capital plan (2023-2025). Health investments account for about 5.0% of total HFSA: Mali | Technical report 71 The World Bank national investments and most of it (if not all) under MOH management. Data on project financing was also available, which suggested that projects in the health sector may be 20% short compared to the national average. Every year, health investment projections as well and n-1 estimates for their budget execution are published by MOF to highlight the various destinations of funds (across sectors, ministries, sub-sectors and projects of affectations) and its managing entity. Those related to health purposes, for instance, show budgeted amounts of the foreseen investments in each health structure (hospitals and PHC centers). Table 6: Magnitude of foreseen health investments in Mali, 2023 Destination Budget (in milllion XOF) Projects and/or programs Internally- Externally- Number of Purpose of investment Total Average funded funded items MOH annual budget 19,420.0 0.0 19,420.0 23 844.3 and its percent share 8.6% 0.0% 5.0% 5.9% 83.9% HR for health and social affairs purposes 20,240.0 1,500.0 21,740.0 and its percent share 9.0% 0.9% 5.6% National 225,300.0 165,000.0 390,300.0 388 1,005.9 Source: Author’s calculation using MOF information (Finance Act 2023) 5.2 Major domestic schemes for health financing Overall, in Mali, domestic funding on health from the central administration and pooled funding from compulsory contributory schemes have increased over time but not enough to fully remove the reliance on domestic private non-contributory funding. The latter remained indispensable to complement public and external revenue sources for health. On average, between 2018 and 2020 (referring to the most recent 3-Year period), private domestic revenues accounted for XOF 120.1 bn annually, constituting a massive source of revenue for health (30.6%). Government-funded revenues for health represented a lower means of financing, on average estimated at XOF 96.3 bn annually over the 3-Year period of reference (24.5%). The following figure presents a disaggregated view of the capacity of each source to generate financial resources for the sector over past decades (Figure 20), with highlights on progress relative to the respective shares over past three years of reference against a baseline three years in the early 2000s (Figure 20). As suggested above, the financial contribution raised through pre-payment schemes for health remain comparatively marginal in Mali, although social insurance represents progress. To date, on average, less than 10% of health financing is contributive. But this remains major progress on the path towards UHC since in the early 2000s, contributory and mandatory pooling for health was non-existent in Mali. On average over the 3-Year reference period, social insurance and voluntary prepayments contributed to XOF 33.9 bn (8.6%) and XOF 980.7 million (0.2%) respectively. HFSA: Mali | Technical report 72 The World Bank Figure 20: Major health financing domestic schemes in Mali, 2000-2020 Source: GHED 5.3 Revenue sources for health Malian households remain indispensable funders of the national health system, which demonstrates an insufficient degree of progress in the health financing transition. The reliance on private payments has sharply reduced over time, although it has persisted despite being known as a major obstacle to accessing healthcare and essential health services. The dependency on households has declined as a relative share of health funding over past decades thanks to national efforts, but most of the domestic financial transfers for health still come from them. Between 2015 and 2019, out-of-pocket payments for health accounted for 53.8% of the total domestic revenue for health. Since 2000, domestic private transfers (47.6%) have contributed twice as much as the domestic public transfers (20.2%) to health system financing. In 2019, the financial burden on households was equivalent to XOF 128.9 bn (32.6% of total revenues for health), which is however lower than the 44.9% mobilized by external partners (Figure 21). Compared to 2018, the households’ share declined by 1.3%. Besides, the remaining decreases observed in relative trends of out-of-pocket spending (OOPS) or when expressed per capita likely often hide reduced healthcare service use, which was a pattern seen globally during the first year of the COVID-19 pandemic (101). Prior health reforms have greatly contributed to reducing inequities in financial access to care in Mali, improving access conditions for households. Malian households used to finance between 60% and 70% of health financing during the decade from 2000 to 2009, averaging 62.6% over that period. Several waves of health reforms have expanded health coverage, managing to reduce this share to 40.4% over the past decade from 2009 to 2019. Major improvements have come from the introduction of insurance and subsidized schemes after 2009, and additional efforts to cover other segments of the population (such as those facing injuries from armed conflict and because of natural disasters) in 2016, with more recently the 2018 initiative towards UHIS. Efforts must be HFSA: Mali | Technical report 73 The World Bank maintained to reach UHC. The major annual change was seen in 2013 (minus 10.0%), which was a year apparently compensated by the Government-funded share although it was an exception (9.5%). The next chapter on pooling and purchasing healthcare offers a deeper analysis of the policy changes and trends in out-of-pocket payments ( Figure 42). Another major financing agent is Mali’s State, but there is no clear pattern of a transition towards predominantly public funding for health in Mali. Indeed, in relative proportion to other sources of revenue for health, GOM has not substantially improved its share, it is having even reduced over the two past decades. It averages 21.9%. This rather “stagnant share” contrasts with expectations for better PHC financing for which it is recommended to predominantly rely on public funding. Drivers to reduce the financial burden supported by the care users likely came from budget increases in external aid, and from prepayments after 2013. Over time, there has been a growing influx of external transfers for health in Mali, observed both in volumes of funds and percent share of revenue sources for health. The funds received from development partners and distributed by GOM amounted to XOF 46.8 bn per year (11.9%) on average between 2018 and 2020. These contributions increased over time as they represented XOF 3.3 bn (2.7%) of total revenues for health on average between 2000 and 2003. In Mali, direct foreign transfers represent higher shares and volumes compared to those distributed by GOM, equivalent to XOF 90.0 bn per year (22.9%) on average between 2018 and 2020, against XOF 8.0 bn (6.5%) between 2000 and 2002. The structure evolved towards a greater portion channeled through the Malian administration (on-budget), although extrabudgetary aid remains predominant. In 2020, total external revenue resources for health amounted to XOF 154.1 bn (35.6%), of which 67.8% from direct aid and 32.2% from aid transfers through GOM. Development partners mobilized extrabudgetary funds to specific departmental services, which complements assistance from NGOs and other organizations of civil society and technical assistance. It should be highlighted that external aid does not appear entirely in the health budget, which is detailed later in this report. While prepayment systems have grown nearly 10-fold over the past 20 years, they account for only one out of every 10 francs injected into health care, which is still extremely low considering the need for greater pooling in health financing. While this positive trend is to be welcomed, the funding structure for health for all is not stable enough to ensure effective UHC and compensate for the GOM's weak capacity to leverage public funds for health. In 2019, total prepayments for health from social health insurance (SHI) and voluntary pre-payments (VPI) constituted 9.0% of the total revenues for health, against 1.3% in 2000 and 1.0% in 2010. In 2019, the respective contributive shares were 8.8% from SHI and 0.3% from VPI mechanisms. It is only since 2014 (3.0%) that prepayments have started to increase proportionally to other revenue sources, on average by 1.2 percent points every year. On average, SHI raised 7.4% of the total revenues for health (2015- 19), a considerably higher share than the 0.4% observed since 2000. VPI was at 0.8% until 2009, before increasing to 1% in 2010-2014 and then falling to 0.5% in 2015-2019. Apparently, no other compulsory prepayment scheme is reported in Mali. Although data discrepancy was observed between country and WHO-reported data, the findings were aligned regardless of the data source HFSA: Mali | Technical report 74 The World Bank (NHA country report 2020 versus data transmitted to WHO for digital storage and international comparison). Figure 21: Sources of revenue for health in Mali, 2000-2020 Source: GHED 5.4 Healthcare functions and spending levels Most national spending on health is absorbed by two functions in Mali, which are curative care (hospitals) and medical goods including vaccines. The following figures detail the evolution across functions and relative shares of each function of care, as well as highlight the latest three years composition (Figure 22). Over time, curative care remained a predominant use of health financing and represented on average 44% of the total in recent years. Additionally, drugs, vaccines and other consumable commodities take another share (about 20%), making up more than two-thirds of the total with curative care. The administration of the Malian health system is another core spending function, counting for a fifth of the total. Spending on governance and health system administration and financing increased over time and averaged almost 20% of the total (19%). The higher shares on administration, especially since and in 2017, suggests a transition in public finance with full implementation of budget programs effective in 2018. The MOH oversaw four programs of budgeted activities, which expanded later on with the inclusion of two additional programs in 2020. Cumulating this share with curative care and medical goods illustrated above makes the mammoth’s share of the total, leaving a low proportion of the financing for the remaining functions that are rehabilitative, long-term and preventative care. HFSA: Mali | Technical report 75 The World Bank Figure 22: Functional allocation of health spending in Mali, 2016-2019* Source: GHED (* limited to available data) For primary care, most of the financial resource flows, both domestic and external, are apparently channeled through the central level of the health system administration. The so-called public budget (domestic financing) is carried out through State budget allocation to various implementing structures. For instance, specifically on mother and child interventions, these implementation structures are the following MoH branches i.e., State, the communes, and the community health associations (named ASACOs). According to the resource mapping estimates of the reproductive, maternal, neonatal, child and adolescent health and nutritional care investment case for 2019- 2023, 70% of the public budget is allocated to the national level, compared to 20% and 10% respectively at the regional and district levels. External resource flows, again according to the resources mapping estimates of the investment case for reproductive, maternal, neonatal, child and adolescent health and nutritional care, are mostly allocated to the national level (82%), against 17% at the district level and 1% at the regional level. It should be recalled, however, that the subnational distribution of budgetary commitments is under-documented in Mali (102). Poor control over the distribution of resources across sub-national administrative levels led to several recommendations made in the investment case for Reproductive Maternal, Newborn, Adolescent Health and Nutrition. These involve making a strong plea to the Technical and Financial Partners for better communication on the performance of existing interventions and on the need to distribute investment in this sector equitably at the regional and health district levels, based on the real needs identified at these disaggregated levels. HFSA: Mali | Technical report 76 The World Bank Prior findings have further shown that decentralization and deconcentration expenditure has been steadily growing in recent years. Central administration of the health system still captured 72.2% of spending in 2020, which was estimated at 90.6% in 2018. The projections from the public review, however, pointed out an increased share of the public health budget in infra-national administrative levels of spending, estimated to account for almost 30% over 2019-2020 against less than 10% in 2018 (76). This trend is seen as a positive change although it can be seen as low considering the increased role given to local administrations. According to Health Accounts, and within the decentralization framework, local authorities (CTs) have contributed to public financing for health, especially via capital expenditure at the peripheral level (such as the building of PHC centers i.e., CSCOMs) and wage remunerations of the health workforce. However, most of the investments in health infrastructure come from central government funding. Public resources allocated to frontline care providers amounted to XOF 164,522,000 for the CSCOMs in the Bamako District health area and XOF 197,027,150 for those in the Sikasso health district in 2018-2019 (83). 5.5 Pandemic-related financing If the COVID-19 crisis in Mali was not very severe, it did however lead to mitigation measures. Overall, by early 2023, Mali had 33,045 confirmed positive cases, 743 deaths with a major peak in January 2022, and about 17.8% of the population vaccinated (receiving at least 1 dose), according to the JHU coronavirus resource center. Measures to contain the spread of COVID-19 in Mali included the closure of borders, a state of health emergency, a ban on groupings, the closure of schools, bars, restaurants and hotels, and curfews, and worsened the economic situation. Mali’s response to COVID-19 led to budget reallocations by GOM. The budget impact assessed in June 2020 (9) referred to about 7% of Mali’s GDP reallocated to recover the COVID-19-related economic shock, of which 3% of GDP was directed to infrastructure investments for the coming years and 1.5% of GDP to subsidize the economy (salaries, rents and electricity bills for businesses). Other funding supported a series of additional compensation measures with lower taxes on real- estate transactions and other tax refunds, business support schemes and the provision of cash vouchers helping the hotel, restaurant and catering sector, etc. Another data source by the IMF suggests a lower level of budget reallocations in response to COVID-19 (103). After the initial containment measures, GOM introduced a package of economic and social expenditure measures of about 2.3% of GDP in April 2020, as well as tax relief measures estimated in the budget law amendment at 0.6% of GDP. Among the government's measures, the emergency health plan and the purchase of medical supplies was estimated at 0.6% of GDP, compared to a similar volume granted to businesses (0.5% of GDP), but greater volume was granted to vulnerable households (1.2% of GDP). The increase in social and health spending, when fully executed, should have increased priority spending by 1.5% of GDP in 2020. According to the IMF report, this set of measures was financed by grants and concessional loans from development partners (respectively 0.2% and 1.8% of GDP) and by the G20 initiative for the debt suspension service during the period HFSA: Mali | Technical report 77 The World Bank from May to December 2020 (agreement on about 0.2% of GDP, but only 0.05% of GDP was effective). 5.6 Spending adequacy for UHC 5.6.1 Per capita health spending and gap Mali spends about 35 dollars on health per inhabitant, which ranks the country among the bottom 20 countries in the world with the lowest investment in its health system. In 2020, the annual spending of about US$35.5 per capita on health was inferior to the average observed in LICs (US$38.5). It also put Mali below the level that could have been expected from the general trend (Figure 23). It is worth recalling that middle- and high-income countries spend substantially more on health, as illustrated in Figure 23. Mali's health system therefore stands among the sixteen- bottom national systems in the world with the lowest (inferior to US$40 per capita) health financing. In 2019, Mali already ranked 13th lowest in the world classification regarding per capita spending for current health expenditure. Against the income group and regional benchmarks, it was respectively the 12th lowest resourced health system of the LICs (US$39.5) and SSA region (US$37.6). Similarly, it was 7th lowest among the fragile and conflict-affected states (US$60.6). As a result, Mali lags behind almost all identified benchmarks, which suggests that higher adequacy should be found while advancing the UHC agenda. Mali’s health financing gap is substantial and estimated at up to US$ 77 per capita per year under the best-case scenario. With available financing at about US$ 35 per capita per year, Mali’s health system falls short of about US$ 35.5, US$ 50.2 or even up to US$ 76.5 per person every year – as respectively projected against several scenarios of the WHO commission on macroeconomics and health ($71) and two other projections, the generic US$ 86 for health, and an ambitious $112 for PHC in LIC targets (104–106). These could be considered as aspirational goals for 2030, therefore progressive national targets to implement the ongoing UHC reform. There is other evidence such as the WHO threshold range of investing in health at least US$ 50 to US$ 60, a threshold that would be required annually and per person to achieve the UHC goals (SDG3.8.) (107). Although these targets can be judged unattainable for Mali and eventually unrealistic, especially regarding the current levels of money devoted to health, they remain aspirational and should inspire decision- making for UHC. As a matter of fact, the Malian journey to effective UHC requires its government to consider investing more and better in health and primary care – advancing a quarter of the way to full health for all and then another quarter until the national goals are met. Achieving fair public financing of PHC is needed and cost-effective. Mali has produced limited data on PHC (Figure 23). Between 2016 and 2019, per capita spending on PHC averaged US$ 25.4 per year, with only US$7.3 per year from public funding. Considering a value-for-money ratio of 60 to 1 for investing in the expansion of immunization and 120 to 1 for universal access to contraception, the social returns on the dollars invested in health are titanic (108). Even if less optimistic returns are achieved in Mali due to the country context, PHC will remain good value for money. There is a policy momentum at the global level calling for increased and better financing for PHC. In its UHC monitoring report 2019 (109), WHO urged countries to increase their expenditure allocation on HFSA: Mali | Technical report 78 The World Bank PHC by at least one incremental percent (1%) of their GDP to meet the 2030 health targets of the UN agenda for Sustainable Development. For Mali, the 1% of GDP increment would have meant increasing PHC financing by US$ 8.6 per capita in 2020. Recently, a Lancet Commission on PHC financing also documented the necessity to predominantly finance PHC from public revenues and secure adequacy of PHC financing. Figure 23: Per capita health spending in Mali benchmarked to trend performance across income level, 2000- 2020 Per capita expenditure trend Trend performance across income level Both axes are expressed in log scale. Axis x: Income (GNI per capita, US$); Axis y: Current health expenditure (per capita, US$) Source: GHED The projection for 2050 on per capita health spending in Mali may remain insufficient and below the benchmarked projections for the region and its income group. With respect to GDP on health, the share is projected at 2.5% for 2050 in Mali, against a baseline at 3.0%. This would mean that, by 2050, health spending has been projected to reach US$ 39 (95% uncertainty: 34–44) (110). Of the projected US$ 39 for Mali by 2050, US$ 17.4 would be covered by public funding, US$16.2 through out-of-pocket spending, US$ 3.5 by developing assistance for health and US$1.9 through prepaid private spending. Such a relatively low quantum of overall health spending is the result of a combination of factors including relatively low overall government revenue generation, low prioritization for health, large levels of informality, and low utilization rates. It is interesting to compare Mali’s projections internationally. For instance, available projections for low-income countries were expected to reach US$ 46 (44–47); and, similarly, for sub-Saharan countries to reach US$ 99 (94 –106). Compared to those common benchmarks, Mali’s capita health spending only achieved 84.8% (77.3%–99.6%) of the averaged health financing projection for LICs, and much less 39.4% (36.2%–41.5%) if compared to the SSA region. It indicates that Mali’s health system may remain significantly less funded than other comparable health systems. HFSA: Mali | Technical report 79 The World Bank 5.6.2 Income growth on health Looking at health spending in relation to income growth shows that Mali devotes less than 5% of its national income to health, which is relatively low and even lower than it used to be. The indicator of health spending as percent of GDP is one of the WAEMU reference indicators for health financing that are reported in health accounts, but data was not available or validated in 2020. In 2020, according to WHO data, 4.3% of GDP was spent on health in Mali, against 5.5% in 2000. Since 2000, the investment in health as a percentage of GDP ranged between 3.7% and 5.5%, with an average estimated at 4.6% over past decades (Figure 24). Mali therefore failed to increasingly share its national income with the health sector, missing an opportunity to reduce the financing gap for health. Mali is a low-income country, meaning that the capacity to generate money remains limited. Health spending can go up to 10% of GDP in low-income settings, Mali barely ranks halfway, which confirms its low spending capacity. The country spends less than the level that could be expected, confirming Mali among the lowest spenders when compared internationally (Figure 24). Mali devoted about 1.1% less than other LICs as, on average, LICs have spent 5.4% of GDP on health. This additional 1% short could have been used to help finance PHC, as previously illustrated and recommended based on WHO recommendations (109). Figure 24: Health spending as a share of GDP in Mali benchmarked to trend performance across income level, 2000-2020 Health spending to GDP trend Trend performance across income level Both axes are expressed in log scale. Axis X: Income (GNI per capita, US$); Axis Y: Current health expenditure (% of GDP) Source: GHED During the pandemic, 2020 marked a rebound in the share of GDP on health in Mali, as in most economies, although countries’ responses across income groups differed. Many advanced economies addressed the need for additional resources for health during the pandemic by increasing health spending by an average of 1.5% of GDP, against an incremental change estimated at 0.9% among emerging economies and developing countries (80). The 2020 health emergency also boosted health spending in relation to GDP in Mali, by 0.4% against 2019 and 0.5% against the HFSA: Mali | Technical report 80 The World Bank prior 3-Year period (2017-2019). This means that the incremental increase response to the pandemic in Mali was more modest than increments observed in wealthier economies. Mali’s ability to satisfy demand for additional resources for health has slightly surpassed LICs (0.3%) and SSA (0.3%) averages but the increment was more modest than most peers (Table 7). Aspirational peers like Rwanda responded with a 1% increment during the pandemic. Except Uganda and Zimbabwe, all other structural peers responded with a higher increment than Mali. Table 7: Increment in health spending as %GDP during the COVID-19 pandemic in Mali and benchmarks, 2020 Health spending Pandemic-related 2019 2020 as %GDP increment Afghanistan 14.8% 15.5% 0.7% Burkina Faso 5.4% 6.7% 1.3% Chad 4.5% 5.4% 0.9% Congo, Dem. Rep. 3.5% 4.1% 0.5% Mali 3.9% 4.3% 0.4% Niger 5.7% 6.2% 0.5% Nigeria 3.0% 3.4% 0.4% Rwanda 6.3% 7.3% 1.0% Senegal 4.5% 5.2% 0.7% Tajikistan 6.9% 8.2% 1.2% Uganda 3.8% 4.0% 0.2% Uzbekistan 5.4% 6.7% 1.3% Zimbabwe 3.7% 3.4% -0.2% LICs 5.8% 6.2% 0.3% LoMICs 5.0% 5.4% 0.4% UpMICs 6.6% 7.5% 0.9% SSA 5.1% 5.4% 0.3% Source: GHED and authors’ calculations using GHED An upward trend can be observed in terms of public health spending as a percent of GDP, while only reaching 2%. Public spending on health averaged 1.5% of GDP over past decades, ranging between 1.2% and 2.0% and increasing from 1.4% in 2000. Mali indeed maintained a level at 1.7% of GDP after it was classified as a fragile state in 2014, against an average estimate of 1.4% during 2000-2013 (Figure 24). Regarding comparative analysis at the global level, a visualization like Figure 24 was performed, which also showed results below expectations (trendline) for Mali. This continues to place the Malian health system among the ten lowest systems in the world despite some resilience in relation to GDP. On average for 2020, public spending on health represented 2.0% of GDP among LICs and 2.4% of GDP in the SSA sub-region. Mali’s public spending on health was below both income group and regional averages when expressed as a percent of GDP. When benchmarked globally, the convergence of health spending growth in relation to national income appears below speculative expectations in Mali. Mali has progressed at a slower pace than HFSA: Mali | Technical report 81 The World Bank the trendline (Figure 25). This means that other countries are increasing their share of GDP on health. To meet the SDG3, on average, Mali as a low-income country would need to increase its annual spending on health by 4.6% of GDP by 2030 (111). It should be recalled that the domestic government share of public health spending represents approximately half of public health spending (55% in 2020 against 87% in 2000). This level is obviously below the percent share of GDP in public spending, which is largely below the aspirational goal of domestic investment in health at the level of 5% of GDP (106). Figure 25: Fluctuations of annual health and public spending in Mali and its expected convergence growth against benchmarks, 2000-2020 Trend in convergence rate Annual changes Source: Author’s calculations using GHED Lessons can be learned from the COVID-19 experience, including that resource mobilization for health could reach 0.7% of GDP. While budgetary support varied across African countries, the Malian Government took COVID-19 related fiscal measures equivalent to 3.2% of GDP, of which 0.7% of GDP in the health sector and 2.5% of GDP in non-health sectors (according to IMF Fiscal Monitor global and country estimates, as of June 5 2021) (112). This estimate is higher than Niger (0.7% of GDP, of which 0.3% of GDP in the health sector) but lower than Burkina Faso (3.8% of GDP, of which 1.7% of GDP in the health sector). SSA countries required between 1.5% and 3% of GDP as additional funding to prepare for, respond to and treat COVID-19, according to international estimations (by the WB made soon after the start of the COVID-19 pandemic and based on WHO and Imperial College parameters) (Schneider 2020), which is a lot more than Mali dedicated to health. At national policy level, along with the ‘Mali Action Plan’ 2020-2030, GOM recently committed to strengthening national efforts to increase its share of GDP on health, despite competing and sectoral demands (e.g., instability in the northern and central regions, and more recently the COVID-19 pandemic). To support its capacity to allocate additional resources to health, available HFSA: Mali | Technical report 82 The World Bank resources shall be determined at the beginning of the period in order to create a window of opportunity for the health financing policy dialogue and favor national dynamics around the MAP. Finally, health spending growth and GDP growth are likely positively associated, meaning that in general terms an increase or decrease in one of them would follow the other. 