Strengthening hospital infrastructure in a war context: the case of the Mopti regional hospital | Globalization and Health

Human resources

Severe deficiencies

A lack of human resources was considered the main obstacle to any tangible improvement in the hospital’s functioning and the improvement of care. In 2022, for example, there were only two gynecologists and four midwives, whereas at least four and eight were needed, respectively, according to the Mopti Hospital Five-Year Plan (2020–2025). Medical and nursing staffing levels were sparse, a condition often expressed in the singular, or as absent: “There is no radiologist…. There is only one pediatrician.” (ADMIN_HOSP2). These shortages were experienced very acutely in the areas of trauma and surgery in the war zone:

The only trauma specialist we have here died [in October 2021]; there’s no replacement, so there’s a military doctor who serves as a trauma specialist. In our zone, these things [such as having a trauma specialist] should be automatic…. So these are small staffing problems that are undermining our functioning. (HCP_Mopti2)

Hiring and assignments

Positions were filled by appointment by the Ministry of Public Health, but health professionals were not attracted to such assignments, leading to repeated vacancies: “We’re missing high-level health technicians, people are transferred [here], they come and then leave, they never return” (HCP_Mopti4). Calls had been issued for assignments to Mopti, but were unsuccessful in attracting applicants. The hospital did not have sufficient financial means to recruit specialized personnel, as this level of autonomy and resources was not in effect. The hospital depended on the State for recruitment.

We were promised a radiologist last year by the civil service… has that been forgotten?… The diabetologist is supposed to arrive, [but] he’s already almost gone…. We’re forgotten, the staff distribution means we’re ineffective in certain areas. (HCP_Mopti2)

Professional exhaustion

This sense of being forgotten by the State was experienced as loneliness and “work overload” at the hospital, resulting in constant physical and emotional fatigue:

Because of the precarious staffing, we don’t get a rest after a night on call, so the law isn’t respected… so it may be that, given all these situations, some people might feel frustrated and then ask to leave. (HCP_Mopti4)

Salaries and benefits

To cope with these difficulties, Mopti Hospital receives subsidies from H-Org that enable it to hire human resources to address the most urgent needs related to the care of the wounded:

The [H-Org] has been our partner since 2019, [which] has allowed us to recruit some doctors paid by them, and also nurses, to strengthen the services they support, because the [H-Org], they’re very interested in care of the wounded. (HCP_Mopti4).

The support was presented as cooperative and helped the administration pay salaries.

We discussed with the hospital how we could increase the number of human resources. That’s why we recruited more than 40 staff members of all grades: doctors, nurses, physiotherapists, nurse anaesthetists, one surgeon, one trauma specialist, and other support staff. We try to pay them every month. It’s not a salary; these are premiums; we pay the hospital, and the hospital uses that to arrange a contract with each person working in this activity. (H_ORG1).

Training

The PADSS II provided individual training in France. A gynecologist received several training periods of a few weeks in a referral hospital. The maintenance engineer underwent two years of specialized training in France. This resulted in long periods of vacancy when they were not replaced. To counter this, H-Org provided onsite war surgery training that combined theory and practice: a “war surgery seminar”, and a 14-days “war surgery course” that included participants from outside the hospital, notably from Bamako and even Niger, all in 2021. With the hospital administration, H-Org provided training on crisis management in case of a sudden influx of patients. All hospital staff were trained, and a stock of materials was reserved to address such an event. This training, developed over the past three years, provided knowledge that benefited other professionals beyond Mopti Hospital.

Governance

The objective of the PADSS II was to strengthen hospital governance by helping the hospital achieve greater autonomy, in line with the hospital reform law adopted by Mali in 2002. In particular, support for governance was intended to lead to the approval and adoption of a hospital plan. This component did not achieve the desired results. While a new building (part of the PADSS II) had been completed, it was not functional at the time of the study, and other PADSS II components (hospital plan, computerization) had not materialized at all, partly because the 2002 hospital reform had not been implemented. Tensions between donor agencies and implementers (the consulting firm providing project management assistance) also led to delays.

