Download Common systemic flaws and possible policy responses

Common systemic flaws and possible policy responses
Common Flaws
Bloated, under-skilled
workforce
Possible Policy Responses
Freeze recruitment of unskilled
and low-skilled staff
Politically difficult to enforce,
particularly in decentralised settings.
The peace process (like in Angola)
may imply the incorporation of rebel
health workers into the workforce, in
this way further expanding its ranks.
Expand training of high-skilled
cadres
The lack of educated candidates to
enrol into health courses may
undermine this approach.
Retrain / upgrade existing staff
Special challenges are provided by
the proliferation of volunteer or semivolunteer health workers, common in
contexts dominated by NGOs, as in
Afghanistan or Southern Sudan. A
long-term accreditation programme is
needed to professionalise these
cadres.
Introduce incentives to promote
retrenchment
Unaffordable for many resourcestarved health sectors. Given the
unemployment prevalent in many
distressed contexts, retrenchment
may represent a politically
unacceptable option.
Introduce fixed-term, performancebased contracts.
It can be introduced as an interim
measure to fill hardship positions,
often with NGOs as sub-contractors.
Later, it can be expanded to affect
larger parts of the workforce.
Devolve hiring and firing
responsibilities to local health
authorities directly involved in
health care provision.
Demands fairly robust management
capacity at local level. Fungible
budget provisions may encourage
efficient allocations.
Contract out service delivery to
NGOs, charities etc.
Cambodia in the 90s (see Bhushan et
al., 2002 and Soeters and Griffiths,
2003).
(for a discussion of this
flaw, see Module 10)
Rigid civil-service
regulations, resulting in
a workforce inefficient
and unresponsive to
need
Deregulated privatisation
of service provision
Examples and Remarks
Contract out regulatory functions
and / or other services
Increase salaries
Mozambique in the 90s and recently
Angola. Insufficient to curb
widespread practice, if not associated
with complementing regulatory
measures.
Regulate payments
Difficult to achieve when the practice
Common Flaws
Possible Policy Responses
Examples and Remarks
has become entrenched.
Visibly sanction a few blatant
abuses, to discourage widespread
practice
Close down some redundant and
derelict hospitals
Hospital-oriented sector
Downsize some hospitals, while
rehabilitating them
Build new first-referral hospitals in
areas deprived of them
Mozambique in the 90s.
Design PHC-oriented training
programmes
Mozambique in the 90s.
Establish a centralized purchasing
system of generic drugs through
international competitive bidding
The purchasing system may be
operated by government authorities
or by non-profit organisations. A very
weak MoH might prefer to delegate
drug supply duties to external
agencies.
Overpriced and scarce
drugs
(for a discussion of this
flaw, see Module 11)
Always highly contentious. Attempts
in this direction are under way in
Kosovo.
Standardise treatment protocols
Promote the essential drug
concept
Large portions of the
population without
access to basic services
Invest in underserved areas
Mozambique in the 90s. Usually
depending on donor largesse. If not
well planned and managed, it can
create or reinforce serious distortions.
Design and introduce low-cost
service delivery packages
Service delivery in underserved areas
lacking basic infrastructures is usually
more expensive than anticipated.
Introduce incentives to encourage
staff redeployment
Mozambique in the 90s. Staff housing
was included in rehabilitated or new
facilities. Also, drug supply to
peripheral facilities was granted.
Offer incentives to promote
exemption schemes for the poor
Difficult to achieve.
Launch CHWs programmes
Difficult to sustain and to expand, so
as to achieve countrywide coverage.
Of limited effectiveness without the
support of performing formal health
services.
Common Flaws
Insufficient financing,
absolute or against
stated goals
(for a discussion of this
flaw, see Module 6)
High operational costs,
due to the dispersion of
tasks and activities
Fragmented,
inconclusive, evidencefree policy formulation
(for a discussion of this
flaw, see Module 5)
Ineffective management
systems
(for a discussion of this
flaw, see Module 8)
Possible Policy Responses
Examples and Remarks
Narrow the scope of health service
provision
Politically very difficult. No known
examples of explicit policies in this
sense. Often carried out quietly, in an
escapist way, generally with
unsatisfactory results.
Advocate for additional funding
(internal and external). Negotiate
loans with development banks
Poor absorption may reduce the
benefits of expanded financing.
Robust cost analysis may help to
raise additional funding.
Capture existing financing, such as
informal charges
May yield substantial returns in
middle-income settings. In very poor
ones, service delivery must remain
heavily subsidised (explicitly or not).
Correct existing inefficiencies in
service provision
Often neglected, both in practice and
in the policy discourse (which usually
emphasizes the need for additional
resources).
Encourage the merging of some
functions, like drug supply,
training, data collection.
Easier to achieve if linked to
convincing policies and realistic
goals.
Establish autonomous policy
intelligence unit(s) and resource
centre(s)
Disseminating reliable and relevant
information is as important as
producing it.
Establish effective coordination
venues
The commitment of participants is
stronger when the discussion is
centred around concrete operational
issues
Promote wide, evidence-based
policy discussion
Difficult to put into practice for weak
and often contested governments,
constrained by limited capacity and
inadequate information, and under
pressure with daily operations.
Introduce competitive, fixed-term
appointment schemes for
management positions
Introduce performance-related
rewards and sanctions for
managers
Encourage the emergence of
professional managers
Imply a break with traditional civilservice provisions. Easier to establish
within a contracting-out framework.
Always difficult in health sectors
dominated by medical doctors. A
sizeable investment in the training of
professional managers must be
complemented by provisions aimed at
strengthening management practice.
Common Flaws
Possible Policy Responses
Examples and Remarks
Reduce civil-service constraints
and controls
Easier to achieve after the collapse of
state functions.
Decentralise accountability
A weak central government is often at
pains to keep together a fractured
country, as in Afghanistan.
Decentralisation in these cases is
praised in the policy discourse, but
hardly pursued in practice.
Solve conflicts of interests
Develop cost-effective functional
categories of health facilities
Unbalanced, derelict
network
Allocate investments to cover
neglected areas and populations
Mozambique in the 90s
Develop standard layouts for
health facilities