Analyse des nouvelles formes organisationnelles hospitalières en émergence au Mali

In Mali, a hospital law was passed in 2002 to define the institutional framework of a major reform. This law decreed substantial transformation of the internal structure, both administrative and clinical public hospitals including the involvement of local people in decision making of the establishment, administrative and financial autonomy through the delegation and the budget involvement of health professionals in the management, integration services and specialty private sector participation in the public hospital. However, the ability of hospitals to achieve the planned changes has been questioned by the majority of internal and external stakeholders. The objective of this thesis was to study how the hospital in Mali have been transformed turns under the pressure of the decentralization of state powers and to study how groups of actors are responding to these changes from two analytical frameworks. The first part incorporates the essential characteristics of hospital transformations in terms of different types of decentralization and the second part inspired by the work of Crozier and al. (1977) analysis the power games between groups of actors hospital at two levels namely strategic and systemic levels. For this, we conducted a study of two cases multiple studies we used three modes of data collection ie semi-structured interviews with key informants, document analysis, and observation during meetings.  Initially, the analyzes revealed for the changes in the structure, depending on the size of the assigned responsibilities to the public hospital, (1) several variants of decentralization. Overall, the intent was focused on a political delegation and deconcentration and devolution, the mechanisms put in place have swung more towards devolution and delegation and devolution while the transformations actually worked in public hospitals have tended to confirm a deconcentration and more particularly of a delegation in the case of the involvement of local people in hospital management. While the public hospital could make revenue from the partial recovery of costs of care among users, the state kept a strong hand on financial management and personnel management, and defined guidelines and objectives to be pursued. (2) They provide an understanding of the linkages between different elements of the reform process, the type of mechanism put in place as part of the reform seems to determine the type of processing performed according to the functions that can ensure the public hospital. The logic reflects a shift from the delegation to a devolution which is judged as the least advanced form of decentralization.  In a second step, the results confirm the presence of conflict between professional standards and recognized by health professionals and institutional and organizational standards put forward by the reform. They are defended by the majority of managers who are facing due to the authorities while the professional standards prevailing in clinical services. Both cases have highlighted the support of their general direction, there was a tension in the reactions of doctors, which was variable depending on the type of structural change aimed at, while nurses were rather accessible face of new measures introduced by the reform.  A unique feature of this thesis is that very little work on developing countries have attempted to operationalize a multidimensional concepts of decentralization before analyzing the variations that may exist between them and the strategies developed by stakeholder groups of the hospital. Furthermore, while the relevance of taking into account the characteristics of organizational context in the implementation of reforms is at the heart of care concerns, this work is one of the first to analyze the influence of the interaction between the process of hospital reform and the positions of the actors. The results of this thesis provide recommendations to policy makers and managers on the modes of structural change to favor or avoid in planning, execution and implementation of hospital reform process based on the characteristics of organizational context health. Planning reform is essential: Develop a school plan discussed and validated by all stakeholders of the hospital. This project must be compatible with the objectives of a national health organization and determine how personnel and equipment, which the hospital must have to achieve its objectives. Designing a fiscal and financial flexibility hospital (which will reduce the chain of decision making), upon which a new system of hospital management. Capacity for mobilization and execution of hospital resources should empower management. Finally, promoting a culture of evaluation and facilitate periodic evaluations of the implementation of hospital reform by agencies external and independent evaluation.

Keyphrases: structure hospitalière, Decentralization, hospital structure, integrating clinical, integrating administrative, interprofessional collaboration, management mechanism, hospital, role players, hospital law