The respondents reported that the hospital’s self-financing capacity was limited to 25–30%. They felt that the hospital should be less dependent on state subsidies and be able to raise its fees. Health professionals believe that this would give the hospital more means to buy equipment and thereby upgrade the rank of referral hospital. With respect to fees, only care provided to the war wounded was entirely free, and covered by the H-Org.

Any [care for] wounds due to war, in any case, the initial treatment, is done free of charge. Often, even certain complementary examinations, they [H-Org] cover those. They pay for hospitalization for war victims. (HCP_Mopti2)

While many health professionals favoured raising fees, they noted that the hospital’s board of directors was opposed to such an increase, to ensure access to care for the greatest number of people.

Organization of medical specialties

Many professionals interviewed wanted to raise the hospital’s level to tertiary care (referral hospital) and criticized the current organization into specialty poles (medicine, surgery). They argued for organizing services separately and more autonomously: “They made a ‘surgery pole’ and a ‘medicine pole’. All the medical specialties are in one place, and all the surgical specialties are in another” (HCP_Mopti2). They thought, for instance, that “Mopti deserves to have a cardiology service and an infectious disease service” (HCP_Mopti3). Professionals also complained about a lack of space, as they were compelled to share premises:

I’m an anaesthetist, I don’t have an office to consult, I use the paediatric office for my consultations…. We have about ten surgeons who all have problems getting space. (HCP_Mopti2).

Failed attempt to computerize patient management

To strengthen hospital governance, PADSS II intended to computerize patients’ medical records and admissions. This component was eagerly awaited by hospital professionals in Mopti, who saw it as way to ensure transparency and control of the hospital’s financial revenues: “Computerization is needed to be able to track patients and pathologies” (HCP_Mopti2); “Hospital computerization is [intended] to reduce human involvement in the financial process” (ADMIN_Mopti3). This project did not materialize because of an incomplete call for tenders. Even though it was not carried out, professionals referred to this project in the present tense, showing their strong support and intensity of expectations: “It’s a very good project; at least it enables good cost recovery and resource tracking” (HCP_Mopti4).

PADSS II targeted key aspects of hospital governance, in line with the key principles of Mali’s 2002 hospital reform, i.e., financial autonomy based on a hospital project and the upgrading of infrastructure and computerized information systems. However, these interventions were doomed to failure, as the 2002 hospital law was not implemented in the country: “What’s been missing all these years are the decrees to apply the new hospital law. There hasn’t been the political will to implement these texts” [ADMIN_HOSP2].

Equipment and maintenance

No maintenance policy

Even though the head of the maintenance department had been trained and a maintenance department was included in the organizational chart, maintenance activities encountered many serious problems. Delays in ordering equipment or spare parts and repairs were extremely long, which impeded service:

The administration gets by. For example, you request something this year, maybe next year or the year after that, they’ll bring it to you. And maybe by then that thing won’t even be needed anymore. (HCP_Mopti2)

Maintenance specialists were not involved in assessing needs, and there were needs, especially for spare parts, that were not covered in the budget. The lack of a maintenance policy often results in gaps between equipment-related planning and execution.

Decisive support in the context of the conflict

H-Org focused on various specific aspects of the hospital’s infrastructure. First, it provided solutions for essential infrastructure to mitigate water and power outages. It built a cistern connected to the water distribution network. A generator was installed to support the oxygen extractors and provide the fuel needed to operate the generator. Six latrine blocks were built to improve hygiene and sanitation. In addition to supplementing the salaries of health care workers, H-Org supported patients (war wounded) and their accompanying families and blood donors (often family members), for example, by providing meals and snacks. According to several doctors and hospital officials, the H-org addressed a wide range of urgent problems and offered effective and appropriate responses.

Military support during the COVID-19 pandemic

The military force active in the region with a UN mandate had been supporting the Mopti hospital since 2020, with the conversion of a hangar into hospital and office space and the construction of a new building to conduct Covid PCR testing.