5.6.3 Prioritization on PHC spending Contrasting with global trends, Mali’s health budget strongly prioritizes its PHC, both in terms of percentage shares of health spending and GDP, although to a lesser extent if expressed in per capita terms. Mali devotes a sizable share (74.4% in 2019) of its current health expenditure to PHC. In 2019, PHC amounted to US$ 24.9 per person per year. PHC spending is predominant among current health spending in Mali, which contrasts with the general trend of the countries classified across GNI level (Figure 26). Among LICs, the share of current health expenditure going to PHC widely varies from about half (45%) to almost all (90%). But Mali’s share to PHC is significantly above the average for LICs (60%). In SSA, Mali ranked among the top 10 spenders on PHC. Figure 26: PHC expenditure in Mali against the global trends, 2019 PHC as % health spending PHC as % GDP PHC spending, per capita Legend: X axis is expressed in log scale. Axis X: Income (GNI per capita, US$); Axis Y: Primary health expenditure –– Upper left: % of Current health expenditure; Upper right: % of GDP; Lower left: Amount per capita, US$ Source: WHO-GHED HFSA: Mali | Technical report 83 The World Bank Mali’s PHC services are equally financed by three major sources of funding for health, therefore matching the total health expenditure distribution of funds. In relation to GDP, all-source PHC expenditure was equivalent to 2.03% of GDP. Each of the following major funding sources contributed to a third of the total PHC expenditure in 2019: external (36%), government public (33%) and private resources (31%). The 2019 distribution of PHC expenditure across funding sources is very similar to the distribution for total health expenditure as it was in 2019 respectively: 34%, 34% and 33% for external, government and private resources. The above does not mean that each of the health functions (HC) for PHC are equally funded by these three sources of funding. For instance, medical goods that represent a quarter (25%) of CHE are predominantly financed by private health spending (99%). Yet, 80% of this expense item is recognized as PHC (according to the WHO definition), leaving about 20% of PHC expenses on medical goods reliant on private financing mechanisms. Dental outpatient curative care services are another example for which about a tenth (14%) rely on private sources. Evidence from a literature review recalls that adequate allocation of public funds on PHC financing is needed and proven to improve equity purposes (113). Not only adequate but needs-based resource allocation formulae is also needed and proven to improve equity purposes in PHC (113). The following paragraphs explore funding flows for PHC across payers. In Mali, PHC expenditure represents the bulk of the domestic government health expenditure, capturing a substantially higher domestic commitment compared to benchmarks. On average, domestic prioritization on PHC expenditure during 2017-2019 appears significantly higher in Mali (70.8% of GGHE) compared to the benchmarks of LICs (55.7%) and SSA region (57.1%), according to the GHED data. PHC accounted for two-thirds (74.4%) of domestic government health expenditure in 2019, which was the highest percentage share since 2016. It represented in 2017, a share equivalent to 63.6%, which was the lowest percentage share since 2016. If the percentage share fluctuated between about two-thirds and three-quarters of the Government’s financial commitment on health, the level of spending on PHC remains below 10 USD per inhabitant. As a result, the Government barely covers a third of total PHC expenditure. Per inhabitant, Government expenditure on PHC in Mali passed from US$ 6.3 in 2016 to US$ 8.2 in 2019. PHC spending is predominant in donor health spending in Mali and donors can be a single payer for some PHC categories such as preventive care (85% financed by external sources). PHC spending ranged from 98.2% (2016) to 80.9% (2019) of total spending from donors, showing how much PHC is prioritized by them. Regarding PHC sub-categories relying on donor funding, about 85% of preventive care was funded by external sources, against 14% by the Government and 1% by private sources. Although important, but to a lesser extent, 48% of the general outpatient curative care services were funded by external sources, against 38% by Government sources and 14% by private sources. Except for governance and health system administration, all other PHC sub- categories of spending rely on private sources of funding. The poor evidence-based knowledge of PHC financing and PHC data gaps in Mali calls for sustained domestic efforts to generate accurate data available through national channels that could document and benchmark Malian efforts in international assessments of PHC financing. HFSA: Mali | Technical report 84 The World Bank Although PHC financing is recognized as key to improving the provision of equitable universal care in Mali and other low-income countries, a marked deficiency was shown in studies providing country context-specific evidence of financing PHC (114). In the core PHC program initiative framework, data is missing for Mali to fully determine which PHC is prioritized in the national health system compared to others (115). The only available information refers to a 2018 spending on PHC of US$ 56 per capita per year in Mali, an estimate that is much higher than the value of US$ 25.5 reported by WHO/NHA global repository (GHED) for the same year in Mali. Compared to other countries, Mali ranks low within the Min/Max spending range of 15 to 309 depending on the country. Immunization is often regarded by decision-makers and development partners as a preferred PHC financing option due to its cost-effectiveness. Yet, Mali’s health accounts insufficiently report on immunization care expenditure trends and sub-categories (Figure 27). Figure 27: Expenditure on immunization in Mali, 2016-2019 Source: GHED HFSA: Mali | Technical report 85 The World Bank 6 Budgetary efficiency, fragmentation and missed resources for health 6.1 Assessing MOH budgetary efficiency20 6.1.1 Human resources for health Spending on human resources for health represented a third of the MOH expenditure on health with excessive waste of resources (below 10%). In 2021, human resources accounted for 31.1% of the total budget and for a slightly higher 35.4% of the effective expenditure on health (Figure 28). Effective spending was respectively XOF 40.6 billion against 43.9 initially budgeted in human resources. Un-mobilized initial budget allocation for human resources was comparatively inferior (7.4%) to the overall average loss (18.7%) or to the loss on other types of expenditures (23.8%). The bottom threshold of 85% for budget execution and liquidation, as defined by the PEFA Secretariat 2016, is met for spending on human resources. Overall, spending on human resources for health mostly covers the running of MOH activities, with a relatively small proportion captured by the central administration. In 2021, the spending was expected to account for 11.1% of the total, which is in line with the 14.3% of effective spending (Figure 28). With respect to effective spending, most (57.8%) was devoted to the inputs and hospital care components nested in the MOH/Program 2. Three other allocations received more or less equitable shares of the remaining: 15.2% to social protection matters that are included in the 2021 MOH budget program, 14.3% to administration and 12.8% to PHC and disease control. 20 Preliminary notice: Budgetary efficiency was assessed for the MOH Programs 1 and 2. Due to data limitations, we focused on these program-related expenditures, but they represent the bulk share of Mali’s health allocation. Indeed, according to PRODESS-IV costing data, the budgeted expenditures were projected to account for 74.5% of the total MOH allocation, equivalent to XOF 180.2 million. Health spending channeled through other ministries was therefore exempt from the following assessment. HFSA: Mali | Technical report 86 The World Bank Figure 28: MOH budget and expenditure on human resources for health in Mali, 2021 Source: Mali Ministry of Finance 6.1.2 Health system (excluding human resources) Mali’s health system spending (excluding human resources for health), that represents two thirds of MOH expenditure on health, has been significantly under-mobilized. In 2021, the health system accounted for 68.9% of the total health budget, corresponding to a budget allocation of XOF 97.5 billion. Similarly, it accounted for 64.6% of the total effective expenditure, corresponding to XOF 74.3 billion (Figure 29). As shown above, the level of wasted resources as expressed by the gap between initial and effective expenditure (23.8%) compared to the average for human resources. The health system therefore lost XOF 26.5 bn in 2021, which represents a loss above the bottom threshold of 85% recommended for budget execution and liquidation. Overall, health system spending outside of HRH spending mostly covers the running of activities in the MOH Program 2, with skewed expenses on inputs and hospital care. According to the MOH- labeled sub-programs (Figure 29), in 2021, the relative weight of expenses made for the central administration of the health system seems relatively under control (i.e., 16.8% of the effective spending and 11.1% of the allocated budget). In contrast, inputs and hospital care appeared to capture the largest share of allocations (50.3% of effective spending and 56.2% of allocated budget), representing the best-funded budget line. PHC and disease control captured about a tenth of the total, with 11.2% of effective spending and 14.5% of allocated budget. Now compared to the ratio of initial (allocated) budget to effective spending (liquidation), all the P2/sub-programs (inputs and hospital care, PHC and disease control, and social protection) dropped, whereas the P1/program for administration received more than initially budgeted. At first sight, PHC and disease control accounted for a lot less than a fifth of the total non-HRH spending (15.0% of the effective spending and 14.8% of the allocated budget), hence registering a loss of XOF 3.3 bn in 2021. However, more disaggregated data showed that this sub-program involves several budget lines for administrating PHC and disease control services (e.g., steering and monitoring of the reform, or communication for change). HFSA: Mali | Technical report 87 The World Bank Misclassifications may therefore occur and potentially inaccurately influence data interpretation when performed with a low-level of disaggregation, which calls for a broader publication of relevant health financing data in support of policymaking in Mali. For instance, spending on inputs and hospital care may have been overestimated. Indeed, according to our own “grouping” classification based on more disaggregated budget lines, effective spending on drugs, vaccines and healthcare availability and transportation (excluding research and studies) only accounted for 37.8% of the total, instead of the above cited 50.3% of the effective spending for non-HRH expenditure. This highlights the need for very disaggregated data analysis in health and more in- depth analyses in the Health Accounts. Similarly, for the administration spending that seemed to account for 16.8% of the total, according to our re-classification model, it seems to account for up to 26.3% when including a greater range of spending that could relate to the administration (such as health planning, programming, and monitoring and evaluation (M&E), controls, human resource management, and research and studies activities) – in addition to spending classified in the P1/sub- program for steering and coordination of the health system. Figure 29: MOH budget and expenditure on health system (excluding human resources for health) in Mali, 2021 Source: MOF 6.2 Budgetary channels and expenditure fragmentation Health spending is highly fragmented in Mali, potentially spread over 14 different ministries. We assessed the budget execution data and sorted it against the “Libelle Fonction” accounting categories, for the lines containing health and social protection keywords. In 2021, a budget expenditure allocation was estimated at up to XOF 21.5 bn (i.e., initial budget as voted in the finance law), covering both health and social protection spending that was allocated outside the MOH. Of the total initial allocation, it should be highlighted that only XOF 3.7 bn was executed, equivalent to 17.4% of the initial budget allocation and 18.1% of the revised budget allocation. The allocations categorized in health spending accounted for a small share of this total, estimated at XOF 2.4 bn, almost entirely executed (95.6% of the initial budget allocation). The five categories reported by HFSA: Mali | Technical report 88 The World Bank the MOF were: i) Public health services accounted for less than 1% and were distributed to 14 different ministries and entities (across 16 budget lines), according to the following list: Presidency, the office of the Prime Minister, and the following ministries; Malians Abroad and African Integration; National Defense; Economics and Finance, Justice and Human Rights, Labor, Public Service and Social Dialogue; Employment; Territorial Administration and Decentralization; Reconciliation and Social Cohesion, Commerce and Industry; Education; Culture, Handicrafts and Tourism; Youth and Sports. ; ii) Hospital care was channeled through 3 different ministries across five budget lines. ; iii) Medical products were nested in the Ministry of Foreign Affairs and International Cooperation (1 budget line) ; iv) R&D was nested in the Ministry of National Defense (1 budget line). ; v) Other health (uncategorized) was channeled through 2 different ministries (National Defense and Education) across five budget lines. Social protection and social exclusion spending can be linked to health, which may constitute the highest volume of additional funds in support of health equity. These funds are channeled to three different ministries (Foreign Affairs and International Cooperation, Justice and Human Rights, and Territorial Administration and Decentralization). Initial budget allocation was equivalent to XOF 19.2 bn, of which less than 8% was executed (XOF 1.5 bn), essentially due to a lack of budget mobilization and engagement. More precisely, to our knowledge, the following ministries reported spending on health. We were able to retrieve data from each ministry and perform a deeper analysis with the following results: - Health spending channeled through the Ministry of National Defense accounts for 0.23% of the Ministry of National Defense effective expenditure (XOF 969 million). It refers to spending on hospital care (four budget lines), public health services (one single budget line), logistic support in health (three budget lines), R&D in health (one single budget line). In addition, Ministry of National Defense spending on social protection services (five budget lines) amounts to XOF 150 million, which is equivalent to 0.03% of total Ministry of National Defense expenditure. - Health spending through the Ministry of Education amounted to XOF 81 million (0.02% of the ministerial allocation), of which only 67.5% was executed due to a revision of the initial budget allocation. Four budget lines are available, three for central administration and one for basic services. The Ministry of Higher Education had no budget line for health. - Health spending through the Ministry of Agriculture and Rural Development was spread across seven different budget lines, of which all were related to veterinary health, a total of XOF 2.1 bn effective expenditure (liquidation). HFSA: Mali | Technical report 89 The World Bank Figure 30: Health budget and expenditure of the Ministry of National Defense Source: Mali Ministry of Finance 6.3 Comparative performance of selected competing sectors, programs and activities Our findings suggest that even if the health sector benefits from budgetary prioritization, in practice, the sector does not receive all of it. Health expenditure is indeed not fully executed in Mali. On average, over 2019-2021, the provisional budget allocation for health was executed at 78.2%. In its WHR 2010, WHO raised awareness of the financial losses due to public finance inefficiencies. A decade ago, between 10% and 25% of public health spending relating to procurement was lost annually due to mismanagement and/or corruption. Building on current public finance performance in health and prior global knowledge, Mali’s health authorities should be able to better track and learn to correct those potential financial losses. Public finance performance might be weaker in health than other sectors of the economy. Budget execution for health (78.2%) was inferior to the average (84.6%) and overall (81.0%) performance observed in competing sectors (Figure 31). Several other sectors, including other social sectors like education (96.6%) and social protection (81.5%) tend to better perform in terms of public finance management since their effective expenditure represented an increased proportion of the adjusted budget forecast (“CP, crédit de paiement”) in 2019–2021. Two other sectors covering national defense and public security have also seen higher levels of execution than those observed in the health sector during the last three years, in terms of volume executed, budget execution rate and weight in total government expenditure (116). The adjusted budget prevision sets the budget allocation for the sector, resulting from the intersectoral budgetary arbitration. The fact that budget execution in health dropped to 66.5% in 2020 suggests that the sector may face greater difficulty executing its spending, despite the general context of COVID-19. HFSA: Mali | Technical report 90 The World Bank Figure 31: Budget execution of annual forecasts (CP) by function in Mali (as of December 31), 2019-2021 Source: MOF/DGB Official report on the budget execution situation Budget execution varies across types of spending, with some programs coping with lower PFM performance for certain activities. Figure 27 shows the variability of budget execution rates for each health program, and across each activity. For instance, the program devoted to the administration of the health system was organized around ten major budget lines for activities planned during 2021. Findings suggest that at least three budget lines (1: steering and policy; 6: planning, programming and monitoring & evaluation; 7: control of social policies) faced a much wider variability in budget execution rates than others (3: HR; 10: decentralization, and 9: investment in health infrastructure). Similarly, for the PHC and disease control program, out of four major budget lines of activity, the implementation of the health policy (activity 1) and health reference (activity 3) had greater variability of budget execution across actions compared to community health (activity 2) and communication (activity 5). Other programs, like the program to improve availability of drugs, vaccines and consumables and financial access to care are more likely to be implemented in full, also the program on hospital care and research. Figure 32: Variability of health budget execution across programs and activities, 2021 Health programs Health programs by activity HFSA: Mali | Technical report 91 The World Bank Source: MOF/DGB Official report on the budget execution situation Disaggregated data offers further perspective on PFM performance in health against other ministerial, and other types of expenditure. In 2021, budget execution (as defined by the values of liquidation out of the adjusted prevision for budget expenditure) faced higher variability in health than other ministries, even if other ministries still see some exceptions. 6.4 Realities around budgeting adequate resources for the health sector 6.4.1 National mid-term budgetary forecasting The mid-term budget forecast for health until 2023 is supported by a costing exercise, with apparent underestimation of the health financing gap, at least for 2019. The costed 5-year plan for the health budget was estimated at XOF 735.9 bn for health, equivalent to annual spending needs of XOF 147.2 bn on average (Table 8). This would roughly correspond to about US$ 12 per capita per year, using the 2021 IMF/IFS official exchange rate LCU per US$, period average and UN Population Division count. The whole PRODESS IV, which covers health, social and family spending costs, would average XOF 400.5 bn annually (Table 8). Converted into per capita amounts, it would roughly correspond to a projected US$ 31 per capita on average in 2023, using the current exchange rate and assuming steady population growth. As described in PRODESS-IV, health funds would predominantly be channeled through the regions, about two-thirds (61.7%) of the total on health, on average – denoting increased decentralization of health funds compared to 2019 (29.1% through the regions). The health financing gap is substantial and potentially underestimated, creating uncertainty that may undermine the efficiency of prospective budgeting for health in Mali. As reported by the MOH in its 5-year implementation plan, about 36.8% of needs are financially covered, which means that the financing gap is projected to account for 63.2% of the total needed to implement PRODESS IV activities. In 2019, the real health financing gap (36.0% according to effective public revenues of XOF 98.2 bn) exceeded the PRODESS forecasted financing gap (26.9%), which would mean that the 2019 forecast was underestimated by Malian authorities. If divergence can be tolerated, a margin of error of about 10% highlights the MOH challenges to implement its planned activities. While the financing gap is forecast to increase, the budgetary commitments made at the highest level of the State are being met, even if they are insufficient. The PRODESS financing gap is expected to reach 65.5% in 2023, compared to the above highlighted 26.9% financing gap announced for 2019. At mid-term, the PRODESS financing gap represents an exponential share exceeding two-thirds of financing needs. At the same time, budget prioritization on health meets and even exceeds the threshold target of the Strategy for Accelerating Growth and Sustainable Development. The health sector was however forecast to lose budget prioritization as commitments for 2021-2023 (5.3%) are lower than those for 2019-2020 (6.4%). Overall, health represents 5.7% of general government budget expenditure. The percentage share of the general budgetary framework of CREDD/2019-2023 set the health allocation threshold at 5.2% of the government general budget. This gap highlights that the PRODESS-IV estimate surpasses general government estimates, which were agreed under the most optimistic scenarios. HFSA: Mali | Technical report 92 The World Bank Table 8: Mid-term budgetary framework for health in Mali, 2019-2023 Source: MOH/PRODESS-IV The prior PRODESS III was budgeted, for its health components, at 74% of the total from 2014 to 2018 (117). Social and Family promotion components respectively accounted for 21% and 5% of total budget expenditure. 6.4.2 Overview of health sub-sectors of priority actions for UHC Total and adolescent fertility rates in Mali, while slowly declining, remain among the highest in the world. In 2020, adolescent fertility rate of 152.2 births per 1,000 women ages 15–19 was higher to the global averages for sub-Saharan Africa (101.5 ‰), low-income countries (100.4‰) and fragile and conflict-affected states (90.6‰) (Figure 33). Mali’s fertility rate is estimated at 6 children per woman, which is also among the highest rate compared to peers and global averages (Figure 33). The country is among the six SSA countries with the lowest age at first marriage, female (18.8) in 2018. The proportion of teenage mothers (36% of women aged 15–19 who have had children or are currently pregnant) is the second highest in the region, after Mozambique (19). Yet, family planning is recognized as one of the least expensive, most cost-effective, and most sustainable interventions for health and development. HFSA: Mali | Technical report 93 The World Bank Figure 33: Trends in adolescent fertility rate in Mali, benchmarked to global trends for comparable groups of countries, 1960-2020 Trend among adolescents 250 (births per 1,000 women ages 15-19) 200 Adolescent fertility rate 150 100 50 0 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 Mali Low income Fragile and conflict affected situations Sub-Saharan Africa (excluding high income) Adolescent Adult Adolescent fertility rate (births per 1,000 women Fertility rate, total ages 15-19), 2020 (births per woman), 2020 Niger Niger Mali Mali Chad Chad Burkina Faso Burkina Faso Congo, Dem. Rep. Congo, Dem. Rep. Uganda Uganda Nigeria Nigeria Low income Low income Zimbabwe Zimbabwe Sub-Saharan Africa Sub-Saharan Africa Peers (sample) Peers (sample) Afghanistan Afghanistan Fragile and conflict affected… Fragile and conflict affected… Senegal Senegal Tajikistan Tajikistan Rwanda Rwanda Uzbekistan Uzbekistan 0 50 100 150 200 0 2 4 6 8 Source: UN Population division, World Health Prospects and WDI Mali has a specific Five-Year plan for family planning interventions, setting coherent priorities for 2023. MOH/General Directorate for Health elaborated in 2019 a Costed National Plan for Family Planning interventions for 2019-2023 (PANB), supported by USAID and several other partners (UNFPA, WHO, bilateral cooperation of the Netherlands, Canada and Spain). This Plan reinforces and supports the development plans already implemented in Mali, i.e., the Ten-Year Health and Social Development Plan 2014-2023 (PDDSS), which prioritizes the promotion of family planning, HFSA: Mali | Technical report 94 The World Bank aiming to reduce maternal and neonatal mortality (under the sub-program to control Maternal and Neonatal Mortality). It has the objective of increasing the contraceptive prevalence rate to 20% by 2023, through Pillar 3 on “Inclusive Human Capital Development” and the Reproductive Health Commodity Security Strategic Plan of 2016-2021. These strategic plans serve as a reference framework to guarantee the constant availability of products and ensure the provision of quality RH/FP services. Mali has also joined the ‘FP2020 Initiative’, with the aim of ensuring greater rights- based access to quality family planning services. Mali Family planning has a costed Five-Year plan of XOF 72 bn, which represents 5.7% of the PRODESS IV costing for health. The national goal (PANB) to reach a modern contraceptive prevalence rate of 30% by 2023 (against the baseline of 16.4% in 2019, according to 2018 DHS data) for all women of childbearing age would require an overall annual growth rate of 2.7% on average (against a historic trend of less than 1.5% for 2012-2018), according to the Five-Year Plan (118). Expected results based on these assumptions refer to averting 582,000 unintended pregnancies, 208,000 unsafe abortions and 2,500 maternal deaths. The implementation of the Five-Year plan was estimated to cost XOF 72,186,854,157 CFA (@US$ 124,161,389), of which 32% on demand creation; 18% on supply and access to services; 31% on commodity security, including contraceptives and consumables; 3% on policy, enabling environment and financing; and 16% on supervision, coordination and monitoring and evaluation. Each of the 29 prioritized actions and 15 planned objectives were costed annually (cf. summary table annexed to the plan, pages 122-124) Along with a costed plan, the country has an investment case for reproductive, maternal, neonatal, child and adolescent health and nutritional care, which are the focus of the GFF. The total financial needs of the Investment Case for reproductive, maternal, neonatal, child and adolescent health and nutritional care (as reported by the resource mapping in 2020) were projected over 2019-2023 and amounted to XOF 823 bn, distributed proportionally over the 5 years and representing, on average, XOF 164.7 bn annually (119). According to the scenarios as estimated in 2019, the need for financial resources would amount to XOF 116.7 bn annually (102). As expressed in terms of US$ per capita per year, it would represent about $10, ranging from $4 to $18 over time. Two alternative scenarios were put forward against national expansion, with these less ambitious scenarios only targeting priority areas. The mapping refers to priority regions with three-tier levels of priority for action, with 7 regions of highest priority, excluding Bamako and Kidal. The choice of priority regions made it possible to plan a gradual implementation of the selected interventions. For the case of national expansion (main scenario), the financing gap was estimated at about 8.5%, on average for the overall period (5 years), amounting to XOF 50 bn (102). The Five-Year Investment Case is based on the objectives of PRODESS IV and is coherent with the PDDSS (2014-2023). By prioritizing the most vulnerable areas and the major bottlenecks of the health system, the Investment Case for reproductive, maternal, neonatal, child and adolescent health and nutritional care attempts to stagger high-impact interventions to improve country health outcomes and advance the health-related SDGs agenda, essentially focusing on the main cross-cutting issues of the health sector – human resources, quality of care, supply chain management, supply and demand creation. In addition, the Investment Case for reproductive, maternal, neonatal, child and adolescent health and nutritional care prioritizes the community- HFSA: Mali | Technical report 95 The World Bank based implementation of these interventions while promoting access to health services for all, gradually scaling up by learning from past mistakes. 