The Fragility of Legitimacy: Access to Health Care in Manantali, Mali

Abstract

At independence in 1960, Mali’s new government wanted to make health care available to all, but poverty and lack of resources prevented it from realizing its ideals. Thus, Mali’s health care system faced a growing crisis of legitimacy through the 1980s. Although the health care system had some normative legitimacy as people believed that modern medicine could offer useful care, it lacked performance and process legitimacy, since it could not adequately address health problems in a fair and caring fair way. When international financial institutions required privatization in the 1980s, Malian policy makers introduced innovations in community health care to create more legitimacy. This chapter evaluates the extent to which these innovations have created greater legitimacy in the area of Manantali, in western Mali, using data from an empirical study in 2016–2019. The establishment of community health centres has done much to increase both process and performance legitimacy, but available, accessible, and affordable health care is still difficult to provide, jeopardizing performance legitimacy. Tensions in governance raise questions for process legitimacy as well. Thus, legitimacy remains fragile. If policy makers want to ensure adequate health throughout the country, the government should consider offering greater support for universal basic health services.