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Analysing disrupted health sectors: a toolkit: Previous page | 1,2,3,4,5,6,7,8

Annex 12: Case studies

  Table of contents

The case of Mozambique

The situation at the end of the war (1990-1992)

  • Massive destruction and displacement
  • Low coverage of basic services (accessible to only 1/4 of the population). Hospital and urban biases
  • Overall poor quality of care (outside privileged project areas)
  • Under-skilled workforce, concentrated in towns
  • Negligible state financing (< US$ 1 per head), alleviated by external contributions (US$ 4-5 per head).
  • Severe donor dependency. NGO proliferation. Massive projectisation and fragmentation of health activities
  • Scarce, incomplete and unreliable information about available resources and service outputs. Desertion of sound financial management practices (by both donors and recipients)

The chosen approach to reconstruction

  • Continuity of institutional and management settings
  • Dominance of the public sector in health service provision
  • Incremental, organic growth of facility-based services
  • Equity, rather than quality of care or efficiency, as the main driving concern
  • Painful decisions regularly postponed to ‘more propitious times’

The resources made available for reconstruction

About US$ 300 million invested in the reconstruction process over a decade by donor agencies and development banks. Main channels:

  • UN agencies (through the CAP mechanisms during the first years)
  • NGOs (mainly targeting PHC delivery)
  • Government (mainly targeting hospitals, training, support systems)

The constraints met

  • Overcrowding of the policy agenda. Proliferation of (mainly donor driven) priorities
  • Weak political leadership. The line of least resistance was regularly preferred
  • Weak technical and managerial capacity. No explicit strategy to overhaul management structures and capacity introduced
  • Delayed and erratic availability of resources (internal and external)
  • Despite the stated PHC policy, decision-making remained dominated by hospital-oriented medical doctors

The long-term results

  • Positive
    • Expanded health services, both in volumes (+59% from 1993 to 2000) and coverages (roughly 2/3 of the population used basic services in 2002)
    • Redistributed health care provision to cover underserved areas
    • Increased total financing (around US$10 per head in 2002). Expanding internal funding (51% in 2000)
    • Upgraded and re-deployed workforce
    • Reduced fragmentation and inefficiencies
    • Increased management responsibilities of recipient authorities
    • Improved information and transparency
  • Negative
    • Poor absorption capacity of expanded financing
    • Widespread informal privatisation of health care provision
    • Weak or absent regulatory systems
    • Management structure and practice remaining outdated, top-down, rigid, procedure- rather than result-oriented
    • Poor patterns of quality of care
    • Hospital-bias maintained. Facility-focus maintained and strengthened
    • Lack of preparedness of the health sector to respond to HIV/AIDS
    • Unclear direction of sector development. Reforms (decentralisation, public sector reform, financing, health sector reform etc.) talked about but not acted upon
    • Overstretched public sector, trying to deliver all services and address all issues
    • Powerful negative incentives outweigh stated policies

The lessons to be retained for other reconstruction processes

  • To forever postpone painful decisions leads to problems of intractable proportions
  • In the long-term, the lack of robust regulatory system may jeopardise even substantive achievements in service provision
  • The cautious incrementalism often appropriate to transitional contexts may slowly give way to indifferent conservatism
  • To anticipate events is key to system development
  • To get incentives right is the most important component of a recovery process

The case of Uganda

by Maurizio Murru

The situation at the end of the war (1986)

  • Widespread population impoverishment, displacement, destruction of infrastructure, breakdown of social structures, localised conflicts, continuing especially in the North and East of the country (about 25% of the national territory)
  • Health workforce decimated by brain drain and widespread killing. The under-skilled cadres left concentrated in hospitals and in towns
  • Health system collapsed. Hospital bias. Health units, especially lower-level ones, without qualified personnel, equipment, drugs.
  • Scarce, incomplete and unreliable information for policy design. This somehow increased the freedom of action of the different actors. Absence of a real Health Policy and of a meaningful health policy debate
  • Different actors bypassed the MoH and collected their own data with their own information systems
  • Services available mainly in health units run by churches (especially hospitals and in the North)
  • Overall poor quality of care (with very few exceptions)
  • Very low levels of public revenue. By 1986 public health budget about 6.4% of its 1970 levels
  • Severe donor dependency. No coordination. No guidance from Ministry of Health
  • Many unintegrated projects supported by dozens of international agencies and hundreds of local NGOs: massive projectisation and fragmentation