6.4.3 Estimated cost of vaccine-preventable diseases The cost of spending resources on vaccine-preventable diseases surveillance (VPDS) was estimated at US$ 0.02 per person per year (equivalent to US$ 0.4 per infant) in Mali, as expressed in 2015 US$ based on CMYP costing data (120). Mali’s cost for VPDS was below the average estimate for peers and regional LICs groups (Table 9). In Mali, VPDS represented less than 1% of the total routine immunization expenditure, which is five to six times lower than benchmarked averages. Further learning from disaggregated data comparisons and analyses would be needed. Table 9: Overview of vaccine-preventable expenditure in Mali against comparators and regional LICs VPD VPD Total VPD VPD Surveillance Surveillance Surveillance Surveillance as Baseline Year Expenditures Expenditures Baseline Year Expenditures, % of Routine Country cMYP Baseline Year Number of per Capita, per Infant, Population Baseline Year Immunization Births Baseline Year Baseline Year (Expressed in Expenditures, (Expressed in (Expressed in 2015 USD) Baseline Year 2015 USD) 2015 USD) Burkina Faso 2010 15.837.909,00 728.544,00 196.291,00 0,01 0,27 1,47% Mali 2009 14.517.176,00 643.111,00 254.082,00 0,02 0,40 0,96% Niger 2009 14.340.660,00 867.251,00 601.281,00 0,04 0,69 6,18% Rwanda 2011 10.240.932,00 419.878,00 102.387,00 0,01 0,24 2,16% Senegal 2010 12.200.387,00 475.815,00 406.108,00 0,03 0,85 4,35% Tajikistan 2009 7.584.858,62 219.960,90 184.399,49 0,02 0,84 3,00% Zimbabwe 2010 12.595.418,00 390.457,96 832.596,98 0,07 2,13 5,75% Average (6 peers) 12.473.906 535.003 368.164 0,03 0,77 3,41% Average (22 African LICs) 18.561.886 759.556 1.284.599 0,10 2,59 6,53% Average (30 LICs) 21.930.566 787.680 1.117.732 0,08 2,10 5,65% Average (30 LoMICs) 65.394.779 1.586.205 2.367.324 0,08 2,96 5,62% Average (all: 63 LMICs) 41.755.200 1.133.605 1.671.443 0,09 2,94 5,85% Source: Compilation using national costing in immunization (cMYPs latest data); Vaccine-preventable disease (VPD) HFSA: Mali | Technical report 96 The World Bank 7 Patterns and drivers in decision-making Chapter 7 aims to provide useful guidance for future policymaking. We explored the capacity of Mali’s health system to mobilize enough funds for health, the consequences of apparent low capacity, and the routes for higher convergence towards UHC. In this chapter, we put forward that sustained progress in transitioning to effective UHC requires adequate public and government- funded health financing, because it has been highlighted as a major driver to reach effective PHC for all by 2030 (104). The ways in which revenues for health are generated, and the structure of health financing contributions, influence the extent to which Mali’s health system will implement its national agenda towards UHC. To determine the extent that domestic resource mobilization should be strengthened, we looked at and tried to answer the following list of questions: How much is publicly spent on health in Mali?, with what contribution from government-funded spending?, what could be the lessons from the past?, and finally, where does sector financing stand in its ability to become more resilient to future shocks?. 7.1 Resource mobilization 7.1.1 Domestic resource mobilization (DRM) Post-COVID-19, between 2022 and 2023, MOH health spending by GOM increased by 33% in volume and gained less than 1% in budget prioritization. According to the latest Finance Act (2023 Initial law), health spending to the MOH was prioritized by GOM with 5.2% in 2023, gaining 0.8% compared to 2022 (Table 10). Major shares of the MOH budget were equally devoted to PHC and disease control (33.4%) and curative care services (33.0%) in 2023. The PHC and disease control budget was allocated additional funds of up to XOF 5.8 bn but those priority expenditures lost 4.5% in terms of relative share of the total to MOH. The latest Health Accounts also report that the effective budgetary prioritization on health does not meet the forecast levels as stated in the medium-term expenditure frameworks. It keeps falling short of the Abuja commitments – a threshold contribution of 15% on health. HFSA: Mali | Technical report 97 The World Bank Table 10: Post-COVID-19 health spending prioritization and breakdown allocation to MOH in Mali, 2022-2023 Development aid to Mali 2018 2019 2020 3-Y average Net ODA (US$ million) 1,556.9 1,814.3 1,565.5 1,645.6 Net ODA (% of GNI) 9.4% 10.9% 9.3% 9.9% Gross ODA (US$ million) 1,651.5 1,888.1 1,667.1 1,735.6 Bilateral share (% Gross ODA) 49.7% 56.6% 47.4% 51.2% Total net disbursments (US$ million) 1,581.4 1,845.7 1,623.4 1,683.5 Total net disbursments (US$ per capita) 79.3 89.7 76.5 81.8 Source: Authors’ calculations using Finance Act (LFI/23, 21 September 2022) Pre-COVID-19, the sector as a whole faced lower budget prioritization on health, possibly linked to the consequences of political instability, and the 2012 coup. Contrasting considerably with prior commitments to health in Mali, budget prioritization deteriorated up to 4.8% in 2019, reducing from up to 8.4% (Figure 34). Prior to 2012, the continuous efforts towards fairer and more adequate health system financing were better at securing a greater share of general government expenditures allocations. From 2004-2011, the percentage share fluctuated above the average trend of 6.7% on general government expenditure, before dropping and never surpassing the average since. Budgetary commitments on health have clearly lost impetus since 2012 and throughout the period for which Mali was classified as being fragile. In October 2019, GOM announced it would increase spending on health by 2% by 2022, but due to the 2020 crises these forecasts have not been executed (47). It suggests that the health sector competes with other sector interests, resulting in the absence of reprioritization on health in times of fragility. It is worth noting that health is even less prioritized when budget cuts are applied to initial budget allocations (LFI – Loi de finance initiale) as part of periodic adjustments (LR – Lois rectificatrices) led by the MOF. All sectors are obviously subject to adjustments to their initial budget allocations during a fiscal year, however, between 2015 and 2017, health budget allocations were revised downwards, recording the largest budget cuts. These cumulative cuts in the health budget were estimated at a loss of more than XOF 30 billion (nominal value) in three years. On average, over 2015-2017, health budget allocations were reduced by 9.3% over a fiscal year, for instance, against a reduction of 6.3% for infrastructures. During this same period, on average, other sectors registered positive budget reallocations of 0.2% for social services, 5.4% for education, 11.6% for general administration and 12.5% for defense and security. These figures come from a summary study in which authors used data provided by the MOF/DGB (121). The authors attribute these budget cuts to weak absorptive capacity in the health sector and indicate that this shortfall for the sector could have financed the Community Health Worker program for almost five years. It should be noted that the budget reallocation decisions that come from the highest levels of executive power are influenced, of course, by contextual factors, but also by the budgetary performance of the various sectors. These insights should give health a way to gain from sectoral trade-offs in the future. HFSA: Mali | Technical report 98 The World Bank Figure 34: Trends in budget prioritization on health in Mali (national estimates), 2004-2019 Source: Health Accounts and author’s calculations using data produced by the budget general directorate (DGB) Overall, post-2012, MOH budget prioritization on health has experienced a substantial decline compared to the levels that preceded periods of instability. In Mali, except for in 2019, the MOH receives low priority in the general budget and a sizable share of health spending is channeled outside of the MOH budget. It should be highlighted that a sizeable share of health budgets can be channeled outside of the MOH management. Other ministries including health matters in their portfolios have captured almost half (43.6%) of overall health spending, on average, between 2004 and 2019 (Figure 35). A unique focus at the sector level (health function) certainly hides effective budgetary prioritization given to MOH interventions, whose ministry only received 3.8% of general government expenditure. The MOH budget peaked at 5.3% but also fell to 2.4% as indicated by the range observed in budget prioritization on MOH spending since 2004. As demonstrated above, MOH failed to take effective advantage of receiving more financing while commitments on social investments were promoted at the highest level of the State and during the period in which the country was qualified as a fragile state with the exception of 2019. HFSA: Mali | Technical report 99 The World Bank Figure 35: Evolution of the budget prioritization on health through MOH in Mali (national estimates), 2004- 2019 Source: Health Accounts and author’s calculations using data produced by the budget general directorate (DGB) Comparative analytics using WHO global data led to the exact same conclusion, confirming that health in Mali is insufficiently prioritized by high-level authorities and health decision-makers. In 2020, Mali’s budgetary prioritization on health stood below the threshold used as benchmark for country-to-country comparisons, both regarding public government and total public spending on health (Figure 36). International comparison shows the extent to which the Malian health sector is coping with lower budget prioritization, better than Uganda but worse than Burkina Faso or Rwanda. Figure 36: Budget prioritization on health in Mali against benchmarks, 2020 Public spending Domestic public spending Domestic General Government Health Expenditure, as % GGE Public health expenditure, as % GGE BFA RWA BFA UZB UZB 10 10 9 SEN 9 RWA 8 TJK 8 7 TCD 7 TJK AFG 6 Mali ZWE 6 SEN UGA 5 5 ZWE 4 NGA 4 AFG TCD Mali NGA 3 3 UGA 2 2 1 Low Income Lower Middle Upper Middle High Income 1 Low Income Lower Middle Upper Middle High Income 0 Income Income 0 Income Income 280 600 2,030 4,410 10,390 16,500 30,330 53,010 117,740 280 600 2,030 4,410 10,390 16,500 30,330 53,010 117,740 GNI per capita, US$ GNI per capita, US$ Axis X is expressed in log scale. Axis X: Income (GNI per capita, Source. WHO Global Health Expenditure Database, 2020. Axis X is expressed on a log scale. Axis X is expressed in log scale. Axis X: Income (GNI per capita, Source. WHO Global Health Expenditure Database, 2020. Axis X is expressed on a log scale. US$); Axis Y: Public expenditure on health (as % general US$); Axis Y: Domestic public expenditure on health (as % gen. government expenditure) gov. expenditure) Source: GHED Public revenue on health remains at risk of deterioration in Mali, which deviates from the real need to transition from PHC fragility to resilience. Using WHO data, the health share of public HFSA: Mali | Technical report 100 The World Bank expenditure in Mali averaged 7.1% over 2000-2020, with a maximum contribution of 8.5% increasing from 7.5% in 2000 to 7.6% in 2020 (122). Public health spending is 34.9% of total spending in the sector, which places Mali on a par with its benchmarks (comparator countries), while the health sector’s share of government expenditure (5.8%) is benchmarked lower. This deviates from the national targets as local authorities did not benefit from government transfers as expected. To finance the implementation of decentralization, it was expected that 30% of budgetary revenues would be transferred to the so-called CTs (local authorities) (123). The policy tool Strategy for Accelerating Growth and Sustainable Development was developed to ensure the rapid execution of the transfer of competences to the local CT level and, above all, the transfer of resources from the State to the CTs to enable them to meet the needs of the population. Between 2011 and 2016, the CTs received between 9% and 18% of the fiscal revenues transferred to them. These transfers of revenues therefore remain modest despite their increase and fall short of the arrangements made by the State. These transfers are modulated according to the different decrees issued, and each sector has specific arrangements21. The above cited 2017 Oxfam report provides recommendations for the different level, including the CTs (123). Poor capacity for tax collection limits the volume of CTs revenues. There have also been major difficulties with the collection of tax revenues by the decentralized entities (CTs). Their weak capacity to collect tax revenue was notably attributed to a lack of awareness of, or poor application of, existing texts and regulations (2011 and 2018) (124). The lack of standardization of tools at the municipalities level also complicates their task. The study report highlights some strengths and weaknesses of the CTs mission for tax collection, proposing ways to improve regulations, accounting, management, and organization. Mali’s health financing does not favor the execution of planned health activities and low DRM for health is responsible for the lack of strategic and operational effectiveness observed in the sector. In fact, health system financing has been officially reported by domestic authorities as the main obstacle to full implementation of the PRODESS III (117). With less than 5% of the general State budget devoted to the health sector, the implementation of health activities is strongly affected. In addition to the inadequacy of public financing, the availability of domestic public resources for the health sector is often limited and delayed. Two additional limiting factors were reported as affecting health programs effectiveness, namely the declining participation of external partners (in the PRODESS) and the enormous difficulty of mobilizing resources at the community level. These comprehensive findings from country analytics therefore emphasize the significant impact of the lack of available resources in health and blame non-adequation of health financing for the failure to achieve the objectives of the health planning program. In addition, analysts lament the limited financial freedom 22 of hospitals. 21 Décret n° 02 - 314 / P-RM du 04 juin 2002 22 Faible marge de manœuvre des hôpitaux sur le plan financier - des outils comme le PBF pourraient répondre à cette insuffisance HFSA: Mali | Technical report 101 The World Bank The 2020 pandemic further strained health budgets, our findings have clearly shown a loss of prioritization (in terms of % of GDP) linked to this fragility. In 2020, finance authorities assessed the budget impact attributable to the 2020 pandemic, announcing a drastic deterioration in domestic revenues (minus 14.5% of GDP), also affecting the budgetary balances (minus 6% of GDP) (125). Investment in social protection was downsized; and crosscutting was observed across ministerial departments, according to an expert key informant (13 Sept. 2022). In 2022, the share devoted to health was estimated at 4.5% instead of the provisional 6.2%, according to DGB. Moreover, the 2019-2023 resource mapping for Reproductive Maternal, Newborn, Adolescent Health and Nutrition in Mali underlined a low commitment of the government compared to external sources of funding (102). Therefore, budget cuts or low budget prioritization on health will weaken the ongoing UHC reform in Mali. As a matter of fact, PHC financing needs more than adjustments at the margins to establish high-performing PHC, which is a key driver of the UHC reform. From a broader perspective, it is increasingly recognized that achieving greater resource mobilization from general government revenues is the best financing source for PHC (28). To avoid devastating effects on PHC, domestic resource mobilization should be widely supported by health and non-health stakeholders to cope with post-COVID-19 uncertainty and recession prospects. 7.1.2 External resource mobilization (ERM) 7.1.2.1 Support to the health sector The health system benefits from technical and financial assistance from the international community. External aid and assistance are provided by international organizations and multilateral organizations (about two-thirds), bilateral organizations (one third) and several hundred NGOs. In 2019, multilateral partners provided about 80% of the health expenditures funded by the rest of the world (Figure 37). Among these donors, UNFPA occupies first place with XOF 35,198.5 million, equivalent to a third (33.1%) of total external funding. With the Global Fund bringing 20% of the total, this is half of the external contributions. Among the bilateral donors, the Netherlands contributed 2.3% of the total but 80% of the bilateral external contributions. The composition of external financing is volatile and can fluctuate greatly from year to year, 2019 is therefore not representative of historical inflows but remains the latest year available and presented in Mali’s Health Accounts. As evoked earlier, another specificity in Mali is the presence of budget support (global and sectoral) that is presented separately. Among the social movements in Mali, there is a health consortium bringing together more than 200 NGOs and associations active in the health sector. Counting 230 members, this consortium called “GP/SP – Groupe Pivot Santé Population (www.gpspmli.org)” notably works towards greater inclusion and cooperation in health decision-making, influencing public policies on health rights through advocacy, which could be used as an opportunity to advocate for an efficient and sustainable health financing system. Between 2005 and 2020, their funding was estimated at US$ 5 million. This consortium has been an active member of Mali’s civil society organizations since 1994. For its activity as an implementer, the consortium is approved by USAID and the Global Fund. HFSA: Mali | Technical report 102 The World Bank Figure 37: Overview of the distribution of foreign aid active in health in Mali, 2019 Source: Health Accounts (country report) The GFF resource mapping was a key to tracked most recent expenditure and estimate the financing gap, which was estimated at US$ 38.7 million (13% of total tracked expenditure) in 2020. Actual expenditures were tracked for 2020 in Mali. Their publication is part of the GFF approach to help the country with the funding gaps estimate, and donor and government resources alignment. In 2020, Mali conducted the first round of resource mapping of its investment case (IC) for 2019 through 2023. The 2020 resource mapping exercise is shown in Figure 38. Figure 38: GFF resource mapping in health (in million US$ per stakeholder), 2020 Mali Resource mapping (2020), in million US$ USAID 73.06 Global Fund 55.19 Gap 38.68 Netherlands 34.69 Save the Children 25.61 World Bank IDA 20.66 Government 17.09 Other 13.16 Canada 9.12 French Development Agency 5.13 European Union 3.59 GFF Trust Fund 2.54 African Development Bank (AfDB) WHO Source: Global Facility Financing (Data extracted on May 23, 2023) HFSA: Mali | Technical report 103 The World Bank The preferred aid instrument of Mali’s donors has for many years been project-based support, which is less extra-budgetary than before. Project-based support has dominated external support in Mali, with extra-budgetary foreign transfers representing 37.9% of the forecast in 2019 compared to higher proportion over prior years (>50% in 2014 and 2015). Total ODA recorded for the year 2015 was XOF 711.7 billion, which was 11% lower than 2014. The decrease between 2014 and 2015 followed the same trend recorded by the OECD and the Aid Transparency Initiative. Forecasts for Mali’s ODA then exceeded XOF 900 billion in 2016 and 2017. Beyond increased UE aid, the increase in funding was also attributed to growing contributions from the development banks, which are becoming more involved in the aid landscape in Mali (126). Another source confirms the trend, representing approximately 50%, of which about 70% is from the EU and other sources (127). In terms of volume, another instrument is on-budget project aid, representing approximately a third or more, mainly funded by development banks. Recent trends in aid modalities in Mali, which also refers to all-sector external resource mobilization (ERM), thus including health, offers a complete overview of all modalities without division for project-based support (Table 11). As previously underlined, Mali’s aid instruments include nonnegligible general budget support (GBS), notably on health. Recent data from the MOF shows how GBS to Mali fluctuated in recent years, with shares at 41.2% (Min-max range: 26.4% - 54.0%) over 2019-2021 for GBS and 3.4% (Min- max range: 2.7% - 4.6%) for sector budget support (SBS) (Table 11). Lastly, a COVID-19 related fund was created in 2020 in response to the pandemic, but no data was available for 2021. Prior to 2015, GBS represented approximately 20% of the total volume and was mainly funded by the World Bank and the EU. Over 2003-2009, GBS was found to finance an average increase equivalent to 0.8% of GDP per year in spending on health and social development (128). Thus, GBS aid modality compared to SBS could be more efficient at increasing financial resources for health. It showed how much the social sectors including health could benefit from this GBS tool, while the contribution of SBS for health remained comparatively very negligible in terms of financial volumes. Over 2014-2015, GBS represented XOF 92.4 bn (11.5% of total development aid) and XOF 144.9 bn (20.4%) while SBS for health and education represented XOF 5.6 bn (0.7%) and XOF 18.9 bn (2.7%) (126), which confirms that the potential remained important after 2009. But it should be reminded that the country’s context matters and that current crises may not offer similar opportunities due to competing interests. Aid modality through SBS was found to have positive effects in health spending efficiency but with mixed impact in terms of raising high volumes of funds. In terms of aid effectiveness and decentralization effectiveness, it was shown that the dialogue and SBS conditionality (which emphasized the deconcentration and decentralization of resources) had enabled a better distribution of resources in favor of decentralized structures (128). It is interesting to note that the SBS aid modality, at least over a certain period, led to the resources intended for the CTs being effectively transferred to them, and on top of that provided a health expenditure tracking report. Based on the limited data available, a prior quantitative analysis had for example shown that the composition of the health budget had evolved towards greater deconcentration (over 2006-2009), with the effect that the budget share devoted to the Regional Health Directorates and Referral health centers (CSREF) had increased, while the MOH share decreased (128). It would also have contributed to increasing the number of functional CSCOMs by a third (605 in 2002 to 993 in 2009). HFSA: Mali | Technical report 104 The World Bank In addition, other positive changes were shown in terms of budgetary management and public finances in the health sector, the programming process, planning and implementation of sector policy, composition of public expenditure in the health and social development sector, and its consequences for the production of public goods and services (128). The analysis of the GBS aid modality also suggested a positive impact for health, through the modification of the structure of expenditure in favor of an increase in current expenditure (128). In addition to GBS and SBS, other budget support modalities co-existed, which was the decentralized budget support, although this was used relatively little. It corresponded to between 0.1% and 0.2% of the total mobilized and was only donated by the Swiss Agency for Development and Cooperation (126). In 2014-2015, SBS for health and education represented approximately 1% of the total mobilized and was only supplied by Canada in the Education and Health sectors (126). Sector budget support to health (through SBS) was estimated to account for about 1% of the funds and was entirely funded by Cooperation Canada, who was also the unique donator for sector support to education (126). Health sector budget support is highly dependent on Mali’s contexts and national leadership, with relative shares ranging from less than 10% to almost 20% of the total. Between 2006 and 2009, sector budget support for health and social development was funded by four Technical and Financial Partners (Canada, Spain (who joined as new contributor in 2008 due to positive experiences for prior donors), the Netherlands and Sweden23) and represented about 10% of health sector resources (against about 30% for donor projects (128). SBS represented respectively 7.5%, 13.4%, 11.1% and 11.0% of total health expenditure. Over the same period, SBS towards social expenditure (excluding health) was estimated at about 5% of social sector resource (against about 20% for the Special External Investment Budget). Overall, SBS funds were disbursed as planned, but often late in the year, which (combined with the late opening of credit) significantly delayed the implementation of activities (128). Another report showed that the share of external financing of the MOH is seen to have fallen from 38% to 9% between 2011 and 2014. SBS for health recorded a sharp decline, from an average of 19.5% between 2009 and 2011 to an average of 8.8% between 2012 and 2014. The difficult “return” of external financing combined with DP’s moving away from SBS reflects a certain lack of national leadership in relation to funding management, governance and monitoring and health financing needs. In addition, SBS financing was historically used for activities such as supervision and planning and must have had direct consequences on the functioning of Mali’s health system at operational level. More information on SBS: Regarding transaction costs linked to SBS, they have been reduced with experience and some adjustments were made after 2010 (e.g., some SBS donors had decided to provide their ABD support in a single tranche post-2010) (128). Later, the sectoral approach was developed through the creation of a Compact/International Health Partnership (IHP+) resulting from joint analysis, agreement on a harmonized PRODESS monitoring framework and joint 23 The Netherlands represented Sweden and Spain (after 2009) for SBS at PRODESS, through delegated partnerships, which confirmed a sign of harmonization between partners (128). HFSA: Mali | Technical report 105 The World Bank monitoring (128). Yet, it was not possible to show increased resource mobilization as the SBS aid modality replaced projects and therefore could not have contributed to a net increase in resources for health between 2003 and 2009 (128). Another data source indicates a substantial drop in the volume of grants received by Mali, which was directly attributed to Mali’s political and institutional crises and the Ukraine-Russia war. Mali recently faced a gradual decline in project grants, which has been estimated by UNICEF as a loss of approximately XOF 68.44 billion in 2018 to XOF 48.90 billion in 2021, an average decline of 28.6% over the 2018-2021 period - a decline attributable to the country's security and socio-political crisis (10). In the past, along with education, health was one of the two sectors that really succeeded in developing robust MTEFs. Efforts have been made to reduce project funding levels and incorporate all external funding into a single policy framework. This stage suggests that a certain rationalization and restructuring of external funding by projects were sine qua non conditions for the development of effective MTEFs (129). The above estimations of volumes drained under budget support instruments may lack exhaustivity. It should be raised that contributions from external partners do not all