-7-

The breakdown of the health services reflectei in these figures has no doubt been occurring in most of the African countries over the last 30 years. In Senegal, for example, the contacts rate was over 100X in 1960 and was still running at 64X in 1979, in which year the hospitalization rate was around 31 (cf. [221 pp. 13S-135).

In light of the probable mortality rate (see above) and the few systematic epidemiological surveys (cf. for example (241, [251, (261), such utilization levels are an irrefutable sign that the health system takes care of only a low, even a verv low, percentage of pathology. But the technical level of the care provided is also very low: evidence of this is the fact that paraclinical examinations, even the most elementary, are very little used (less than one examination per patient hospitalized in a secondary hospital and about four per patient in a national hospital (cf. [231 pp. 123-138) and th-t the diagnoses traites in the national hospitals differ very little from those soigned by the _arrondissement_ and cercle health centers (cf. (231 pp. 79-89).

These general observations further conceal an important phenomenon, that of inequity in access to health care. The skew in favor of the cities is evident in Mali as elsewhere: for example, there is one midwife for just over 3,000 inhabitants in Bamako, against nearly 80,000 in the Mopti and Sikasso regions, which are not the most disadvantaged ones (cf. (281 p. 83); moreover, two out of three midwives in the Mopti region are located in Mopti itself (cf. (291 p. 32). Annual government health expenditure per inhabitant and per cercle retges from unde. CFAF 70 to over CFAF 1,300 and total expenditure from under CFAF 200 to over CFAF 9,500 (t271 p. 7).

This situation is aggravated by inequality between social groups. This stems from a number of factors, including clandestine private medical practice, accessible only to those with the ability to pay for it, provision of free health care to relatives by public health service steff, and the privileges enjoyed by employees of the health services (or of the Social Security Institute (INPS) and their families. While these phenomena have not been fully described, concerning the second and third it is known that, for example, **77%** of biological tests run by the Public Health Research Institute (INRSP) during the first six months of 1987 were done for patients presented as employees of the health services (the large majority of them of the INRSP itself) or members of their families ((301). It is also known that 60-701 of lNPS spending on pharmaceutical purchases is consumed by its own personnel (see 2.2 below). Finally, it is known that, despite purported strict control, 17.41 of biological tests run by the laboratory of the Point G hospital in 1988 were done on behalf of its staff (cf. (311 p. 27).

# 1.3 Health financing

Even today some people apparently still believe that health care is free in Mali and government pays practically the whole of its cost. That is not the case at all.

We cannot ascertain precisely what the situation was 20 or 30 years ago. What is clear **is** that the government effort has declined continuously, certainly since 1970: detailed anaLysis of the available data on the budget of the Ministry of Public Health (cf. (231 pp. 181-186) indicates that the