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in discussing strategies ((381 pp. 53-55), about the reasons why it was ag-eed, at the same time, at the highest levels of the party, to examine the "problems cf the practice of private medicine" ((41] p. 18). It is true that at the same time the international organizations fully shared the national illusions concerning the feasibility of carrying out simultaneously the ambitious classical program defined in the 1960s and a no loss enormois primary health care program (cf. (421).

# 2. New Financing Sources?

It will have taken several years, during which the health services have centinued to deteriorate, for effective account to be taken of the difficulties perceived from the beginning of the decade. Concerning financing in the true sense, it is only during the last few months that a number of alternatives have been put forward and discussed, either within the Mali administration (cf, in particular (431 and (44]) or in the international agencies. They concern in particular what is designated cost recovery (or for the national hospitals, an obvious abuse of language, management autonomy), sickness insurance and mutual schemes, and privatization of exercise of the health professions. It is appropriate to consider the practical -- ue of each of these suggestions.

# 2.1 Cost recovery

Decree No. 243/PG.RM of September !9, 1983 laid down "the system of remuneration for medical care, hospitalization and other services of health units," accompanied however by very extensive provisions concerning free health care (for certain health conditions, students and pupils, health personnQl, the very poor, etc.). The enabling regulations, which were issued a few months later (Interministerial Order No. 1943/MF.MSPAS of April 16, 1984) are a masterpiece of ambiguity: in Article 2 it excludes all health centers from the field of application of the decree while providing that the health center management boards can implement "various forms of community participation," i.e. "fees that may in no case exceed those prescribed in the decree" mentioned above, with the further understanding (article 22) that "free care is retained in the clinics in the context of primary health care." The conditions were thus laid down for total anarchy, and in fact at the beginning of 1988 the Ministry of Health absolutely did not know which health centers charged for their services, which services had to be paid for and at what price, what was the amount of revenue and how it was used. In this situation it obviously impossible for the health policy authorities to engage in any enlightened thinking on the problem of cost recovery. The surveys we organized enabled us to show that:

- More than half the cercle health centers charge for at least some of their services; the charges vary widely but are always much higner than could have been expected, particularly for surgical interventions (see the appended table). The receipts so collected are managed in such a way that only one chief physician out of two among those that apply cost-recovery has been able to recoup the annual amount for the last three years; and no cercle chief physician can state with assurance what the situation is in the _arrondlsaument_ health centers of his district (for which he is responsible!).