appear in the health budget. According to the IHP+ report, only one-third of the donors24 involved in the IHP+ 2016 monitoring cycle declared that their financial contributions were reported in the national budget (130). Table 11: Breakdown of grants modalities to Mali, 2019-2021 3-Year Grants to Mali (in XOF billion) 2019 % 2020 % 2021* % % average Projects 146.8 62.8% 163.4 39.5% 155.6 70.2% 93.4 53.6% General Budget Support (GBS) 76.4 32.7% 223.4 54.0% 58.5 26.4% 71.8 41.2% Sector Budget Support (SBS) 10.7 4.6% 11.3 2.7% 7.6 3.4% 5.9 3.4% Covid-19 funds ('Fonds de concours') NA NA 15.5 3.7% 0.0 NA NA NA Sub-total (Grants) 233.9 100% 413.6 100% 221.7 100% 174.2 98% Total revenue and grants 2,043.6 2,102.4 2,171.5 2105.8 % of total revenue and grants 11.4% 19.7% 10.2% 8.3% Source: MOF/General Directorate Budget (LFI 2023, Page 292) 7.1.2.2 Trends in development assistance We further explored the trends in development aid in Mali against regional and income group benchmarks. According to its definition, Official Development Assistance (ODA) consists of resource flows to countries which are made up of grants, loans and equity. In 2020, net ODA received in Mali was equivalent to 9.4% of GNI and a mammoth share (61.8%) of central government expenses in 2020. Since 2000, the respective shares of GNI and central government expenses have averaged 10.4% and 80.9% in Mali. ODA in Mali therefore represents a particularly sizable share of the national economy and central government expense, against comparators. On average, over a 24 i.e., the Netherlands (US$10 million), Spain (US$6.4 million), Canada (US$30 million) and GAVI (US$20 million) HFSA: Mali | Technical report 106 The World Bank recent 3-Year period (2018-2020), net ODA received in Mali was 72.4% of central government expenses, which is substantially higher than the shares observed in Zimbabwe (21.2%), Senegal (21.8%), Burkina Faso (49.5%), Uganda (50.8%) and even Rwanda (64.9%). This trend is confirmed by OECD findings that ranked Mali among the top 10 ODA recipient countries in Africa, with 2019 net disbursements estimated at US$1,816 million. More generally, the 2021 WB report on aid architecture raised awareness of the high concentration of aid fragmentation in the social sectors, including health, and requested strong evidence regarding the impact of aid proliferation and effectiveness. Figure 39: Percent shares in net ODA received (%GNI and % GOV) in Mali against benchmarks, 2000-2020 Source: WDI In general, donors reported on different weaknesses linked to the public financial management (PFM) capacities of the Government. The main weaknesses, already raised in 2016 (130), relate to delays in justifying use of funds, a lack of communication on the financing and gap between the health sector and the ministry in charge of the budget for the consideration of funding announcements (external commitments), which generates additional difficulties including their inclusion in the Finance Act. Given known financing constraints in Mali, especially post-COVID-19, the external partners have a crucial role in sustaining their support for the ongoing health financing reform for UHC. Many Technical and Financial Partners declared a greater intention to invest in PHC systems and PFM (28). This augurs a shift from investing in specific priority programs to investing in systems covering capital investments and recurrent operational costs needed for stronger PHC. However, currently, most of the ODA funding is often directed at specific communicable disease programs like HIV/AIDS, tuberculosis, and malaria. Such an allocative pattern may leave a large gap in the diagnosis and treatment of non-communicable diseases (like cancer, diabetes, and heart disease), which we know are increasing in Africa. Accelerating access to funding for PHC systems is part of the WBG recommendations, which are supported by the GFF and Global Action Plan (GAP) PHC Accelerator (28). The GFF especially pushes for better PHC outcomes, covering reproductive, maternal, HFSA: Mali | Technical report 107 The World Bank newborn, child, and adolescent health and nutrition. Mali being a GFF focus country may leverage these opportunities to further promote its PHC system. Development aid to Mali remains volatile, with lower volumes of aid in 2020 than 2019. On average, over 2018-2020, Mali’s net disbursements amounted to US$ 1,7 billion, equivalent to US$ 81.8 per capita (Table 12). Aid development was lower in 2020 compared to 2019, including net ODA and when expressed per capita. On average, bilateral aid for development to Mali amounted to about half of ODA volumes. Over 2019-2020, the top 10 donors of Gross ODA were IDA, USAID, EU institutions, the United Arab Emirates, IMF concessional trust fund, France, Germany, Canada, the African Development Fund and the Global Fund. Previously, the 2012 crisis also impacted aid commitments, with a scenario that projected a loss of half of the volume due to the instability (23). This prior study on the effects of the 2012 crisis on the economy and finances also mentioned that ODA had considerable influence on the economic growth of the country. This report also pointed out Mali’s weakness in political, institutional, and jurisdictional governance as well as the difficulties linked to the management of the crisis in Northern Mali. Table 12: Net ODA disbursements to Mali, 2018-2020 Development aid to Mali 2018 2019 2020 3-Y average Net ODA (US$ million) 1,556.9 1,814.3 1,565.5 1,645.6 Net ODA (%GNI) 9.4% 10.9% 9.3% 9.9% Gross ODA (US$ million) 1,651.5 1,888.1 1,667.1 1,735.6 Bilateral share (% Gross ODA) 49.7% 56.6% 47.4% 51.2% Net disbursments, total (US$ million) 1,581.4 1,845.7 1,623.4 1,683.5 Net disbursments, total (US$ per capita) 79.3 89.7 76.5 81.8 Source: OECD-DAC and author’s calculations using WDI for per capita terms As expressed in per capita terms, Mali’s health sector may not capture an optimal share of the overall external support on development compared to its benchmarks. On development aid, Mali most likely benefited from a higher per capita volume of external resources than the average of LICs and most peers, which contrasts support for health. On average, Mali received a per capita volume (international US$) of US$83.7 in 2018-2020 and US$75.6 over the whole past decade 2010- 2020, respectively versus US$75.9 and US$65.6 for LICs. Per capita, the trend of external overall support received in Mali is mostly above benchmarks (LICs and several peers) (Figure 40). For health, the trend is however less clear, suggesting the existence of competing interest for external support. In Mali, net ODA received has fluctuated between 60% and 85% of the general government expenditure these past ten years. The 2012 drop was linked to the military coup that caused external partners to be more critical in their assessment of the situation and led to aid sanctions (131). However, ODA on health flowed again with the return to civilian rule later that year and the holding of presidential and parliamentary elections in 2013 before suffering a further setback. Under the transitional government linked to the 2012 crisis, Mali had at the time analyzed the conditions to promote the resumption of ODA, which was vital to Mali’s recovery. Among the factors deemed conducive to the resumption of ODA post-2012, the Malian authorities noted the positioning of the European Union (especially that of France) and the USA in relation to territorial integrity and secularism. Hosting an international conference on Mali (Bamako, October 19, 2012), HFSA: Mali | Technical report 108 The World Bank the return of Mali to the African Union (AU), the prospects of future support from the WB and the IMF and finally the resumption of negotiations for the ‘11ème FED’ were already scheduled (23). Despite years of substantial inflows from Technical and Financial Partners, Mali recently received a lower volume of external resources for health (per capita) in comparative terms than its benchmarks. On average for 2017-2019, Mali received a per capita volume of US$28.6, which is close to but slightly lower than the average for LICs (US$29.7). On average for 2017-2019, four out of the five structural peers (Uganda, Central African Rep., Zimbabwe and Afghanistan) received higher per capita volumes for health. However, the per capita volume remains higher than the average for SSA, excluding high-income countries, (US$25.6). Similarly, when looking at the long run, Mali received US$28.8 per capita in 2010-2019 against US$ 26.3 for LICs. Figure 40: Net ODA received on health (per capita US$) in Mali against benchmarks, 2000-2020 Source: WDI HFSA: Mali | Technical report 109 The World Bank 7.1.2.3 Limited resources for medical research Compared to benchmarks, medical research and the basic health sector seem less supported in Mali, despite increasing annual budgets up to almost 5 times the baseline investment made two decades ago in the early 2000s. Monitoring the total net ODA for medical research and the basic health sector (according to DAC classification) is part of the SDG goals (SDG 3.b.2). This specific target is nested within the “Target 3.b” that calls to “support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, and provide access to affordable essential medicines and vaccines in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to fully use the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all”. In Mali, donor funding for medical research and the basic health sector greatly improved over time. It reached a volume of US$ (constant 2018) 131.2 million in 2018, which was almost five times the support received in the early 2000s. On average, over the last three years, Mali has spent US$ (constant 2018) 136.8 million, which is below the average spending of US$ (constant 2018) 181.8 million observed in comparator countries (n=11). Figure 41: Total net ODA to medical research and basic health sector in Mali and against peers, 2000-2018 Source: GHO HFSA: Mali | Technical report 110 The World Bank 7.1.3 Effects of the crises on development aid and effectiveness Donors will need to consider the short- and longer-term effects of crises in future projects and programs. Recently, sector specialists conducted a review of the many effects of the ECOWAS- UEMOA sanctions (embargo) decided on January 9, 2022 and the Ukrainian crisis triggered on February 24, 2022 (10). These events have undoubtedly had an impact on the socio-economic situation in Mali, particularly on the implementation of development projects and programs supported by external donors. Among the short-term stumbling blocks, it seems crucial to take into account the effects of crises such as inflation, supply chain disruptions, trade transactions and transportation costs, social infrastructure extra-costs, and undue health care costs in development support projects and programs. UNICEF has for instance identified several factors affecting its development activities in Mali, which should be of concern for other donors in the health sector (10). Firstly, the cost of development cooperation projects and programs has increased due to rising fuel prices and transportation costs, with a direct consequence on the performance of these projects and programs. Project performance has also been reduced because some activities could not be carried out and/or financing deficits have been reported. Secondly, UNICEF reports effects in the health sector notably due to the increased cost of health equipment and materials, resulting in a decrease in the quantities available and needed for health activities. In addition, the increase in the cost of health services and medicines has led to a certain decrease in the use of health services by the population, who generally fall back on traditional medicine. Finally, effects have also been noted in other social sectors such as education (with increases in the price of educational supplies and materials, difficulties in accessing private schools, closure of some public schools in several areas of the country, increases in the number of internally displaced persons due to the persistent insecurity in certain areas of northern and central Mali). Mali’s health system has experienced multiple institutional changes and copes with the country’s fragile status. Mali is among the fragile, conflict and violence (FCV) countries classified by the WB since 2014 due to the establishment of a UN peace keeping mission (132). In fragile contexts, aid is usually delivered through non-government parallel systems, even though the international community strives to avoid distortions to the national health system. Since 2012, Mali has become increasingly fragile and threats to the national health system have become a reality. Countries like Mali, with inequitable and vulnerable health systems are less prepared to prevent and respond to threats. Resilience can be defined as the extent to which the country can prepare, manage and recover from a crisis, relative to the severity of that crisis, which is sorely lacking in Mali. Mali’s capacities and capabilities are under stress, as quantified by the ‘Fund for Peace’ at a State Resilience Index (SRI) of 4.3., Violence and conflict have spiked dramatically in the last decade. Year-on-year changes of the Fragile Index Status (FSI) – which stands alongside the State Resilience Index and is also documented by the ‘Fund for Peace’ – keep worsening in Mali scoring 98.6 (maximum value 120) and ranking 14th place out of 179 countries classified as fragile in 2022, against 30th in 2015 and 79th in 2012. Mali’s situation of extreme violence and subsequent social discontent quadrupled the volume of Internally Displaced Peoples (IDPs) during 2020-2021, with an additional burden of 401,000 people by early 2022 (29). An acute HFSA: Mali | Technical report 111 The World Bank humanitarian crisis is also reported in Mali, counting half (6.3 million people) of the 12.9 million people affected by conflict and in need of humanitarian assistance in 2022 (UN OCHA, 2022). The health financing system faces several strong competing interests, diverting financial resources for health and restricting the fiscal space for public expenditure. Beyond armed conflicts, natural disasters also have a devastating impact on the health financing system, in the short and long term. By increasing the competing demands on domestic finances, these tend to further shrink government fiscal space for health. The need for the State to re-establish trust with the Malian population is a concern of the State. The many vulnerabilities shown in Mali compound poverty and poor health. We have looked at the country’s context and its multiple effects on all levels of the country's operation, including disruption to public finance. Regarding public finance, the sanctions against Mali have led to a halt in financial transactions with banking institutions, with the direct consequence of a backlog of public debt payments and a slowdown, or even a halt, to project/program work due to the cessation of disbursements of partners' contributions. In addition, no new project/program creation agreements have been signed. As for domestic debt, the government has made some arrangements for partial payment, which has helped to relieve economic operators, but the State budget has been severely affected by this situation. Humanitarian aid in Mali contributes to meeting the most urgent needs of displaced and vulnerable populations in fragile or conflict zones. The EU has granted more than €472 million in humanitarian aid to Mali since the start of the crisis in 2012. EU aid covers several areas including health, supporting access to primary and secondary healthcare and nutrition. The other areas covered by EU aid are primary food insecurity aid, distribution of basic necessities & emergency accommodation, protection interventions and psychosocial support, education for children as well as interventions for increased aid coordination and access to remote locations for aid workers. In 2023, the EU has allocated €26 million in humanitarian aid to Mali, which makes the EU the major humanitarian donor for the country. In 2021, EU humanitarian aid amounted to €36.5 million. The EU increased their humanitarian funding to €47.3 million in 2022, which included about €6 million from the European Development Fund that was used to alleviate the food crisis caused by the war in Ukraine. Over the last decade, EU support amounted to €86 million invested in nutritional care between 2011 and 2021. These EU estimates were made using data published by the European Emergency and Disaster Response Information System (EDRIS). In Mali, like almost everywhere worldwide, COVID-19 funds were raised and/or reallocated to mitigation and health measures in response to the consequences of the pandemic. If needed, these funds were channeled off-budget in Mali, most of which were therefore not subject to regular PFM rules (133). The strength of this tool, the extra-budgetary funds (EBFs), lies in its ability to avoid delays, rigidities and other shortcomings often attributed to on-budget systems. It also improves aid predictability. The EBFs tool was needed to prompt budget execution during the pandemic. A WHO e-survey (April-June 2020) gathered firsthand information from 70 country participants and showed the wide diversity of implementing EBFs. HFSA: Mali | Technical report 112 The World Bank Every country developed its own response and Mali resorted to a specific fund for COVID-19. According to the above cited WHO e-survey, Mali created a “Fonds special” using an account meant to be funded primarily from private revenues (such as donations from individuals and firms and donor grants), like Niger, Uganda and Zimbabwe did (WHO 2020, e-survey outputs available upon request). Mali’s choices contrast with countries like Chad, the DRC and Senegal where COVID-19 revenue sources were a mix of public, private and external resources. In several countries (Mali was not evaluated), their evaluation after 2 years of implementation raised that implementing such funds was not an easy task, some countries modified the design of the funds and it seems guidance will be needed for future health emergencies (134). In Mali, several decrees related to the creation, organization and functional modalities of a COVID-19 monitoring committee (JO-2020-06-12, n° 15, pp. 610-611). More generally, aid effectiveness and the efficiency of public development projects and programs in Mali have been compromised by several factors, some of which are the responsibility of the stakeholders involved in project and program governance. The Technical and Financial Partners pay particular attention to disbursement procedures, which are often at the heart of the problem of availability of external support to recipient countries. Under joint leadership of three ministries (but not the MOH) and with UNDP support, a recent review of external projects and programs has shown that the commitments made by the Technical and Financial Partners and GOM in the frame of the Paris Declaration, the Accra Agenda for Action and the New Partnership for Africa's Development (Busan) have not been fulfilled, providing mixed results in Mali (135). The study found that there are gaps in project and program governance at all levels of the process. Mali’s efforts to harmonize the Technical and Financial Partners’ actions led to agreements for collective and coordinated action and for improved governance (136). The Joint Budget Review serves as a framework for dialogue between the Government and the Technical and Financial Partners, on the priorities and general orientations of the budgetary policy and, on the main institutional, economic and financial issues. In accordance with the rotating presidency mechanism within the three Technical and Financial Partners, Germany was Lead Partner of the Technical and Financial Partners’ Collective in 2021 with the United Nations as an incoming member and Switzerland. As such, Germany was responsible for representing all the Technical and Financial Partners to GOM and other stakeholders, and also for ensuring coordination within the Technical and Financial Partners’ Collective. Germany’s mandate takes place during a period of political transition marked by many challenges (elections, security, restoration of the State and its redeployment throughout the territory, support for reforms, COVID-19, etc...) (137). Strengthening citizen surveillance of public finances and actions is one of the priorities promoted in this political dialogue. Mali has been a partner country of the GFF since mid-2018. The World Bank’s Board of Executive Directors approved, in March 2019, resources amounting to $10 (GFF) and $50 (IDA). On June 30, 2022, the GFF Trust Fund committed a total of US$817.5 million for 45 GFF country grants in 36 countries, of which most funding (88.8%) supports African countries. Mali joined the GFF in June 2018, which increased support provided in the areas of the Investment Case i.e., health financing and systems reforms, the country platform, partner alignment, and data use for decision-making. An Investment Case for reproductive, maternal, neonatal, child and adolescent health and HFSA: Mali | Technical report 113 The World Bank nutritional care (2020-2023) was validated in 2021 (102). It constitutes the final stage of implementation of the GFF mechanism, which is a financing partnership supporting the UN initiatives “Every woman, every child” and country leadership to help end preventable deaths in Mali by 2030. This document is aligned with the CREDD/2019-2023 and part of the vision of leading the country towards achieving the SDGs by 2030. 7.2 Pooling and purchasing functions 7.2.1 Legal framework behind the reform Mali has taken the critical step of overhauling a fragmented health financing system, aiming to offer greater protection against high-cost health expenditure by pooling the risk. Since 2017, Mali has developed its legal and programmatic framework for improved financial protection for health through reduced fragmentation. Mali’s health authorities’ decision to achieve UHC by 2030 was to extend health insurance to its informal sector, using the RAMU unified system for prepayments and subsidiary schemes. In 2018, a national fund and a universal health insurance scheme (CNAMU and RAMU respectively) were created and supported by a legal framework (45). In June 2018, a Council of Ministers endorsed the so-called RAMU universal health insurance scheme, auguring major reforms at several levels (including, a mandate to integrate all contributory and non-contributory health insurance schemes, contributions from all community-based health insurance schemes collected in the same way as contributions to the formal public and private sectors, state contribution of up to 80% of voluntary contributions collected by community-based insurance schemes, and creation of a national fund for UHC). In September 2018, the bill for the establishment of the upcoming RAMU was submitted to Parliament. In December 2018, the RAMU universal health insurance scheme was enacted and its decree of application voted in January 2022 (46). To date, several meetings and studies have been conducted and are underway to develop a costed plan for the RAMU universal health insurance scheme (138–140). Major aspects of the RAMU universal health insurance scheme implementation remain to be defined and regulated for the benefit package of services, premiums and costing. Prior salient steps in the programmatic and legislative processes were (139): the National Social Protection Policy Declaration (‘Déclaration de Politique Nationale de Protection Sociale’), which defines the strategic orientations of national social protection; the National Social Protection Policy (‘Politique Nationale de Protection Sociale’), which replaces a former statement made in 2011; the national action plans for the expansion of Mali’s social protection (‘PAN-EPS – Plans d’actions nationaux d’extension de la protection sociale’) successively for 2005-2009, 2011-2015 and 2016- 2018. Other commitments included: i) the creation of the National platform “One Health” in 2018 (141), ii) the creation of financial protection mechanisms for targeted groups of the population – the Compulsory Health Insurance scheme (AMO) established in 2009 covering civil servants and workers for curative, preventive and rehabilitation care, including medicines, but subject to a user co-payment for outpatient care (30%) and hospitalization (20%) (142–144); and the CANAM created in 2009 and revised in 2021 (145–148); the medical assistance scheme (RAMED) established in 2009 covering care needs free-of-charge for “indigent” populations, which is publicly funded by the State (65%) and the CTs (35%) (149,150); and the National Agency for Medical Assistance ‘ANAM – HFSA: Mali | Technical report 114 The World Bank Agence Nationale d'Assistance Médicale’ created in 2009 (151) , iii) the development of health mutual organizations since 1996 (152–154), iv) a social security code in 1962 and 1995 that included support for prenatal care and families with a child under one year old (155,156) and various texts establishing a set of “free” schemes (les gratuités). In Mali, the socio-political crisis of 2012 encouraged the arrival of new stakeholders, particularly in the field of social safety nets, to strengthen the resilience of households affected by the crisis. In 2015, the country adopted a national social protection policy (158). It succeeds the 2002 National Social Protection Policy Declaration, which defined the national strategic orientations in this area. GOM has also decided to extend the duration of the National Action Plan for the Extension of Social Protection for 2011-2015 (‘PAN-EPS - Plan d’Actions National d’Extension de la Protection Sociale’) until 2018 to align it with PRODESS. The 2018 social protection for health reform in Mali is the result of a participative process. The country held national consultations to prepare the post-2015 development agenda, which resulted in a plan for “Sustainable Human Development, Basic Social Sectors and the Fight against Exclusion” identifying priority areas for intervention (159). The Malian social protection for health scope was extended in 2017, following several recommendations made at the 3rd National Conference on Social Protection (CNPS 2017, Mali) and capitalizing on three prior studies25. The National Directorate for Social Protection and Solidarity Economy (DNPSES – Direction Nationale de la Protection Sociale et de l’Economie Solidaire) has been empowered to initiate the process of defining the social protection floor in Mali, with the support of the ILO and UNICEF. It was established in 2022, with a decree of application of the 2018 law in which the country committed to address social exclusion and extreme poverty (7). Its gradual establishment was based around four strategic commitments (160), which are: i) the Universal Health Insurance Scheme (UHIS or in French the RAMU – Régime d’Assurance Maladie Universelle) to ensure access to health services (UHC reform); ii) the social safety net programs to ensure access to basic services (food, education, and all other basic social goods and services) for children and the poorest families; iii) the guarantee of a minimum income for all workers (public and private sectors); iv) protection granted to the elderly and the disabled population. Social protection for health being part of the PRODESS IV (7) is fundamental for UHC. The new RAMU single-scheme model is to be managed by a single purchasing agency (CANAM). The 2022 decree (art. 126) requires CANAM to set up contingency funds (in the form of a cashflow reserve, a security reserve and a technical reserve) to cope with conjunctural fluctuations, uncertainties affecting expected revenues and expenditures or to temper future fluctuations in premiums. The decree also imposes regular actuarial studies (every 3 years) to support the sustainability of financial balance. RAMU is expected to cover the provision of a basic benefit scheme nationwide, funded by a mix of contributory memberships and non-contributory funding (45). The 2022 decree mentions the option of complementary coverage for those affiliated with the basic coverage. The 2022 decree explicitly lists the main financing sources for establishing the 25 These are: (i) Cash Working Group study on the Minimum Household Expenditure Basket (PMB – Panier de Dépense Minimum des ménages), (ii) UN World Food Program study on the definition of the Integrated Social Protection Package, (iii) Study on the extension of social protection to Mali’s rural populations sponsored by the DNPSES/World Food Program and carried out by the Institute for Research and Applications of Development Methods (IRAM) with the support of Miseli and G-Force. HFSA: Mali | Technical report 115 The World Bank RAMU (46). The poorest and most vulnerable beneficiaries will be provided full coverage (RAMED). The innovation was in integrating existing financial protection schemes under the same umbrella. RAMU therefore brings together a compulsory health insurance scheme (AMO – Assurance Maladie Obligatoire), the network of community-based health insurance schemes and the non-contributory medical assistance scheme (RAMED) for indigents. This reform augurs a sound reorganization of the health system, with CANAM overseeing the RAMU’s management. Despite the stimulus brought on by the MAP reform, many segments of the Malian population remain uncovered or have low financial protection for health, notably due to the high fragmentation of Mali’s social protection for health. Mali’s UHC resolution was made in 2005 but it took until 2013 before the concept was embodied (8) and an additional few years for Mali’s authorities to elevate the UHC reform to a presidential initiative (on February 25, 2019). 