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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