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Approaches

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At the onset of the strategy formulation process, precision is never possible and to some extent is usually unnecessary. Most countrywide allocative decisions are by their nature aggregate and approximate, thus robust in relation to the imprecision of the estimates upon which they are based. For example, preliminary figures may suggest that a neglected area need a dramatic overhaul of its PHC network. Rough calculations estimate the existing gap in the order of US$ 4-6 million. The decision to be made is whether to encourage an NGO, able to invest in PHC-facilities about US$ 600,000 per year during 3-5 years. Whatever is the gap size computed from accurate figures eventually obtained, it will be substantially reduced by the NGO intervention. The essential feature of the initial analysis is its accuracy in relation to main problems and constraints. In other words, decision makers need to be reasonably confident that a given major problem, such as the inadequacy of the PHC network in the example mentioned above, is not an artefact, bound to disappear once data precision improves. The exact quantification of such a problem can wait for a later phase, when corrective measures are actually introduced and better data are gathered.

At the first attempt of going through the steps suggested below, it will become painfully patent that many of the required figures are not available or are seriously flawed. The manipulation of the available data will contribute to detect their shortcomings and will provide a powerful stimulus to strengthen them. By commissioning dedicated studies, when this is feasible, and revisiting source data, so as to strengthen available estimates, the information base must be strengthened. Periods of lull in the crisis, as during peace negotiations, may offer a precious opportunity for building an enhanced information basis and to start recovery with mature, agreed-upon plans. While the needed studies proceed, educated guesses can be used, provided their inadequacy is recorded and future users of the projections obtained in this way are made aware of the caution demanded when using them. As soon as better data become available, the projections must be revisited.

To complete sound recovery plans, a timeframe of 1-2 years can be anticipated, depending on the baseline situation and the complexity of the health sector. In some cases, sudden political or military developments hasten the pace of the recovery strategy formulation process, which must take place within months rather than years. Whereas the overall conceptual approach remains the same, a recovery strategy must emerge as soon as possible, to inform pressing decisions that cannot wait. Avoiding that catastrophic mistakes are made in the frantic climate of certain hurried transitions must be the main concern of those involved in them.

The initial round of exploration of the available information and its consolidation may take some months, during which informants and stakeholders are contacted and involved. Precious clues about prevailing perceptions and preferences are obtained. The main recovery directions may emerge at this stage. The findings of this exploratory round may be condensed in a health sector profile highlighting the main problems faced by participants (for details, see Module 13). Additionally, an interim recovery strategy, which suggests possible ways forward, makes their implications explicit and points to the main information gaps to be filled, may be sketched. Measures deemed urgent, or clarified to such an extent that dedicated studies are not mandatory, may be introduced already at this stage. Health sector profile and interim recovery strategy should be conceived as discussion and negotiation tools, and be written in a way accessible to most stakeholders.

The second round, consisting of studies considered as essential to put the policy discussion on firm grounds, may demand a longer period, say 6-12 months. The responsibility for carrying out these studies can be distributed among players, to share the burden and increase participation. At this stage, the temptation of studying most aspects in detail must be resisted. Given the fast pace of change typical of transitional contexts, most details will become outdated before they have been used to inform action. The needed studies must explore the field only to gather intelligence valuable for the decisions to be made in the short and mid-term. Detailed studies must be programmed for later stages, when the sector has stabilised and the planning horizon has expanded. Additionally, the studies must be judiciously spaced, to encourage actors to participate and help them to absorb findings.

In the third round, new inputs are consolidated in a set of alternative projections, to be submitted to decision makers. The ensuing open debate may lead to revised projections, as unforeseen aspects are considered or trade-offs are agreed. Once a measure of consensus and support is attained, strategies can be finalised and formally endorsed. Finally, they have to be translated in operational plans, which integrate the contributions of most participants into a consistent framework.

This approach calls for the establishing of permanent in-country capacity, so as to strengthen the previous work in light of its limitations and consistently with the adopted methods. Unfortunately, continuity of work is a rare, fortunate event. More often, projections are elaborated during short periods of intense activity by visiting consultants. The limitations and ‘heroic’ assumptions built into their results are quickly forgotten and their conclusions are taken uncritically, at face value. Alternatively, their work is superseded by new developments; other consultants are called in to elaborate new projections, which risk the same degree of oblivion met by the previous ones.

The main responsibility for the proposed work should obviously lie with the government, despite the weaknesses it may suffers. To embark in an exercise along the lines discussed in this module will attract competent cadres and encourage the emergence of some capacity. If successfully carried out, the exercise will boost self-confidence within the government and improve its standing with development partners. In very special situations, no ‘government’ is in place, or it is too contested, to play a useful role. Hence, interim authorities and aid agencies must assume the bulk of the responsibilities. Local participation should be pursued to the largest possible extent.

Scenarios can be built by following a top-down approach, by starting with a consideration of the global financing envelope and deducing from it what services will be affordable. This approach suits better severely disrupted contexts, where health care is fragmented, health authorities are absent or incipient, and most information is not available. In these conditions, approaching the analysis in aggregated terms may represent the only realistic option. Also, a top-down approach may be indicated in situations of urgency, when additional data cannot be collected. Examples of situations better studied through a top-down approach: Afghanistan in 2002 and Southern Sudan in 2003.

Alternatively, the analysis may start the other way round, following a bottom-up approach, considering the facility unit recurrent cost and progressing to compute the total expenditure of running the whole health sector. This more information-intensive approach looks appropriate to distressed, but not collapsed and fairly stable health sectors. The existing information base, although deficient, may provide a starting point for the analysis. In some cases, a stalled peace process may offer the opportunity to collect the missing data, in this way enhancing the results of the exercise. Example: Mozambique in 1990-92.

The computations proposed below proceed iteratively. Usually, several rounds are needed to reach acceptable results. The computations are presented in several sequential steps, to convey the logic of the process, but do not need to be carried out necessarily in the same order. Convenience and availability of data may suggest a different sequence. The eventual results should not differ significantly. The steps proposed are common to both approaches; they are discussed only once for the sake of brevity. When feasible, to approach the exercise from both sides is recommended, on learning and consistency grounds. In this way, the resulting final estimates will gain robustness.

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