2019 is halfway to the horizon of the PDDSS for 2023. Social protection for health remains highly fragmented and provided through multiple schemes (AMO, RAMED, other insurance schemes, the free care policy, social safety nets). As a result, and despite the efforts made in terms of coverage of the population through AMO, RAMED and the mutual funds, the national health coverage and financial protection for health reached to date are far from the national targets and Mali’s political commitments. RAMU’s coverage currently protects about one in seven Malian citizens, which leaves too many Malians behind. In terms of statistics, the total number of people covered by the RAMU-combined schemes (AMO, RAMED and mutual health insurance) amounted in 2021 to 2,969,285, which corresponds to a coverage rate of 14.1%. Regarding the RAMU, the key activities carried out in 2021 have focused on four interventions: (i) the organization of information days for the implementation of the RAMU scheme in the regions; (ii) adoption of the RAMU implementing decree; (iii) the establishment of a select committee to accelerate the implementation of RAMU; (iv) the holding of a consultation workshop for stakeholders on the integration of free services into the RAMU (10). An official press release dating from January 2019 put forward an estimate of the social protection for health coverage in the country, announcing that combined coverage schemes (AMO, RAMED and mutual health organizations) would cover up to 12% of the total population and therefore protect approximately 2.2 million Malians. This 12% RAMU coverage was confirmed by other ministries in 2019 (11). The SDG indicator reflecting on the proportion of the population covered by at least one social protection benefit provided a more optimistic coverage estimate of 9.3% in 2020, according to ILO Database. The same source of data also informs on Mali’s statistics for the proportion of vulnerable populations covered by the social assistance program (5.8% in 2020), the proportion of children and/or family receiving cash benefits (5.4% in 2016), the proportion of retired people receiving a pension (2.7% in 2016) and the proportion of people with severe disabilities collecting disability social protection benefits (0.6% in 2016). The RAMU reform is highly challenging considering Mali’s country context and related upcoming developments. As Mali’s ambition is to progress towards 87% coverage by 2030 (139), the country must urgently increase its efforts to accelerate the pace of progress. Mali has only progressed by 2% between 2019 (12%) and 2021 (14.1%). At this speed, it would take about 72 years to meet its 87% target (i.e., 88% coverage in 2095). Moreover, this would only be is the pace of progress is HFSA: Mali | Technical report 116 The World Bank steady, requiring the absence of backward trend due to external shocks, population growth, arrears in health financing or simply capping capacity of the existing schemes. The major upcoming challenge for the country will be to extensively use global experience and overcome its capacity constraints in order to make the RAMU reform effective and efficient as Mali’s authorities aspire to a fairer and more inclusive society. 7.2.2 Effects of limited financial protection for health Mali’s weak capacity and moderate pooling of revenues for health limit its ability to foster social protection for all or to provide a subsidiary system for the poor. Insufficient health care and social infrastructure affects large segments of society, with almost no effective capital- funded schemes to guarantee welfare. The Malian State is unable to systematically combat financial hardship from user fees. The existing health insurance, l’Assurance Maladie Obligatoire (AMO), initially open to employees and civil service agents, had, by 2018, expanded its offer, to include voluntary insurance for everyone. Nonetheless, coverage throughout the country remains low. Access to social security and health care insurance remains limited due to the predominance of the informal sector, where workers do not have any coverage. A lack of financial protection also has a direct impact on the functioning of care providers. The viability of front-line healthcare facilities (CSCOMs), which are central to UHC, is highly dependent on the population's use of the health services offered as cost recovery often represents up to half of facilities’ revenue, meaning significant out-of-pocket payments by patients (76). Public resources that are transferred to frontline care providers are insufficient to cover the running costs. This lack of alignment of intergovernmental transfers to their needs leads to persisting imbalances between local health expenditure needs and weak local tax collection performance (76). Although a devolution framework has long been established in Mali and the transfer of resources to the local level has also begun, intergovernmental fiscal transfers and allocations remain largely insufficient, unpredictable and not based on need. This situation creates and/or exacerbates additional inequities in access to essential care services. The imbalance in the distribution of resources between subnational governments is widely reported. Shortcomings of public resources to local levels of care provision also means the ASACOs need to rely on cost recovery systems, through user fees charged at the point of service, and therefore to manage the volume of PHC services provided. Nevertheless, the health financing transition to reduce OOP reliance has started in Mali. The health financing transition refers to the process by which out-of-pocket payments on health are progressively replaced by risk-pooling mechanisms. When looking at the progress made over past decades, Mali can be qualified as being in the early stages of health financing transition ( Figure 42). In simulations made with a shorter scope, for instance focusing on progress made since 2015, Mali’s position would be on the border of the rapid transition zone. This suggests that the pace of transition accelerated along with the implementation of the previous Five-Year plan (PRODESS III). HFSA: Mali | Technical report 117 The World Bank Figure 42: Health financing transition over past decades in Mali, 2000-2020 Source: GHED (2022) and WDI (2022) êï Legend: Data is for countries with OOP share superior to 20% in 2000 From the demand-side perspective on specialized care, co-payment and subsidized care at regional and national hospitals remains limited, leaving about two-thirds of inpatient care billed in full to the users. According to additional information from the statistical yearbooks (SIH 2021), on average in 2021 for both 2nd and 3rd hospital care referral systems, 66.6% of inpatient payments were billed in full to the users without any type of co-payments. The proportion varied depending on the level of referral, with 62.7% and 70.4% respectively at the 2nd and 3rd reference. As for users benefitting from the free policy, it represented 7.9% on average in 2021 for both 2nd and 3rd hospital care referral systems. Similarly, the proportion fell to 1.1% on average for the 3rd referral level and corresponded to 15.1% on average for the 2nd referral system. The 2nd referral hospital of Mopti recorded the highest proportion of free-of-charge hospitalization, up to 31.8% in 2021, which was notably attributed to the free hospitalization of children aged 0-14 years and the war wounded. It should be noted that the Point G hospital did not provide information on the method of payment for hospitalized patients at the admissions office. The following table presents the incidence of each financing method in 2021 (Table 13). HFSA: Mali | Technical report 118 The World Bank Table 13: Inpatient care use of the 2nd and 3rd referral levels of service across payment modalities in Mali, 2021 Number of users (2021) Proportion of users (2021) Hospital care 3rd referral 2nd referral Hospital care 3rd referral 2nd referral Health financing modalities (2nd + 3rd) (national hospitals) (regional hopsitals) (2nd + 3rd) (national hospitals) (regional hopsitals) No co-payment (billed in full) 429,731 225,079 204,652 64.3% 67.4% 61.1% AMO 80,894 80,894 0 28.2% 24.2% 32.2% RAMED 13,122 10,812 2,310 2.2% 3.2% 1.1% Mutuals 3,412 823 2,589 0.6% 0.3% 1.0% Other 6,178 5,318 860 1.2% 1.6% 0.8% Half-subsidization 10,997 9,802 1,195 2.8% 5.2% 0.5% Free-of-charge 2,523 1,461 1,062 2.2% 0.4% 4.0% Total 546,857 334,189 212,668 14.5% 14.6% 14.4% Estimated bias in estimation 36.5%(-) 37.0%(+) Care use (consultations/population) 2.6% 1.6% 1.0% Source: Hospital yearbook (SIH 2021) 7.2.3 Components of existing financial health protection 7.2.3.1 Segmentation prior to the reform Mali’s pooled prepayments resources for health are fragmented as they have been managed by several social security institutions. In Mali, the pooling function was based on a multiplicity of insurance schemes, with the main following providers: the so-called CANAM National Health Insurance fund, the National Institute of Social Welfare (INPS), the Malian Social Security Fund (CMSS), the ANAM agency for medical assistance and health mutual organizations. The INPS and the CMSS are Delegated Management Bodies (DMOs) of CANAM operating under a convention. As it has been reported in the Health Accounts, the health insurance function is managed across different systems created to target distinct groups of populations, with a high degree of fragmentation and lacking linkages between them. The financing system is complex and brings together many stakeholders and levels of power. Several funding mechanisms co-exist. Fragmentation has negative effects on UHC achievements and greater efficiency must be promoted (121). The stakeholders and funding sources for health coverage comprise the State budget spread through the MOH and several other ministries (such as the MDSSPA, Defense, ME), cost recovery system (user fees), free-of-charge services (c-section, malaria, U5children and pregnant women, ARV, etc.), AMO (INPS and CMSS both sub-organizations of the CANAM), RAMED (ANAM agency for medical assistance), health mutual organizations (UTM), referral and evacuation systems, village solidarity funds, financial contributions to ASACOs, local authorities (CTs), entrepreneurs (private insurance, direct services, etc.) and development partners. Mali’s system currently operates under two autonomous organizations (CANAM and ANAM agency for medical assistance), which is a choice that goes against resource pooling and management efficiency. CANAM manages compulsory health insurance (AMO) for the formal sector, similarly the ANAM agency for medical assistance manages RAMED for the indigent, with a network of mutual health organizations expected to cover the non-poor informal sector. The health financing system is therefore characterized by a high level of fragmentation (health insurance, aid HFSA: Mali | Technical report 119 The World Bank funds, exemptions) between several agencies (CANAM, ANAM agency for medical assistance, mutual health organizations, Central Directorates of Ministries). The emergence of new institutions or financing arrangements like the PBF expansion without seeking articulation with existing social protection systems, in particular the fee-exemption policies, would lead to additional inconsistencies and persisting fragmentation, including in the legislative texts. According to the findings from a provisional report on RAMU (139), the system in force is very fragmented, lacks transparency and is proving counterproductive to the implementation of RAMU. The main stakeholders in charge of insurance mechanisms (i.e., AMO, RAMED, AMV) are however all aware of the limits caused by the high fragmentation and the difficulties specific to each mechanism. It should be highlighted that the current system is still made up of “partitioned” social protection mechanisms, which are not systematically effective and cover barely more than a fifth of the total population (22%) (139). The poor knowledge of the populations targeted by the different schemes and the absence of explicit strategic goals (linked to the lack of coherence of the existing framework) are two factors mentioned by the experts which would explain the low coverage rate of the population observed to date. In order to provide greater clarity on the respective contribution of each of the components of this “partitioned” system, the various aspects are further discussed in the following paragraphs. 7.2.3.2 Public health insurance schemes AMO’s and RAMED’s benefit packages are defined though a single nomenclature of medical acts and medicines. The services covered by both the CANAM and ANAM agency for medical assistance comprise preventive and curative care, acts of general medicine and medical and surgical specialties, pregnancy-related monitoring care, childbirth care and its aftercare, and care related to hospitalization and surgery. The services exclude other services that comprise eyewear, dental care such as prostheses, cosmetic surgery procedures, services provided in the context of so-called alternative medicine, as well as all other services that are not listed in the MOH nomenclature of medical acts and medicines. Under the RAMED scheme, access to the benefit package, in the public sector, is free of co-payments. Under the AMO scheme, beneficiaries must make a co-payment but should access the same package. AMO relies on a mix of contributive participation and subsidization, RAMED is subsidized. AMO is financed by contributions, shared between employees and employers. CANAM also receives a public subsidy. From a financing standpoint, AMO’s benefit package is considered by some to be attractive although expensive for the system. This contrasts with the voluntary models (AMV) that are considered much less attractive in terms of coverage but more interesting from a financial viability point of view (139). In this regard, a recent analysis indicated the importance, considering these two observations, of reconciling these two to make the RAMU attractive and sustainable (139). AMO’s coverage may have reached about 7.5% of the population. With regard to AMO’s scope of coverage, this scheme registered 149,802 new insured people distributed according to the following two statuses: CMSS counting 71,681 people and INPS with 78,121 people. As at 31 December 2021, the total number of people registered (including beneficiaries) therefore HFSA: Mali | Technical report 120 The World Bank increased to 1,576,510 people, broken down as follows: CMSS: 771,641 and INPS: 804,869 (10). This volume of AMO insured people represents 43.9% of the target population and corresponds to 7.5% of the total population. This coverage rate is nevertheless down compared to that of 2020 (8.27%). This drop was attributed to a change in counting (notably the removal of duplicates when switching from the old “Esquif” system to the new “ACTIV PREMIUM” system). According to national data extracted from SiSo 2020, more than 600 thousand people have benefitted from AMO with an average expense of XOF 64,302.0 per beneficiary. Our calculations using trendline data produced independently using CANAM information (139) referred to an average of XOF 56,490.3 per beneficiary over 2014-2021 (respectively per beneficiary XOF 69,406.3 in 2021, XOF 72.912.6 in 2020), which broadly corroborates the yearbook estimate. According to national yearbooks (SNIS 2020), the majority of individuals enrolled with the CANAM for AMO are contractualized (64.8%), a fifth are civil servants (20.2%), 7.7% are military staff and most of the remaining relate to voluntary insurers (7.3%). A total of 87,528 beneficiaries were covered for AMO in 2020 (‘situation de l’immatriculation’). Prior to 2014, AMO was estimated to cover about a fifth (17%) of the target populations effectively covered by at least one of the schemes (AMO, RAMED or mutual health organizations), but more than half (57.9%) of those that have used the coverage schemes (161). Roughly, prior to 2014, AMO’s coverage rate of its affiliates was estimated at 13.9%, with about 365,000 beneficiaries for about 2,365 thousand affiliates (161). It is worth noting that this 2020 comparative study used data prior to 2014, which suggests that data availability for country comparisons is limited. RAMED’s coverage complements protection against financial health risks, but this scheme still needs sustainable funding to ensure the continuity of its services. With regard to RAMED, the scheme recorded 114,074 new registrations during 2021. However, the cumulative number of registrations fell from 823,209 in 2020 to 937,283 as at December 31, 2021 (10). The number of beneficiaries served experienced a sharp decline between 2021 and 2020. In 2021 only 35,780 treatments were carried out, compared to 52,506 in 2020. This drop was attributed to the following reasons: (i) low attendance at health establishments due to the coronavirus pandemic; (ii) the reluctance of some health structures to take care of indigents due to unpaid bills. With respect to national data from statistical yearbooks for RAMED, a total of 104,017 people were covered and only a quarter of the headcount (27,135 people) were effective beneficiaries in 2020. RAMED used to cover around 593 affiliates (for 369 beneficiaries) in 2011, which increased to 2,269,526 affiliates (for 56,271 beneficiaries) in 2021 (139); these figures differ from the above cited but still reflect the trend in RAMED coverage in Mali. According to another data source from the literature, prior to 2014, RAMED’ was estimated to cover 5% of the target populations effectively covered by at least one of the schemes (AMO, RAMED or health mutual organizations) but very few (1.4%) of those have used the coverage schemes (161). Roughly, prior to 2014, RAMED’s coverage rate was estimated at only 1.1%, with about 8,700 of beneficiaries for about 775,000 people under this scheme (161). According to data from the ANAM agency for medical assistance, for the years 2018- 2022, the State would have (on average) contributed up to 77.8% of the revenue to the scheme compared to only 1.3% coming from the funds collected by the CTs, the rest not being specified. RAMED’s financing framework is relatively vague as the institutional arrangement was for about two-thirds of revenue to come from the State (65%) and one third from the CTs (35%). Practice has HFSA: Mali | Technical report 121 The World Bank shown that the latter do not ensure their share of contribution (161). The financial intervention of the State also turned out to be less than needed and unsecure, in particular because this scheme has experienced serious budget deficits in certain years, notably due to large cuts in State revenues to RAMED. The budget was in serious deficit, peaking in 2020 at an expenditure ratio of around 3.7 the level of revenue for the operation of this scheme, having also suffered a significant deficit (ratio of 1.9) in 2018. Hence, the average annual expenditure was approximately 1 billion, estimated in balanced budget over the average duration. 7.2.3.3 Private health insurance schemes To overcome the lack of equity and social justice in access to care, Mali’s strategy was to rely on civil society organizations for better social coverage of the population. Community organizations like mutual health organizations, associations and other NGOs provide voluntary pooling of funds, which remains limited and limiting. Before the introduction of mandatory prepayments for health (AMO and RAMED) in 2009, pre-existing health coverage plans were entirely organized on a voluntary basis, either through mutual health organizations or private insurers. These structures are self-managed at the community level, and their coverage packages directly depend on the care services delivered by the health structures for which they have a mandate (161). Because of this, all these structures do not systematically offer the same services. Mali’s policy for social protection for health has a growing network of mutual health organizations, acting as voluntary health insurance schemes (VHI26). They are a product developed by the Technical Union for Malian Mutual Organizations27, which is financed by social contributions (premiums), public subsidies from the State and financial support from its partners. Since 1996, the mutual health organizations have benefited from several texts and regulations, but it was during an institutional reform in 2000 that this network gained visibility, in particular thanks to the creation of two structures. These were: 1°) the National Directorate for Social Protection and the Solidarity Economy and, 2°) the Support Center for Associations, Mutuals and Cooperative Societies28. These were the first third-party payment systems different from those developed by large insurance companies in Mali (139). After 2009, their practices further evolved, notably thanks to UEMOA’s recommendations (N°07/2009/CM/UEMOA du 26-Jun-2009) for a better alignment of social protection schemes across its member states (139). The country has also developed a national strategy for the expansion of health coverage by mutual health organizations29 which was adopted in February 2011. This private network is therefore an important component of social protection for health in Mali. 26 Assurance Maladie Volontaire (AMV) 27 Union Technique de la Mutualité Malienne (UTM) 28 Centre d’Appui aux Associations, Mutuelles et Sociétés Coopératives (CAMASC) 29 Stratégie Nationale d’Extension de la Couverture Maladie par les Mutuelles de santé HFSA: Mali | Technical report 122 The World Bank Despite political and strategic efforts to support the development of mutual health organizations in Mali, their coverage remains very limited. Mali’s mutual health organizations cover about 5% of the population and were at 4% in 2013. Mali has been “innovative in creating mutual health schemes through a 2010 strategy to extend insurance coverage (51). Through this strategy local solidarity funds30 have been organized to support the emergency transportation of pregnant women to the health center.” In 2017, a study by a Belgian network in support of the mutual insurance movement described the evolution and landscape of these mutual health organizations in the country (162). By 2014, the country had a network of 187 health mutuals, of which 174 (93%) offered coverage for health whereas the remaining only covered risks in agriculture and/or retirement and deaths – however with less functionality in the Northern region of the country. The coverage rate was estimated at 4.5% of the population in 2014, which remained very limited and corresponded to about 308,354 beneficiaries, according to data reported by the National Directorate of Social Protection and Solidarity Economy. This was, however, an improvement as the coverage level was 0.6% in 2004. More recent figures have been compiled from county data transmitted by the DNPSES, suggesting that the network further expanded its coverage from 79,443 registrations in 2016 to 235,812 in 2021 and, according to our calculations, predominantly covered spending made at frontline care providers which are the CSCOMs (74%) and the CSrefs (10%) (139). Deductions made, these mutuals seem to cover none or very little of the costs incurred during hospitalization, specialized care and drugs outside the first line of care. According to our information, as at December 31, 2019, the voluntary insurance networks affiliated with the INPS had approximately 20,894 members, all schemes combined –in addition to the 235,812 members cited above. More than ten years ago, Mali’s authorities announced a plan to expand health coverage by strengthening the network of mutual health organizations. In May 2010, Mali launched a national strategy for the expansion of mutual health organizations (SNEM), with the intention to significantly improve financial protection for health. The plan was expected to reach populations employed in the informal and rural sectors. Three priorities were put forward, which were 1) reaching increased membership counts in mutual health organizations among the informal and agricultural sectors, 2) improving quality of service delivery, and 3) increasing domestic resource mobilization. The goal of increasing the coverage of health risks by the means of mutual health organizations included five areas of intervention: a) strengthening the collection of contributions from mutual health organization members, b) local resource mobilization, c) subsidization by the State and external partners, d) donations and legacies as well as sponsorships (such as “parrainage et jumelage”), and e) the establishment of income-generating activities. The SNEM commitments were initially poorly implemented, as suggested by the low level of budget execution. For the pilot phase (2012-2014) of the implementation of the SNEM strategy31, the budget execution rates were insufficient (e.g., 19.1% for public transfers). An evaluation of the 30 Caisses de Solidarité Locales (CLS) 31 Stratégie nationale d’extention des mutuelles de santé au Mali, which was describe previsouly (cf. chapter Pooling resources for health). HFSA: Mali | Technical report 123 The World Bank SNEM in 2015 concluded mixed results, with achievement rates of only 20% in terms of activities, 4.5% in terms of beneficiaries and 2.2% in terms of memberships (against planned objectives). It is known that voluntary uptake of community-based health insurance is highly influenced by several socio-economic factors (e.g., education, age, female household heads and income) (163). Beyond these factors, it is interesting to see that people are more likely to enroll if they understand and trust the functions and management of the insurance scheme, and if there is a clear legal or policy framework. This means that governments can act to broaden the membership base. Quality of care is an enabler whereas lack of affordability and inappropriate benefits package are disablers. The GOM created a specific fund to support and boost the development of Mali’s mutual health organizations. Financial contributions to these mutuals however remained largely dependent on, and dominated by, voluntary premiums collected at the community level. The funds pooled thanks to the membership fees were marginally complemented by government-funded financial contributions (“Mutuelle” Support Fund) to compensate for the limited ability to pay of the mutuals’ members (JLN UHC Forward). Recent evidence from a scoping review on community- based health insurance schemes in West Africa highlighted that targeted financial support could increase membership and that the low-income of enrolled households was a factor that is negatively affecting membership’s contributions (164). To sum up, the voluntary insurance schemes prevailing in LMICs require accompanying measures and a strong, clear and adequate framework and financing to increase the effectiveness of their actions (163). 7.2.3.4 Policy developments and the way forward Although validated at the technical level, the National Health Financing Policy for UHC (2014) lacks robust financial sustainability. GOM expressed some reservations and requested additional studies (on innovative health financing mechanisms, bridges between the various existing schemes to reduce fragmentation) in order to proceed with political adoption (162). Reduced fragmentation is pursued in Mali and has been endorsed under the health development plan. Establishing a single risk management organization (RAMU) for all UHC-related mechanisms (AMO, mutual health organizations, RAMED, fee-exemption policies) has been introduced with the ongoing Ten-Year health plan (PDDSS) 2014-2023 (8). By making health insurance compulsory, GOM is willing to accelerate the path towards UHC. According to projections, there will be, by 2023, in Mali: 1) a single central fund based on the existing CANAM that establishes the pooling of resources, the contracting of health facilities coupled with medical control, the management of enrollment and the information system, and actuarial services; 2) delegated management bodies (DMOs) for salaried employees (INPS), for civil servants (CNSS) and for the agricultural and informal sectors (the mutual insurance company), including the indigent. These delegated management bodies will be accountable for collecting contributions, pre-registration and purchasing services. This means that the mutualist movement will get a central role in the implementation of Mali’s RAMU. 7.2.3.5 Medical and health assistance programs Mali has developed a Unified Social Registry (RSU) system, newly created in 2022. The RSU is an information and data management system aiming to define eligibility to access the various social HFSA: Mali | Technical report 124 The World Bank protection or poverty reduction programs. With the recent adoption of a decree (no. 2022- 0276/PT-RM of May 9, 2022), the RSU establishes a unique and national registry compiling all vulnerable groups of the country’s population. The data making up this RSU must be consolidated from existing data coming from several different registers that are recorded at different levels. The purpose of this RSU approach is to achieve better coordination and efficient management of social projects and programs, while addressing a knowledge gap that had already been observed in the management of existing social safety net programs. Due to Mali’s recent contexts and threats, the segment of the population in need of social assistance has grown since 2020. The number of “poorest” households covered by social transfer programs has increased from 1,937,698 beneficiaries of social transfers to 2,316,654 people between 2020 and 2021, which largely exceeded the national target (1,196,726 transfers) according to UNICEF reporting (10). As indicated in the background section of this report, the effects of the crises experienced by Mali’s population largely explain the growing number of people receiving social transfers. Since 2013, the social assistance program (Jigisémèjiri) has been provided outside of MOH supervision to targeted households, with external support. The social safety net program has received external support since its initiation, with the support of up to five donors32. The program aims to reduce poverty and improve human capital accumulation, including a demand-side financing arrangement (165). Increased access to targeted cash transfers for poor and vulnerable households while building an adaptive national safety net system is based on four mechanisms in Mali, which are i) a cash transfer program and its accompanying measures; ii) the establishment of a basic safety net system; iii) project management; and iv) the contingency Emergency Response Component. The project was implemented by Mali’s MOF through a management unit in charge of the program (166), but a partnership with the ANAM agency for medical assistance has been signed. The scope and coverage of the social assistance program has expanded over ten years of activity (2013-2023). The social assistance program intervenes in the 133 municipalities distributed in the regions of Kayes, Koulikoro, Sikasso, Ségou, Mopti, Timbuktu, Gao and the District of Bamako. As at January 2020, it covered 70,000 households (according to the RSU website), which was in line with prior data of 62,000 households in 2015 (158). Most recent data from the WB refers to cumulative households that received cash transfers estimated at 101,961 beneficiaries in 2023 (166). It provides unconditional cash transfers to identified beneficiary households, complemented by other measures. The monetary amount provided is XOF 10,000 per month, distributed quarterly (XOF 30,000 per quarter) (158). Additionally, it offers accompanying measures (communication activities by NGOs) and in-kind delivery of preventive nutrition packages to about 60,000 households (as estimated in 2015) (158). Over 12,000 households have benefited from the first installment of cash transfers to start income generating activities (166). The extension of the project closing from December 30, 2022 to June 30, 2023 intends to sustain cash transfer payments, support the implementation of income generating activities and provide accompanying measures aimed at 32 In 2013, the main donor was the World Bank but it has been extended to other donors. Current partners also include UNICEF, UN World Food Program, European Union and the UN Organization for Food and Agriculture, according to the RSU website. HFSA: Mali | Technical report 125 The World Bank strengthening human capital. The major results achieved are as follows: According to a midline randomized impact evaluation, most beneficiaries spent the entire transfer amount within a week of receiving it and reported using it for food, health, livestock and education (167). The program succeeded in increasing the proportion of households classified as food secure, improving dietary diversity and quality. Regarding health impacts, a small reduction in the prevalence of diarrhea in children aged 6–23 months was reported but no other reduction in child morbidity, which was attributed to poor access to, and low quality, care services. 7.2.3.6 Fee-exemptions policy programs After 2000, a series of new public policies aimed at exempting certain patients from paying for care were introduced, which complemented prior policies established to control leprosy and tuberculosis. In Mali, several ‘free’ programs were introduced in the mid-2000s to deliver free-of- charge treatment of malaria for U5 children and pregnant women (Decree n°06-565, 29/DECEMBER/2006), HIV (Decree n°05-14, 5/MARCH/2005; and n°05-546 20/DECEMBER/2005), and c-section (Decree n°05-350, 04/AUGUST/2005). Mali’s approach to benefit the poorest groups was based on four components: disease targeting (diseases and infections of poverty, reproductive health), geographical targeting (rural and poorest settings), cross-subsidies (free immunization and selected promotive care, high subsidization of childcare combined with co-payments on low- priority diseases) and exemptions for the poor. Mali’s policy of free-of-charge care and medicines initiatives have been publicly subsidized by the State, with the support of developing partners and vertical programs, and with partial exemptions at the beginning. The scope of free policy schemes expanded over the years, reaching 14 programs of activities in 2017. These are managed by MOH. Activities mainly targeted pregnant women, infant and U5 children for certain services (c-sections, malaria, immunization, malnutrition, …) and services/diseases (cancer, HIV-AIDS, tuberculosis, neglected tropical diseases drugs, some eye infections, guinea worm…) for all patients. Additional activities also target pupils and students, soldiers, the elderly or even young children (under the age of 14) – the latter became obsolete, mainly due to its poor use and availability limited to CSRefs, national and regional hospitals (139). In March 2019, Mali’s Head of State supported free primary curative and preventive health care for U5 children, pregnant women including childbirth, and people over 70 years of age, from family planning, dialysis, free first aid in the event of an emergency in all health structures (accidents and disasters), the establishment of a network of community health agents integrated into the CSCOMs and rural maternities that provide free essential services. The model of care delivery influences the success of the “free” policy schemes. Since mid-2000, they have positively impacted the use of and access to healthcare services, but also faced some limitations. Prior to the 2012 crisis (between 2003 and 2009), their impact was assessed to determine best practices and financial arrangements, notably suggesting a potential increase in healthcare attendance by up to 4 times the current utilization if 100% subsidized by the State (168). But the multiplicity of co-existing schemes led to several overlaps, bringing some confusion and ineffectiveness to Mali’s “free” policy. Among the major limitations that have been reported, stock- outs for “free” medicines at the district level was, for instance, estimated at 45% in Bourem district (2014). The national stockouts rate was estimated at about 20% in 2014, against 11% in 2011 (169). HFSA: Mali | Technical report 126 The World Bank In December 2021, health decision-makers decided to take action (during a UHC workshop) to accelerate the transition towards UHC in Mali, concluding on the need to improve the “free” policy financing and greater synergy among existing mechanisms. The process resulted in a roadmap for 2022 for the implementation of four recommendations: 1) set up a high-level consultation framework for UHC stakeholders under the responsibility of the MOH/DNPSES, 2) annually assess, through the CANAM, overall funding needs for the “free” services that are integrated into the RAMU scheme, 3) ensure the MOF’s budgetary entry is adequate to cover the needs as assessed by the CANAM and finally 4) transfer to the CANAM the funds intended for financing the “free” services integrated into RAMU. According to national data, the estimated spending across the main “free” policy schemes, on average, totaled less than 10 million XOF annually. Since 2011, expenditure through fee exemption schemes to improve access to Malaria, HIV/AIDS, immunization, and c-sections services accounted, on average, for 98.5% of the total, as shown in the figure below (Figure 43). These figures should be taken with caution as they may misestimate real amounts spent in those schemes. To our knowledge, the Health Accounts do not specifically report on the budget envelopes or spending devoted to each of the existing “free” policy schemes. National data monitoring of the number of beneficiaries of the free policy schemes presents a cumulative total of 335,076 beneficiaries of free medical services between 2011 and 2021, and an annual total of 35,780 beneficiaries in 202133. Figure 43: Estimated spending across major “free” policy schemes in Mali, 2011-2022 Source: Estimates using data transmitted DFM/Santé in support of a RAMU financing study in 2023. Mali’s “free” policy schemes however failed to deliver their promise of protecting care users from catastrophic health costs. Financial protection for health among tuberculosis and emergency obstetric care (EmOC) patients is incomplete. Regarding access to tuberculosis care, in 2020, about half of the TB-affected households (49.4%; 95% CI 40.7–58.2) experienced costs greater than 20% of the annual household income, as per WHO global monitoring indicators (170). Tuberculosis is usually detected and treated by front-line care providers and provided under a “free” care national program. In Burkina Faso, the incidence of catastrophic health costs (assessed at the 20% threshold) 33 http://www.anam-mali.org/index.php?option=com_sppagebuilder&view=page&id=20&Itemid=202 HFSA: Mali | Technical report 127 The World Bank passed from 51% in 2013 to 27% in 2020 (171). The comparison suggests lagging capacity in Mali’s national tuberculosis program to substantially increase financial accessibility for all. Similarly, Malian efforts to reduce inequities in maternal health focused primarily on averting maternal deaths, failing to eliminate catastrophic health costs arising from the treatment of obstetric complications. In Kayes, the incidence of emergency obstetric care was estimated at 33.5%, meaning that about a third of the households living in that region would face catastrophic health costs (10% threshold) due to emergency obstetric care (172). Authors also documented a social gradient, with incidence climbing to 76.3% among the poorest quintile of the population, against 23.2% among the third quintile. Such a gap in financial protection for health suggests that the fee exemption for women undergoing a C-section was not enough to substantially reduce (or eradicate) the risk of incurring catastrophic health costs. For both examples, controlling drug prices could help achieve higher protection. Mali’s national health system has several characteristics which increase the likelihood of a greater proportion of the population being at risk of incurring catastrophic health expenditure. A separate study on equity in health is underway in Mali, which will assess the current incidence of catastrophic health expenditure. In the meantime, the lack of financial protection in Mali can be considered using benchmarking (ToR). In West Africa, pooled incidence of catastrophic health expenditure was estimated at 19.6% (95%IC: 14.8–24.9), which means that one in five households incurs health expenditure above the 10% threshold (173). Mali’s population is at higher risk of incurring catastrophic health expenditure than Eastern (16.0%) and Southern (8.4%) Africa. Yet, the risk in Mali remains lower than in Central Africa (50.6%). The sub-regional estimate for West Africa was greater than the SSA region average (16.5%) but slightly lower than the income group average for LICs (22.0%). For SSA countries with a UHC index below 45, which is the case for Mali (41.5 in 2019), the incidence was estimated at 22.0%, against an incidence of 9.6% with improved UHC. Similarly, for SSA countries with social health insurance (SHI) coverage under 10%, which should still be Mali’s case, the incidence was estimated at 16.7%, against an incidence of 13.3% with improved social health insurance coverage. The upcoming study by the WB should help design appropriate interventions to reduce Mali’s health inequities and inequities in health financing. 7.2.4 Strategic purchasing for enhanced PHC Mali’s performance-based financing mechanism is designed to account for contextual factors and emerging challenges. The mechanism supported the COVID-19 response, by including additional COVID-19 related services during the pandemic (174). Its financing is based on two types of subsidies that are complemented by an equity bonus. Care providers receive both a basic subsidy for care services provided to regular patients and a higher subsidy (basic subsidy multiplied by a multiple factor) for targeted patients (poor and vulnerable population groups) and services. In addition, equity bonuses are distributed to compensate for unfavorable settings such as health facilities facing i) lower population density; ii) higher poverty incidence; iii) average distance between facility and population; and iv) security risk. Finally, the mechanism foresees possible adjustments to introduce flexibility. Financial arrangements have been adapted in areas where service delivery is increasingly challenging due to security conditions. Overall, the cost of Mali’s performance-based financing mechanism was assessed at about US$3 or US$3.5 per capita (IE report, 2021). Unit costs of production were defined using evidence-based costing, which is used in HFSA: Mali | Technical report 128 The World Bank scaling-up scenarios to extrapolate the mechanism at national-level (160). Equity bonuses amounted to 170.2 million XOF for CSREFs (Min/Max: 142.6; 219.4) and 18.4 million XOF for the PHC centers (CSCOMs) (Min/Max: 10.7 ;33.5) in 2022; corresponding to XOF 292 and XOF654 per capita in 2022. The relative share of PBF verification costs has decreased since its inception, which is encouraging for its expansion. A detailed costing analysis for performance-based financing was completed in 2020, suggesting that the share of PBF budget allocated to implementation support and supervision could be reduced from 22% to 15%. The aim was to allocate a higher budget share to the provision of PBF grants for participating health facilities. The reduced share of the verification costs modified the PBF verification design, notably by using the national organization (CANAM) instead of an international NGO as the verification agency. The subsidiary agreements for the contract verification agency between the CANAM and the MOH was signed in 2020 (174). Reduced verification costs also implied quarterly verification instead of monthly verification as previously planned. 7.3 Performance of available resources 7.3.1 Returns on investment from allocative distribution 7.3.1.1 Health system outcomes Significant progress in life expectancy has been made in Mali, and more is to come. Since 1960, Malian life expectancy improved by 31.5 years to reach 59.7 years in 2020. A visualization of the progress made shows how Mali has gained in terms of return on investment since 2000 (Figure 44). Life expectancy is a standard and easy-understandable measure of a population's health that can constitute a practicable output of the healthcare system. Using life expectancy for output-oriented efficiency assessments is common, even if it cannot consider all influencing factors. Yet, it remains interesting to benchmark its relationship with per capita spending and evaluate life expectancy gains over time. More value for money is expected in Mali as its health system performance achieved comparatively less value in 2020, if focused on life expectancy at birth. When regressed against per capita health spending, Mali’s return on investment for life expectancy is situated below the trendline, which suggests that making different and better use of available resources could possibly help improve life expectancy (Figure 44). In other words, it means that tackling misallocation of resources and reducing wasted spending could bring Mali’s life expectancy “on track” and close to the returns on investment achieved by Uganda, for instance. Compared to the DRC, Mali has spent a lot more and achieved lower life expectancy, whereas Niger and Malawi spent similar amounts in per capita terms but achieved higher life expectancy. Based on this illustration, Mali’s health spending can appear inefficient at increasing the life expectancy of its citizens. Substantial market- value rates of return can be achieved as underlined by WHO, as the market value-for-money of UHC investments was estimated at 1.4 to 1 unit invested in 2018, and later revalued to 9 to 1 in 2021 (186,187). Moving away from the perception of health as only being an expensive burden for the State is needed in Mali. HFSA: Mali | Technical report 129 The World Bank Figure 44: Comparative returns on investment in healthcare for life expectancy in Mali against benchmarks, 1960- 2020 Life years change, 1960-2019 Life years in 2020 Axis X is expressed in log scale. Axis X: Current health Axis X is expressed in log scale. Axis X: Current health expenditure (per capita, PPP US$); Axis Y: Life expectancy expenditure (per capita, US$); Axis Y: Life expectancy at at birth (years) birth (years) Source: WDI and GHED êêNote: Our world in data was used to produce left visual. Evidence from modeling on trend efficiency measurements provides thought-provoking estimates of the lost gains due to lack of efficiency in health financing, with possibly more than 10 life-years lost. Improved efficiency in health spending can increase the number of life years in low-income economies by 2.1 to 3.4, depending on the efforts made. Several estimates were indeed projected by IMF (111). For instance, if the UHC index of low-income economies were elevated to the 75th percentile, it would enable savings equivalent to 0.37% of the GDP in this income group of countries. If reinvested in health these savings could lead to an average gain of 3.4 years without compromising resources from competing sectors. Another example from outside the health sector indicates that an increase of 2.1 years could be reached if income inequalities are tackled. For this second example, savings to the extent of about 0.27 of GDP could be driven from improving the Gini’s coefficient and/or increasing control-of-corruption index to the 75th percentile. Above cited IMF authors have declared in their papers that low-income economies could gain 8.2 life-years if inefficiencies in health spending were removed. The estimation goes up to 10.5 life- years gained when projected to the SSA sub-region. These projections suggest that Mali can create high-impact public interventions with better reallocation of available resources within the health sector. According to WB experts, Malians may lose up to 10 years of life due to inefficiencies in public health spending. In 2017, sizable potential efficiency gains (13%) were found (76).; Mali’s ability to tackle public health spending inefficiencies. The 13% estimate is equivalent to 9 life-years if benchmarked worldwide, or 8.8 life-years if benchmarked to the SSA region (76). These WB results HFSA: Mali | Technical report 130 The World Bank suggest more optimistic returns on the gains in allocative efficiency, as compared to the findings from the recent IMF working paper stating potential gains of up to 3 life-years in low-income economies. Such findings should be informative on the progress to be made. 7.3.1.2 Service coverage Achieving greater efficiency in health spending as a driver for UHC has gained recognition among African countries. Past evidence from an international comparison assessment of 173 countries suggested that the African region, on average, achieved the lowest efficiency score (67%) compared to all other WHO regions (188). In theory, if Mali sits in the average, this indicates that its potential savings could average 33% of its total spending on health. This estimate is close to the level of 20% to 40% of resources wasted globally in the health sectors, according to WHO. Comparisons at regional or global scale may be considered to be limited in their ability to truly describe the efficiency gains that exist at the local level, but regardless of their volume, improving the efficiency of health spending remains important. Gaining in aid effectiveness is already being promoted, since the Paris declaration in 2005. At the end of 2015, 14 African leaders agreed on the necessity to improve efficiency in health spending as one of the four major channels to increase revenues for health. Beyond Mali, a global assessment of aggregate efficiency can shed light on the level of additional resources needed to advance towards UHC. Service coverage for health (UHC index) offered in Mali may not be as effective as it could be, our results suggested that this is due to health spending inefficiencies. Globally, comparative results from 204 countries showed that most countries have a much lower level of UHC effective coverage than the level potentially achievable relative to their health spending (65). Authors highlighted that: “under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach US$(PPP adjusted) 1,398 pooled health spending34 per capita in order to achieve 80% on the UHC effective coverage index”. In 2019, pooled health spending (as expressed per capita) was closely associated with UHC index performance (r = 0.79), which offers a step forward in health financing for UHC decision-making. Mali’s health spending inefficiencies generated service coverage losses that were higher than expected when benchmarked internationally. Like several of its peers, Mali is regressed below the global trend (Figure 45). Tackling its inefficiencies could bring Mali closer to the achievements of Malawi or Uganda, without increasing per capita spending. Past results have seen sizable improvements in service coverage. In 2017, similar work by the WB provided estimates of 27% of Mali’s potential efficiency gains when benchmarked to the SSA region. An absence of allocative inefficiency in health spending would have projected Mali’s UHC index to the level reached in the Republic of Congo, Burundi or Mauritania. 34 Pooled health spending referred to government expenditures, prepaid private spending, and development assistance for health. HFSA: Mali | Technical report 131 The World Bank Figure 45: Comparative returns on investment in healthcare for selected health outcomes, latest year Service coverage (UHC index, scale 0-100), 2019 Maternal mortality ratio (per 100,000 live births), 2017 90 80 70 Tajikistan UHC Index 60 Zimbabwe Uganda 50 Senegal Malawi Laos Nigeria Burkina Faso 40 Ethiopia Mali Afghanistan DRC Niger 30 20 19.8 34.3 51.4 75.1 103 174.2 300 440.2 853.4 1,316 2,005 4,450 10,921 Current health expenditure per capita, US$ Source. WHO Global Health Expenditure Database, 2019. X axis is expressed on a log scale. Under-Five child mortality rate (deaths per 1,000 live births), Infant mortality rate (deaths per 1,000 live births), 2020 2019 Legend: Axis X is expressed in log scale. Axis X: Current health expenditure (per capita, US$); Axis Y: selected indicator (cf. sub-titles) Source: WHO-GHED Unmet health needs and gender gaps in access to primary care are of public concern in Mali. To support the healthcare ecosystem and advance equitable access to quality social services, identifying specific extra-needs requirements for the UHC expansion was needed and has been recognized (189). For instance, health authorities monitor the shortage of infrastructure (e.g., proportion of fully equipped PHC health centers, storage infrastructure for medicines) and human resources (e.g., priority needs in recruitment). Yet unmet primary healthcare needs remain of public concern in Mali. The demand for family planning is unsatisfied for 58% of service beneficiaries, 56.7% of pregnant women do not receive the required prenatal care (at least four visits), and 76.1% of the demand for contraception is still unmet among teenage and adult married women, whereas 562 women per 100,000 live births continue to die due to pregnancy-related causes (19). At 152.2 HFSA: Mali | Technical report 132 The World Bank in every 1,000 teenage girls giving birth (before adulthood) in 2020, Mali’s adolescent fertility rate is shown as critical (Figure 33). Yet it is known that teenagers who give birth are likely to suffer increased health risks, social stigma, and adverse economic impacts for the rest of their lives. 7.3.1.3 Quality of care, safety and prevention Even if progress has been made on UHC in Mali, deaths due to poor-quality services represent a substantial challenge, accounting for half of the preventable deaths that are amenable to health care. Mortality due to poor health service delivery in Mali was estimated at 96,000 deaths per annum, against 87,000 when benchmarked to peer countries (Table 14). Avertable mortality can be defined as the sum of preventable deaths – referring to the deaths averted through public health and other population-level intersectoral policies or interventions that prevent the disease or condition in the first place – and amenable deaths – comprising deaths due to use of poor-quality services and deaths due to non-use of health services –. At the LMIC level or more locally in Western SSA, poor quality contributed to more deaths than non-use of services, which doesn’t seem to be the case in Mali. Of the excess 38,000 deaths per year amenable to health care, about half were due to non-use of health care services, and the other half due to poor quality of available care. A total of 58,000 deaths could be prevented by improved public health. The burden of poor quality was estimated as equivalent to 106 deaths per 100,000 population, which is below the average for peer countries (119). Authors pointed out that “the amenable deaths should be viewed as a conservative estimate because some deaths currently counted as under preventable could have been averted through primary prevention in the health system” (68). If the SSA region had the lowest percentage of amenable mortality due to poor quality, compared to other regions, poor quality health care still contributed to the most deaths per unit population in West Africa, where Mali is located (68). To accelerate the reduction of mortality in Mali, public health interventions should focus on enhancing quality and utilization rates, with major efforts on high impact interventions. Table 14: Avertable and amenable mortality in relation to health system quality and use in Mali and benchmarks, 2018 HFSA: Mali | Technical report 133 The World Bank Source: Adapted from Kruk et al. (2018) using selected data extracts Mali’s MOH aims to launch a national accreditation program to measure and monitor the performance and capacity of health facilities to deliver quality care. Accreditation of the CSCOMs is an initiative that would complement and enhance audit outputs of the ‘free’ policy. A working group was set up to develop a framework of indicators, resulting in the development of guidance for the implementation of the accreditation mechanism. The latter was validated during a national workshop within the 2021 PACSU project activities. Mali must move away from inefficient infection prevention and control (IPC) in healthcare. The cost of infection prevention and control was estimated at XOF 4.5 billion as part of the health program (PRODESS IV). “Health facilities can be the entry point for outbreaks or become amplifiers of pathogen transmission, with subsequent spread of outbreaks to the community”. As a result, and mostly in low-income settings, patients afflicted with other conditions and seeking care or accessing preventive services such as vaccination in good health, find themselves at risk of being infected with health care associated infections (HAIs) (190). The absence of an effective IPC strategy can therefore represent a source of inefficiency due to the occurrence of preventable infections. Globally, inadequate IPC placed a significant burden on those affected (patients and health workers), with a risk evaluated at 20 times higher in low- and middle-income countries compared to high-income countries (where 7% of the patients were infected) (190). The 2022 evidence suggests that up to 70% of health care associated infections can be prevented by scaling up an array of effective IPC interventions. Investing in infection prevention and control is a cost-saving strategy that Mali can use to reallocate funds to high-priority health interventions. Investing in IPC is indeed cost-effective. For instance, only improving hand hygiene in healthcare could save US$ 16.5 in reduced health expenditure for every dollar invested (190). Low IPC is recognized as a determinant of poor quality care delivery and health services disruption, particularly in low income settings (5). This is a concern raised by the 2022 WHO global report in which a recommendation was formulated for Mali and ten other African countries, calling on them to reduce the harm to patients and health workers caused by HAIs. More precisely, IPC basic/advanced training and development of a national IPC action plan should be prioritized in Mali. According to a MOH Plan, various approaches have been designed to enable the country to develop a consensual approach for improved quality of health care, under the National Strategy for Improving the Quality of Care and Services (SNAQSS) (123). To our knowledge, at hospital level, PRODESS IV recalled the need for infection prevention and biomedical waste management in the case management of obstetric fistula. At the level of primary health centers (CSCOMs and Csref), PRODESS IV referred to a “Quality Improvement Collaborative” applied to emergency obstetrics and neonatal care, which led to improved adherence to prevention standards. Monitoring of higher quality care is also implemented through the PBF mechanism. Although no baseline is available in Mali, IPC is stated as strategic result 4.1 (as part of the interventions to reduce the burden of morbidity and mortality), with a target of 0% of post- operative infections from 2021 onward. HFSA: Mali | Technical report 134 The World Bank 7.3.1.4 Some additional thoughts The lower-than-average performance of Mali’s health system compared to the general trend, for both life expectancy and service coverage (UHC), indicates the crucial need to gain in efficiency and reallocate resources towards UHC-driven interventions. Several countries achieved higher output levels (e.g., life expectancy, service coverage) with the same input level (per capita health spending), or alternatively the same output with less resources Figure 45. For instance, Niger, Uganda and Malawi achieved higher life expectancy than in Mali while investing less per capita current health expenditure. Again, Uganda and Malawi (but not Niger) achieved higher service coverage than in Mali while investing less per capita current health expenditure. In other words, for both selected indicators, the Malian health system performed sub-optimally and reached lower output levels than what could have been expected given the level of per capita current expenditure. Findings from a 2022 IMF assessment suggest that reallocating resources within the health sector to elevate countries’ UHC would lead to increasing life-years by 3.4 years, on average, in low-income countries (111). Higher allocative efficiency can be gained and was assessed to enable countries to save 0.37 % of GDP without compromising life expectancy. It has also been suggested that, on average, low-income and SSA region countries tend to lose most life expectancy due to their inefficient use of health resources, respectively estimated at a loss of 10.5 and 8.2 life-years (111). Reallocating resources to UHC should be a high-priority in Mali as it is a best-buy intervention bringing substantial social benefits. Indeed, according to the IMF, the potential gains brought by increasing UHC resources are higher than those potentially brought by other actions, like reducing inequality or fighting against fraud and corruption (111). On average, in low-income countries, reducing inequality as assessed by the GINI index, for instance by converging to the 75th percentile, could lead to a gain of 2.1 life-years (against up to 3.4 life-years for UHC-oriented health spending, as mentioned above). The same scenario applied to the EM’s control-of-corruption index would lead to saving 0.27% of GDP (against up to 0.37% of GDP), while maintaining health outcomes. Within the post-2015 agenda, leading economists reached a consensus, qualifying health spending among the highest priorities to enable “phenomenal” social returns on every dollar spent in a country. Therefore, health interventions –more precisely UHC-oriented, with expanded immunization coming up with some of the highest efficiency gains (i.e., a ROI of 60 times the $1 spent)35 – were projected to generate much higher returns than many other (non-health) interventions (such as reaching 100% primary education36 (ROI of 7) or tackling illicit financial flows by making beneficial ownership information public (ROI of 49). Obviously, concurrent measures will likely be needed to enable most, if not all, efficiency gains, especially as the country struggles with limited financial resources. In 2020, an estimate based on internal Global Fund data put Mali’s funding gap for HIV at 34%. 35 Family planning, and singularly the target of reaching universal access to contraception, was projected with ROI of 120 times the $1 spent. 36 Cautious is needed as salaries (easy to disburse) typically account for a much larger share in the education sector. HFSA: Mali | Technical report 135 The World Bank 7.3.2 Technical and productive performance 7.3.2.1 Programming and planning Mali’s health system has experienced limited strategic and operational effectiveness, as assessed during 2014 – 2018, prior to the ongoing PRODESS IV. The effectiveness of PRODESS III for the implementation of the health programs and activities was assessed in anticipation of the development of PRODESS IV, which was an asset for the sector. But bottlenecks remain significant with the direct consequence that the majority of the objectives of PRODESS III have not been met (117). Among the non-financial factors contributing to the slowdown in health progress, the authors noted the inadequacy and poor distribution of HRH and the lack of coordination between actions taken to implement health sector interventions. Furthermore, it was noted that health planning and programming is too ambitious for the financial resources invested in the sector. This indicates that operational planning (during PRODESS III) was unrealistic. Expectations and targets were ambitious but lacked the means for their attainment. Several bottlenecks have hampered the full realization of planned activities. This included misalignments on the donors’ part (with national schedule procedures), and poor articulation of the free policy with other insurance schemes due to high fragmentation. Out-of-pocket payments for ‘free care’ persist in Mali, which prevents universal access to free- of-charge public care services, and this is inefficient. In 2016, a study conducted in two regions of Mali demonstrated that the actual and perceived costs of preventive treatment of malaria in pregnancy may constitute barriers to free care (191). Authors highlighted divergent practices among the study sites, suggesting a wide variation of practices between facilities and visits: pregnant women may pay to receive preventive treatment of malaria, receive it free, or both at different times. The bundled package of antenatal care (ANC), combining both free and fee-based drugs and services, explains the difficulty encountered at facility level . Health facilities often charge a lump sum for the “mixed” ANC package. As a result, on both supply and demand sides, people lack information and fail to fully distinguish free and fee-based care. The variability of the supply side on cost practices adds confusion, introduces misperception of the actual cost of care, and may lead some segments of the population to forego even free care services. Other West African countries previously showed similar practices in free Tuberculosis care (192). In addition, some facilities operating under the cost-recovery model strive to provide free care packages, due to the risk of financial imbalance. This calls for facility-level operational research to better highlight the financial constraints and determine how to make national policies more responsive to existing operational constraints, creating additional burden on households. Elevating the performance of Mali’s health spending in terms of reduced mortality rates or increased immunization coverage is also an issue. As described previously, visualizations of Mali’s performance in health spending against maternal, under-five or infant mortality rates, and against HFSA: Mali | Technical report 136 The World Bank immunization coverage for DPT3 (which is a tracer for UHC improvements) are illustrated in Figure 34 and 35, in which Mali is systematically positioned on the under-performing side of the general trend. For instance, with a similar level of per capita health spending, Mali has much higher rates of child mortality compared to Malawi or Uganda and also a higher maternal mortality rate than Niger, whose performance is better than Mali but still lower than the general trend. Similarly, Mali is below average for immunization coverage for DPT3, achieving inferior results than Niger or Malawi, who have comparably the same per capita health spending. Other results in rural settings (India) conveyed the desirable impact of improved efficiency on reducing the U5 mortality rate (193). Figure 46: Comparative returns on investment in healthcare for immunization, 2019 DPT3 coverage rate Fully immunized children Axis X is expressed in log scale. Axis X: Current health expenditure (per capita, US$); Axis Y: Vaccine coverage (%) for three doses of the combined diphtheria, tetanus toxoid and pertussis (DPT3) vaccine in a given year Source: GHED The organization of Mali’s drugs and medicines policy faces various limitations, related to its capacity and financing that undermines the “free” policy. The PPM has been documented as having difficulty collecting funds. Indeed, the MOH, to which the PPM delivers free products has been unable to honor its commitments, which poses a cash flow problem (56). For instance, as at February 15, 2018, the arrears payments imputed to the MOH towards the PPM amounted to XOF 3.2 bn. The products purchased by the PPM on health program accounts would account for 40% of the sales (194). Mali’s health authorities are well aware of the significant delays in the payment of the bills by the public treasury, with the direct effect of reducing the financial resources of the PPM and as a consequence not fulfilling of its obligations towards the suppliers (194). Also, the PPM is constrained by a variety of procurement procedures that are linked to the variety of partners who finance the products through the health programs (194). These shortcomings undermine the implementation of health interventions, including those of the “free” policy. HFSA: Mali | Technical report 137 The World Bank The PPM has struggled to put in place the recommendations received after an audit to improve its operations (56). For instance, the MOF was instructed to better respect its financial commitments (linked to the contractual plan) with the expected effect of achieving full and regular payments of the subsidy to the PPM. Another pending recommendation is about the repayment of MOH arrears. Poor management and planning capacity are also reported, such as a lack of reporting of expired stocks of medications, and imbalances between drug supply and demand (195). As a result, the PPM does not systematically establish an annual supply program, which results in shortages in the field, or very high stocks with the risk of expired products. It has therefore been established that the PPM does not fully respect its commitments to the State (56). In 2019-2020, the lack of proof of payment in public procurement was estimated at XOF 173 million37. The PPM probably did not pay its full share of the proceeds from the sale of the files to the Public Procurement Regulatory Authority ("Autorité de Régulation des Marchés Publics") either. Unpaid amounts identified as the responsibility of the PPM were estimated at XOF 3.8 million in 2019 (according to our calculations based on official audit data), which is equivalent to 20% of the amount due, if our information is complete. The other major concerns of the PPM therefore relate to cost recovery issues. Mali has three levels of referral mechanisms, as described previously. In terms of reproductive health, it has been shown that during PRODESS III, the rapid management of obstetrical complications was improved, suggesting good results in the implementation of the referral mechanism. But this mechanism is still undermined by the effects of health financing shortcomings, such as non-payment of co-payments by some stakeholders (117). AMO's invoice processing is not optimal, revealing the existence of unpaid or delayed invoices that affect the impact of the mandatory insurance system (117). To overcome this weakness, the ASACOs and CSRefs must strengthen local consultations (‘concertations locales’) in order to rethink the financing modalities and secure regular and sustainable funding for the medical evacuation system. Health financing related difficulties were not the only problem, as it has also been shown that the poor state of the road infrastructure in rural areas limited the effectiveness of the referral mechanism (117). This finding underscores the importance of systemic and cross-sectoral thinking to improve performance in the health sector, including at health facility level. In addition to allocative readjustments in health spending as illustrated above, other gains can come from tackling technical inefficiencies. At facility-level, improved efficiency was seen between 2017 and 2019. Median efficiency scores among health facilities in Mali were estimated at 85% for curative consultations in 2019, meaning that 15% were wasted due to inefficiencies (76). In 2017, efficiency scores were at 83%. For skilled birth attendance (assisted deliveries), the median efficiency score was assessed at 90% in 2019, up from 81% in 2017. It has been shown that Mali could also gain in efficiency through better use of antibiotics (treatment adherence efficiency), optimized antimalarial treatment prescriptions with public doctors serving as gatekeepers, 37 This amount refers to “des contrats de marchés non revêtus de preuve de paiement de la redevance de régularisation” imputée à la PPM. La PPM n’aurait vraissemblablement pas non plus reversé la totalité de sa part des produits issus de la vente des dossiers à l’"Autorité de Régulation des Marchés Publics”. HFSA: Mali | Technical report 138 The World Bank subsidized acute care with the aim to further reduce care deferral and adverse events among children. At facility level, another way to improve financing for health is to support health facilities and reduce their dependence on cost recovery through user fees. We’ve illustrated the consequences of out-of-pocket payments for health previously. The funding shortfall is also attributed to the capping of activity fees38 and the free-of-charge policy. Addressing these was a recommendation made for the sector during the preparation of PRODESS IV (117). Technical efficiency in district hospitals has been assessed at around 85% at national level, with efficiency losses of about 10% to 25% of the resources, depending on the types of output and the location of care delivery. In 2019, the first referral system for care services delivered through the CSRefs had efficiency scores close to 84.9% for curative consultations and 89% for assisted deliveries, as assessed using facility level data provided by the district health information system (DHIS2). It improved over time, and more quickly in certain sub-sectors, as it increased from 82.9% and 80.7% respectively for curative consultations and assisted deliveries in 2017. Yet, region-to- region and district-to-district disparities remain in both sub-sectors, with certain structures only achieving efficiency scores of 75% in 2019. Reasons behind the geographical disparities may relate to the high variation in the volumes of services delivered by the facilities. Bamako and the region of Mopti were estimated to have the highest efficiency levels, compared to Kayes and Sikasso with the lowest. Modeling was based on a data envelopment analysis reflecting on the extent to which facility level inputs (meaning employed human resources and beds) were combined to produce optimal volumes of health services (meaning curative consultations and deliveries assisted by skilled personnel) (76). 7.3.2.2 The role of human resource management Poor human resource management and/or dysfunctional public systems have a cost, weighing on the health financing system. Measurements of hospital efficiency have led to empirical results suggesting that more than 10% of HRH could be saved and efficiently reallocated. On average, cost inefficiency in hospital production had been calculated at 24.5% (196). In more recent works, several authors further elaborated on past results and came to the conclusion that 7% of doctors’ and 14% of nurses’ headcounts could be saved and reallocated to other tasks without requiring additional financial resources (111). Another illustration can be derived from the use of community health workforce. Without lowering quality, recent findings indicate that community health workforce costs could be significantly reduced in Mali (197). On-time salary payments, which are critical to secure continuity in public service delivery, fail in the sector. It has been shown that doctors in Mali can receive their pay with significant delays of up to three months in arrears and, for instance, if paid under the Heavily Indebted Poor Countries (HIPC) Initiative, with potential delays of beyond 10 months (198). The situation unfortunately continues. Reallocating funds away from known inefficiencies (absenteeism, dual practice, failure to serve) could relieve the burden from existing HRH shortages. It has been documented l that the 38 “plafonnement de la tarification” HFSA: Mali | Technical report 139 The World Bank phenomenon of absenteeism wastes public funding if a sizable proportion of health workers in the civil service receive undue government compensation, which is reported in Mali. Sector-wide, about 4,000 senior civil servants were reported to be receiving pay without honoring their duties (9). The level of absenteeism of State employees, at all levels, is significant. Several additional observations have been made by the above cited authors. For instance, the concentration of State personnel in the capital and urban areas to the detriment of the regions and local administrative units (Cercles) still prevails in Mali. About 68% of health staff reported dissatisfaction regarding the financial means to conduct their missions (117), which can be a root cause to tackle. Several findings indicate that human resources as well as financial resources in the sector were not used effectively, but the country has the means to implement cost-savings strategies. Tracking inefficiencies in HRH could help to remove the burden caused by HRH shortages. One way to reduce absenteeism is, for instance, to track and eliminate the phenomenon of ghost workers (i.e., individuals on payroll who do not exist and/or show up at work). Too little is known about this in the health sector, but ghost workers have been reported in the country (9). One of Mali’s aspirational peers attempted to gain greater efficiencies in HRH by tackling the issue of public funds diverted by ghost workers. Rwanda’s health worker compensation system was restructured in 2005 to create preconditions, linking wages to attendance under a PBF strategy, and the measure fulfilled the promise as it resulted in 5,000 names being removed from undue pay checks (199). In fragile states, information systems often fail to report on existing inefficiencies. In the DRC, authorities developed an open-source HRH information system to identify and manage ghost workers, which resulted in 27% of salary recipients of the e-payroll system being identified as ghost health workers (200). The DRC took advantage of the PBF system to mitigate inefficiencies in HRH (201). Improving the government payroll in a fragile and conflict-affected state like Mali remains challenging. Major challenges, beyond lacking a robust information system on public sector workers, lie in coordination problems coming from institutional complexity (e.g., different ministries often responsible for managing various aspects of payroll reform) and reluctance to change from those benefiting from misdirected public resources. This complexity requires further peers learning, system thinking and intersectoral approaches to better apprehend inefficiencies in HRH. With the ongoing ambitious reform, Mali is facing a paradox as its HRH shortage is significant while population needs in health are growing. Mali’s situation is, however, on a par with other LICs. HRH accounts for a little over 1% of total employment in low- and middle-income countries, against about 10% in high-income countries (202). Improving the conditions of the labor market is a way to attract additional HRH, as well as retain existing HRH. If purchasers’ willingness to pay remains low, Mali will continue to face HRH shortages, which doesn’t seem tenable on the path towards UHC by 2030. The expansion of the PBF financing mechanism for health is seen by Malian health stakeholders as a driver towards improved staff remuneration and financial autonomy for contracted health structures. Insufficient or uncoordinated investments in health professionals’ education and training has also led to an insufficient health workforce in Mali. Investment to reskill and optimize HRH is needed in Mali to better cover old and new needs. HFSA: Mali | Technical report 140 The World Bank 7.3.2.3 Health facility level and supply chain Data available at the level of public hospitals would indicate that corruption is limited in Mali. Based on survey data, the tenth edition of the Global Corruption Barometer for Africa reports that bribes in Mali’s public hospitals occurred in 7% of the contacts in 2019 (against 8% in 2015), which is half the average for Africa (15%), and lower than the rate of bribery in Mali’s general administration (e.g., identity documents requests, birth certificates) of 20% in 2019 against 22% in 2015 (203). Traditional healers, national and local governments as well as all-sector NGOs are no exception to bribery. From the same survey conducted in Mali by the “Groupe de Recherche en Économie Appliquée et Théorique (GREAT)”, it was reported that 60% of Malians perceived a greater level of corruption in 2019 than 2018. One of the pillars of a well-functioning health system is the continuous and optimal availability of medical products including vaccines, which has been shown to be lacking at various levels in Mali. According to USAID/SIAPS findings, especially for NTDs, Mali’s supply chain management has a series of weaknesses (204). These include delays in compiling and reporting data to the national program, making timely continuation applications to the donors difficult; central medical stores and other pharmaceutical management related staff are not oriented or trained in their missions. Drugs are not stored properly due to the inadequacy of storage facilities in districts. Part of the drugs stock is stored at program managers and NGO partners’ offices, with little inventory control (stock/bin cards), which prevent active monitoring of the stock status. There are also indications of occasional stockouts, overstocks, and expiries that highlight the need for better quantification of drugs. Disposal of pharmaceutical waste, such as expired and unwanted medicines, remains a challenge at all levels of the supply chain — with no clear guidelines on procedures for disposal and also a lack of incineration facilities. It is important to remember that WHO has indicated that, globally, at least a fifth of health spending could be better used by avoiding waste. It most likely occurs 1) when health products are priced higher than necessary, 2) when less expensive but equally effective alternatives are not used, and 3) when purchased products are not used at all (205). These potential occurrences would need to be investigated in Mali. - Governance: Regional pharmacy personnel are not involved in NTDD management. There is a lack of coordination between the regional NTD focal person and the regional pharmacist for NTDD management. - NTDs information system management: the stock inventory registers are often not up to date, thus rendering the estimation of real needs difficult at the district and community levels. Besides, the NTD program has difficulty receiving information on the actual quantity of NTDDs distributed, making forecasts for the next round a challenge. - Drug stock management / storage: NTDDs that are stored at NTD program managers’ offices and at NGO partners’ facilities do not have any inventory control tools (stock/bin cards) ; Poor storage conditions exist at district and health facility stores—in most instances, the environment is not suitable for medicine storage and the facilities are unorganized. HFSA: Mali | Technical report 141 The World Bank 7.4 Links with public finance management and health Before redesigning health financing, policymakers should further assess spending versus effective spending to identify ‘low-hanging fruit’ for public finance in health. This final section further explores the extent to which financial resources for health are diverted from efficient spending, as well as major areas of public finance leakages. 7.4.1 Overall performance Mali’s public expenditure and financial accountability scores low, with limited progress between recent assessments. In 2021, public expenditure and financial accountability in Mali suggested a relatively robust system but whose general performance remains basic, as recently assessed (206). Progress has been made in the management of assets and liabilities (fiscal risk, public investments, asset and debt management), policy-based fiscal strategy and budgeting (macro-fiscal forecasting, budget preparation, medium-term expenditure budgeting), and predictability and control in budget execution (revenue administration, arrears monitoring, payroll controls, procurement, audit), whose respective indicators still scored as basic in 2021 (Figure 47). Other pillars have not improved much or have recently deteriorated, notably budget reliability and the transparency of public finances (budget classification and documentation, domestic financial transfers, public access to information), accounting and reporting, and external scrutiny and audit, due to the low quality of some programming documents and reporting, delays in setting up asset accounting, and ineffective control structures (76). Mali performs better at preparing its budgets than executing them. Of the seven ‘PEFA’ dimensions of PFM performance, a good level of performance is only achieved for budget strategy, with all the remaining dimensions having either weak or poor performance. The transparency score in Mali (39) is lower than the global average (42), as reported in the 2019 Open Budget Survey (76). The citizens’ budget has been prepared in Mali since 2011. Yet, several challenges persist. For instance, those “associated with aligning the economic classification with international standards, establishing asset accounting, the coverage of central administration operations not recorded in the State’s financial statements, and the transparency of the fiscal transfer system”. The 2022 PEFA Global report on PFM (207) calls for stronger performance in accounting and reporting, and for making public expenditure reviews publicly available to citizens in Mali. For Mali, being able to tackle the crisis in a better way still depends on establishing a stronger PFM system. This is a situation that exists in most WAEMU countries. No country has yet achieved the highest attainable PEFA score for its management of public assets, but Mali remains among the low performers. Figure 47: Public Finance Management progress and current status according to PEFA scores, 2018-2021 HFSA: Mali | Technical report 142 The World Bank Source: Public Expenditure and Financial Accountability (PEFA) Secretariat PFM-related weaknesses diminished donor alignment with national procedures, which remains insufficient in Mali. Before 2012, Mali adopted a Government Action Program for the improvement and modernization of public finance management (PAGAM I and II). Later, the PREM 2017-2021 was expected to provide better alignment. Despite recent efforts, post-2012, the number of donors going through NGOs for the execution of their financial contributions has increased, and year to year, sector budget support has tended to decrease (130). Other partners have chosen to rely more on direct support at decentralized levels. Despite an improved security situation between 2012 and 2016, some partners continued to spend their contribution outside national procedures. Opportunities to increase the volume of grants executed through the public finance system came from Mali being a priority country for development assistance. As a result, proper management of the funding received could have further strengthened the solidity and credibility of public instruments. 7.4.2 Strengthening public finance On budget performance, Mali’s public finance system is no exception and was found to have a high risk of resource leakages that contributed to diminishing the performance of the health system. On the Transparency international index, Mali scored 28% and ranked 137th out of 180 countries in 2022, which suggests a high risk of leakage and resource loss. Prior findings from an IMF audit had noted the complexity of public expenditure execution at the State level, and across sectors of activity including the health sector (208). The effectiveness of the monitoring and control system is insufficient, with payment delays (both for running costs and capital investments) but not arrears for most items, making the phasing of public expenditure complex and inefficient. Health authorities and development partners are aware of these PFM shortcomings, and the country is looking for the most appropriate solutions. The lack of governance and regulations in health expenditure have had a negative impact on health outcomes, causing loss in quality-of- service delivery and distortion in the budget allocation of health investments. The cost of fraud and abuse of entrusted power in public funding is often underestimated in decision-making. WHO provided estimates at 7.3% (2008) and 6.2% (2013) of health spending (209). In Mali, several official reports from the general audit office (BVG) have incriminated practices that deviate from the HFSA: Mali | Technical report 143 The World Bank standards of good governance, including in the health sector. A system of judicial sanctions (correctional or penal) exists in Mali but the processes are very slow and do not make it possible to eliminate PFM deviations (48). Practices that deprive public resources therefore go unpunished even though several scandals have been recorded in the health sector linked to funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Alliance for Vaccines and Immunization (GAVI). In a targeted manner, solutions are sought to improve accountability, strengthen the role of the boards of directors of State entities and structures. An experiment on PBF in the Koulikoro region made it possible to test a new system of management transparency and accountability for service providers, managers and beneficiaries alike. The stakeholders seemed satisfied with the results at the local level, which could work in favor of an extension of this experiment (48). The poor management of COVID-19 response resources has been the subject of debate in Mali. Declared in Mali on March 17, 2020, the COVID-19 outbreak significantly disrupted the delivery of healthcare services. Although the MOH continued with planned programming as much as possible, staff had to comply with prevention measures. Due to teleworking practices, for instance, some activities (e.g., HRH2030’s coaching visits) were immediately impacted and canceled, and others delayed (e.g., HRH2030’s scaling-up nutrition activities). (69). In particular, various governance problems, among them a notorious lack of transparency in the management of the public resources collected through the COVID-19 Fund, were critical, as reported by a MOH official during the summer of 2022 (information collected by Africa Integrity). These shortcomings impacted the already fragile implementation of the COVID-19 response. Resources leakages do not only affect the health sector. Past audits of financial flows were conducted in Mali to measure the proportion of government resources actually benefiting social sectors. A specific survey in education revealed public resources losses, occasionally exceeding 90% (Bamako), which were attributed to the absence of transparency on budget information (198). In 2012, prior to the PDSS, a new entity was created to encourage good governance in Mali (210). In the context of an assessment report (211), it is recalled that the fight against corruption and economic and financial delinquency is a long-term process that has been initiated in Mali. The report reveals the existence in Mali of an intelligent and well-thought-out camouflage of misappropriation of public assets, which affects about 10% of public services and organizations. Irregularities identified in audits regarding the mismanagement of public funds are an undeniable waste of public spending. This process, led by the Office of the Auditor General, should be entirely integrated into the daily actions of all governance stakeholders. Mali’s concern for the health sector is not unique. In Chad, a structural peer to Mali, the government “officially” spent on average US$ 1.17 per person, but they actually received US$ 0.02 per person (1.7%) due to major leaks at all levels of government (198). This substantial gap was attributed to high rates of resource leakage likely occurring with non-wage health expenditures. Leakages led to dire consequences undermining the performances of service delivery in health. In Chad, for example, resource leakage was observed at the central government level, which means occurring before the resources reached local government levels. According to evidence from a prior financial flows audit (PETS’ survey), only 1% of non-wage health expenditure to regional heath HFSA: Mali | Technical report 144 The World Bank administrations was estimated to arrive at the facility level. Other countries like Uganda, Senegal and Rwanda also reported predominantly facing resource leakage at district level. 7.4.2.1 Co-governance and decentralization Mali’s participative management, which is a peculiarity of the health system, should have enabled better administration of the public health service, but did not keep all its promises. The Malian model of decentralized decision-making has allowed for better administration of the public health service, particularly by making the population stakeholders in their own health. In this sense, it has promoted local democracy and generated more enthusiasm and commitment from communities to work for the success of community health in Mali. As a result, the model has created a strong increase in the satisfaction of the populations served by CSCOMs (117). However, shortcomings in the functionality of the guidance, coordination and evaluation bodies of PRODESS III and certain operational problems within the management bodies of the ASACOs and collaboration with the CTs have affected the hopes of a good decentralized governance system. The lack of a permanent mechanism for financing the meetings of the management councils and CROCEP was raised as a key concern in the matter, during the evaluation of PRODESS III (117). All layers of the federations of community health associations (i.e., FENASCOM, FERASCOM and FELASCOM) must be revitalized so that these structures can fully play their roles in effective good governance in support of the functioning of the ASACOs. Finally, frontline providers (such as the CSCOMs) and the Communes also have a greater role to play in improving their collaborative relationship in accordance with the Mutual Assistance Agreement (AMM). By opting for territorial decentralization, Mali chose a co-governance policy with the CTs, but their capacities remain weak. It has been reported that the decentralized management capacity of the health system in the regions and districts of Mali is weaker than at the central level (51), introducing additional accountability challenges. The audits carried out in the CTs have indeed revealed dysfunctions and financial irregularities that are the antithesis of good public finance management. Resources at CT level tend to be managed with less concern for accountability, and the behavior of CT managers indicates that the autonomy granted by the State (competences transferred) needed rigorous monitoring and control of the use of public resources. To our knowledge, the most recent official audit of the use of public health resources at district level revealed that very few of the governance recommendations were implemented and effective in the districts of Bamako and Sikasso, confirming other findings (211). In addition, it has been documented that a sizable share (70%) of available financial resources are kept as savings in a bank account instead of being used to finance CSCOMs’ activities (Table 15). Table 15: Overview of unused public resources managed by the ASACOs, 2020 Use of financial resources collected at a decentralized level (by Total amount the CTs) Pricing Drugs Savings (in million XOF) ASACO #1 10% 20% 70% 22.9 ASACO #2 26% 3% 71% 0.7 ASACO #3 18% 56% 27% 8.7 HFSA: Mali | Technical report 145 The World Bank Source: Mali’s office of general audit (BVG/ 05-March-2020) Recent evidence raised awareness of the lack of budget efficiency in health in Mali, calling for increased accountability among high-level authorities. Regarding health spending entrusted to the MOH, the execution of credits from the budget line of the General Directorate of Health and Public Hygiene (MOH/DGSHP) in recent years (2019 and 2020) has been beset by real problems in the liquidation of notified credits. This study showed that liquidation rates of the XOF 20 bn in 2019 and 27 bn in 2020 were respectively 66% and 42% (212). These financial resources, representing the potential for PRODESS implementation are a budget priority for the sector. Such liquidation rates, largely below 85%, are of great concern. The study also revealed weaknesses in public expenditure management at sub-national levels (regional directorates and municipalities). The MOF and the parliamentarians would have concrete elements to question the solidity of these important investments in public resources for health if the trend was to be confirmed in 2021. Budget inefficiencies are also documented at a disaggregated level, even for HRH spending. For instance, the fee-exemption policy for c-sections, which is fully subsidized by domestic public resources, faced insufficient credit line liquidation with rates largely below the 85% threshold in 2019 and 2020 for most regions. Public spending to the regions was insufficiently liquidated, as all regions reported rates below the 85% threshold. The regional average was 48.2% in 2019, and 30.0% in 2020, with Kidal at the extreme bottom at 0.0% (212). At the commune level, liquidated credits for health staff were registered with delays, 6.0% of the communes (42) had a liquidation rate below the 85% threshold, and 4.6% (32) had a liquidation rate of zero in 2019 (212). About the delays, key informants from this prior study had raised the issue that regional directorates were late in registering liquidated funds (registration after the time of liquidation), which means that part of these funds were truly liquidated. Such a dysfunctional pattern complicates analysis of the situation because the apparent low rates may reflect delayed “spending” instead of sub-optimal liquidation. This phenomenon demonstrates that it remains extremely difficult for the authorities to know with certainty whether the region or the municipality is facing real problems in the payment of its personnel. 7.4.2.2 Ongoing PFM reforms Significant reforms have been made to PFM in recent years, but significant challenges remain ahead in Mali. Adopted on September 21, 2016 by the Government, the Public Finance Management Reform Plan (PREM) 2017–2021 is the third public finance management reform program in Mali, which builds on previous strategies (PAGAM/GFP I 2006–2009 and PAGAM II/GFP II 2011–2015), (213). A support unit for PFM (CARFIP) should ensure PFM reform coordination with the technical directorates of sector ministries, the National Council of Civil Society and Territorial Communities, the National Assembly, and development partners, and prepares annual progress reports (Mali PER 2021). “Recent efforts focused on core reforms such as the move to program budgeting and strengthening financial information systems and control structures. Fiscal administration has also been significantly modernized through digitalization and simplified procedures. However, the reforms will need to be fully implemented to maximize value for money and have the desired impact. For instance, program budgeting needs to be fully operationalized by giving program managers the authority to reallocate spending within their programs according to HFSA: Mali | Technical report 146 The World Bank their priorities and expected results. Further digitalization of procedures coupled with staff training and auditing will be another key means to enhance revenue mobilization.” (Mali PER 2021). Along with this PFM reform, Mali established a coherent and effective (internal and external) control system that guarantees the efficiency of public finance management and the participation of citizens in the control of public action. One of the objectives pursued under this reform is to reinforce capacity building in order to improve the performance of the various structures involved in the public expenditure execution chain (CARFIP: Cellule d'Appui à la Réforme des Finances Publiques). The MOF “Circulaire” for harmonized reviews organizes the following budget reviews: program-budget reviews, project-program reviews, sectoral reviews, regional reviews, Strategy for Accelerating Growth and Sustainable Development and SDG reviews, joint budget reviews (214). An office of general audit (BVG) also provides analytics and guidance for improved governance in all sectors. The Strategy for Accelerating Growth and Sustainable Development, which serves as Mali's main development benchmark although due in 2023, takes into account the issue of governance with its first strategic axis on the consolidation of democracy and improvement of governance. 7.4.2.3 Timeliness and adequacy of actions within national budget decision-making Health protagonists must identify potential areas of influence (timeliness of action, stakeholders, data use, …) to increase budget allocation to health and priority expenditure. One way would be to develop strategies, at the right time, through the right channels, carried by the stakeholders identified as active and influential, and based on health and non-health evidence. As the budget process encompasses several stages, the timing of discussions on priority expenditure needs and UHC-related decisions is key. The process is detailed in a following paragraph. Since 2018, Mali has moved from a means-based budget to a program-budget, implying a change in its legislative framework and addition of new stakeholders. New key stakeholders in budget management are the program managers (“RPROG”, LOLF, art.12), Others are operational budget managers (“RBOP”) and operational unit managers (“RUOP”), authorizing officers (“Ordonnateurs”, public accountants, the role of cross-functional structures, the new control Finance, Parliament and the Accounts Section (215). Trade union action in economic and social matters is also important, as they have committed to improved good governance in Mali (215). Trade unions, as well as the civil society organizations (CSOs) also have channels to get involved in decision-making and must, for example, strengthen their actions so that their proposals can be better taken into account in the budget debates. Last but not least, the national parliament, which votes on the finance and regulative laws, organizes the Budget Orientation Debate (BOD) to improve political control of the finance law, often taking place ahead of the development of the initial finance law with the aim of influencing Government choices. Increased knowledge of the budget process is crucial to attain increased domestic resource mobilization for health. The successive key steps of the budget process in Mali encompass a performance assessment (January-February), technical trade-offs to develop budgets across sectoral programs (May to June), and ministerial trade-offs to determine the provisional budget allocations (July) before the year-end examination and vote on the finance law that should secure budget allocation to each entity (November and December). HFSA: Mali | Technical report 147 The World Bank Every year, during the first quarter (February-March), the budget envelopes of the various ministerial departments are discussed and transmitted by the MOF to the ministerial departments in the form of an official letter (e.g., circular 2022). The missions, constraints, challenges, and expenses of these entities are detailed in an official multi-year programmatic document (e.g., DPPD- PAP 2023-2025), usually prepared or revised in March-April. April is also the month during which specific investments can be considered in the annual budget, as part of a triennial period set for 2023-2025. It is in May-June that the programmatic strategy is developed by key stakeholders such as the heads of ministerial programs, with the support of the MOF/DFM (Direction des Finances et du Matériel), thus setting the policy targets for each program or sectoral project. This is called the technical trade-off stage, which precedes the political trade-off stage. The latter is key to determining the competing sectoral budget envelopes since it is at this moment that the Prime Minister evaluates and approves the programmatic arbitration choices. The MOF/DGB therefore reconciles and compiles all budgetary decisions during the third quarter of the year (August and September), with the prospect of voting the initial financial law at the end of the fiscal year (November and December). Figure 48: Overview of the decisional calendar for budget programming in Mali Source: Author based on MOF/DGB information Access to budget data is crucial to develop proper advocacy. Several official documents should be available to support decision-makers. The annual program-budget (2022) is, for instance, assessed based on an Annual Performance Report (RAP), which allows monitoring of the performance obtained compared to the targets set in the annual programs and projects. This Annual Performance Report is an official document appended to the Finance law, which must be presented to Parliament at the latest for the first budgetary session of the following year (2023). Such a tool can be used to improve decision-making, by informing health authorities and serving health stakeholders to develop timely advocacy. Monitoring budget execution performance, in health and beyond for benchmarking purposes is also crucial. In order to efficiently monitor health expenditure, health stakeholders must be fully aware of the budget cycle (four steps) and effective expenditure amounts at each of the four steps of the process. Box 1: The four steps of the budget cycle (MOF) - Step 1: Expenditure commitment (“Engagement par l’ordonnateur”), a first step in which the budget authorizing officer (or his delegate) creates an obligation from which the expenditure will result, and which corresponds to a claim on the general government budget. - Step 2: Liquidation, which aims to verify the financial reality and determine the exact amount of the expenditure. HFSA: Mali | Technical report 148 The World Bank - Step 3: Mandate or authorization to issue a payment mandate, giving the order to pay the expenditure, which should be equivalent to the amount of the liquidation. Thus, the authorizing officer sends to the public administration accountant the request for full (or partial) payment, according to the availability of funds or priority-setting directives. - Step 4: Payment is finally issued, using checks, transfer orders or cash payments to the beneficiary. Establishing good budgetary governance practices represents a highly strategic challenge for the country and no economic and social development policy can do without it, especially when resources are scarce. Transparency alone is not enough to improve governance. Inclusive public participation is key to achieving the positive outcomes associated with greater budget transparency. In Mali, there is a system of citizen consultations that allows civil society to follow and interact with budget development, but to enhance its impact, public participation in the budget process is imperative (as reported in the OBS survey 2021). The trade unions defend this position (215), within the general framework established by WAEMU. Social and development expenditure, including health, are monitored at least quarterly during the fiscal year, which is key to timely addressing PFM weaknesses. Along with four other sectors, the budget execution of the health sector is monitored across fiscal year quarters, revealing the likelihood of seasonal under-execution. In Mali, the MOF/DGB regularly conducts mid-year and year-end budget execution assessments of the social and priority expenditure (116,125,216). Figure 49: Health budget execution across fiscal year quarters in 2021-2022 HFSA: Mali | Technical report 149 The World Bank Source: MOF/DGB-SEB HFSA: Mali | Technical report 150 The World Bank 8 The Way Forward Mali’s HFSA operated in a challenging context linked to the COVID-19 pandemic, auguring new opportunities for the health sector. At the sector and country levels, Mali has undergone several reforms in health coverage expansion, governance, decentralization and budget management in recent years. Mali is a vast Sahelian country in West Africa whose population growth should highly matter for future health sector decisions. The study showed the importance of several other contextual elements, including the status of a fragile and conflict-affected country, the country's economic prospects and the socio-political environment in Mali. Ambitious targets have been announced as the country targets UHC in 2030. The challenges ahead are therefore substantial. Successful health financing for UHC by 2030 requires a strong political will on the resource mobilization strategy and a shared understanding of the key data, indicators, milestones and priorities effectively promoting UHC in Mali. Mali’s HFSA explored how good and how far the national health system could perform under low-resource constraint, especially with regards to announced ambitious goals. The per capita health financing gap is significant to meet the desirable levels of health coverage (e.g., UHC index of 80%) and required health investment for quality essential care services for all (e.g., the US$ 112 per capita per year reference target for low-income countries). The country will have to consider doubling its efforts in the next 7 years between now and the 2030 endline. Moving forward, it is important to understand and acknowledge the crucial need to improve the quality, availability, and use of health financing data in Mali. Data only makes full sense if easily, actively, and regularly used by steering decision-makers, planners and managers, and all relevant stakeholders. The more data is used, the more accurate and meaningful it become. Building on evidence, even if imperfect, must inspire the desire for change and impact. The sound health reform that is underway in Mali will require informed processes for its implementation, spanning from health planning and budgeting to effective and efficient health spending. Strategic options for increased domestic and external resource mobilization, including from efficiency gains, must be found to develop a wealthy national strategy for health financing towards UHC. On the road to UHC 2030, low-income countries started developing and adopting national health financing strategies for UHC, like Niger39 recently did by linking its decision to evidence (notably using HFSA’s results). The study dissemination strategy envisages that stakeholders can agree on future health financing decisions using enhanced policy dialogue around 39 Niger Ministry of health (2023), “Stratégie Nationale de Financement de la Santé (SNFS) pour une couverture sanitaire universelle à l’horizon 2030 au Niger (Version finale au 28 Mai 2023)” HFSA: Mali | Technical report 151 The World Bank health financing. The development of short policy notes and inclusive workshop decisions are needed to support the ongoing health reform in Mali. This final chapter opens a discussion on a series of possible data-driven policy orientations arising from this Mali’s HFSA. Our findings suggest that Mali’s health financing system would benefit from evidence-based national and sub-national targets, which could be monitored and evaluated in- country in the frame of Mali’s UHC 2030 reform. Authors provide a tentative summary of possible policy implications (Box 2). Such proposals can serve as baseline outputs to frame future discussions. Key outputs need to be further discussed in-country, politically anchored, and eventually updated against newly available data and information. Our conclusions also attempt to encompass the key takeaways that arose from newly released and linked WB studies. Box 2: Tentative takeaways for policy implications in health financing for UHC in Mali ¨ The level of health spending of about US$ 35 per capita per year ranks Mali’s health system among the bottom 20 lowest-resourced health systems worldwide, which represents a major constraint limiting the implementation of UHC reform in Mali. ¨ Public health spending is fundamental to secure UHC achievements, but only accounts for 1.7% of the GDP, on average; and lags behind in terms of convergence rate over the past 20 years. ¨ Financial barriers to care persist and Mali’s share of health spending supported by direct payments is above the desired threshold of 20% for which the incidence of catastrophic health expenditure is reduced. ¨ Mali has achieved important progress in increasing coverage and reducing inequities in several essential services, but important coverage gaps remain, especially if we consider service capacity, quality of care and effective coverage. Target for effective universal health coverage would be 80% whereas Mali’s UHC index is at 41.5% in 2019. Current health policy options are insufficient to fully address health infrastructure, human resources and health financing shortcomings and resource gaps for UHC. Six study recommendations and actions to be taken in a near future: - Fostering the use of evidence (HFSA and related results) to support decision-makings in the frame of the ongoing reform, including promotion of the development of inclusive evidence-based approaches (MOH, MOF, health partners, etc.) - Developing national guidance for the specific design of sustainable health financing to meet UHC 2030, including prioritizing health financing options according to country context and prospects - Strengthening quality data production and surveillance in health financing for UHC. - Assessing the healthcare infrastructure, intrants and staffing gaps in underserved regions, utilizing geographic mapping and population required needs analysis. - Establishing tracking of health budget linked to public health expenditure, from domestic and external resources offering disaggregated analyses of central and decentralized financial flows - Strengthening capacity to ensure regular and high-quality Health Accounts publications in Mali, optionally complemented by specific appendixes on PHC spending flows HFSA: Mali | Technical report 152 The World Bank Notes ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. ¨ …………………………………………………………………………………………………. 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