The chosen approach to reconstruction

  • The main objective was the restoration of the health system to its pre-1970s levels (no questions asked about its appropriateness or viability): restoration rather than redefinition
  • Reliance on vertical programmes to expand services coverage (Immunisations, Essential Drugs)
  • Unquestioned donor choices often in line with their own expertise and interests. Little, if any, real concern to know population priority needs and satisfy them
  • No attempt to develop a strategic vision for the health system
  • Physical rehabilitation seen as a means to gain legitimacy by the new government

The resources made available for reconstruction

  • Substantial donor contribution to physical rehabilitation of infrastructure (especially, but not only, from the World Bank and through loans rather than grants)
  • United Nations and bilateral agencies mainly involved in “Selective” Primary Health Care activities
  • Donor funds increased from about US$ 5 million in 1982-83 to about US$ 40 million in 1986-87
  • Government expenditures primarily directed towards secondary and tertiary care
  • In 1986-87 the main Hospital, Mulago, situated in the capital Kampala, consumed 30% of the recurrent an 70% of the development budget

The constraints met

  • No policy debate. Poor analytical, technical and managerial capacity. Proliferation of mainly donor-driven “priorities”, based on little evidence
  • Health system’s rehabilitation meant to serve the political objectives of the new leadership
  • Several districts still ravaged by guerrilla war after the new government took power. This led to high defence budget, limited funds available for social sectors like health, and donors in very powerful position
  • Huge capital investments mainly funded by donors. No apparent concern and no resources made available by donors to pay for recurrent costs
  • Low salaries in public sector led to informal charges and uncontrolled privatisation of services provision
  • Despite the stated PHC policy, decision-making remained dominated by hospital-oriented medical doctors
  • Equity, social justice, community participation, of no real concern to government and donors

The long-term results

  • Positive
    • Many units physically rehabilitated added to the legitimacy of the new government
    • Service provision expanded, although mainly in urban and peri-urban areas
    • Capacity for information gathering and analysis recovered slowly, to attain now respectable levels
    • Critical voices were raised and provided the basis for a meaningful health policy debate in the years to come. In fact, a period of reforms started about a decade later
  • Negative
    • Reconstruction missed the opportunity of promoting an immediate policy debate and a reshaping of the health system.
    • Pursuing their priorities, donors introduced a perverse system of incentives and allowances that hijacked health workers towards certain (remunerated) activities (e.g. immunisations, attending workshops and seminars) to the detriment of others
    • Weak or absent regulatory systems. Widespread informal, unregulated privatisation of health care provision
    • Poor patterns of quality of care
    • Hospital-bias maintained. Facility-focus maintained and strengthened Development of many vertical programs

The lessons to be retained for other reconstruction processes

  • To work without a coherent and comprehensive policy leads to the chaotic proliferation of interventions, whose wide-ranging negative consequences will be felt for decades to come
  • If long-term results are of real concern, donors should work inside government structures, so as to strengthen them
  • Promoting a wide, evidence-based policy debate may help in raising the real issues at an early stage. Inclusion of local authorities in such a debate is crucial for creating and strengthening capacity and ownership
  • In situations where areas of the country are still unsafe, reconstruction (rather than pure military force) could be a useful strategy to win legitimacy and confidence
  • The perverse incentives introduced by donors bear the potential of distorting the whole health sector and of offsetting progress otherwise registered
  • To anticipate events is key to system development. To pursue restoration without considering the structural changes induced by decades of civil war is short-sighted.

The case of Cambodia

by Peter Hill

The situation at the end of the war (1993)

  • Over two decades of attrition of health services, beginning in 1970 with the civil war following the Lon Nol coup, the Khmer Rouge genocide (1975-9), UN sanctions against the Vietnam backed People’s Republic of Kampuchea (1980-1991)
  • Persisting insecurity in more remote areas until 1997
  • Extensive destruction of facilities
  • Decimation of medical workforce due to Khmer Rouge and migration
  • Accelerated training of health personnel, with limited resources, and hospital focus
  • Concentration of resources in Phnom Penh and provincial capitals
  • Poor coverage of basic services (approximately 30%)
  • Poor Ministry of Health capacity
  • No designated health budget. MOH expenditure US$ 1.02 per capita in 1994.
  • Heavy donor dependency
  • No multilateral involvement other than UNICEF
  • NGO role prominent. MEDICAM, an informal coordinating mechanism, established by international NGOs
  • Vertical programs dominated health sector with strong donor links
  • Poor information base, with data limited to hospital collections

The chosen approach to reconstruction

  • Comprehensive health sector reform program initiated in 1996 following strengthening of MOH capacity
  • Health Coverage Plan with two tier Operational District structure based on population rather than Administrative boundaries
  • Extensive rehabilitation and building of infrastructure
  • UNICEF, WHO technical advisers at MOH and Provincial level
  • Minimum Package of Activities (MPA) delivered by health centres to aggregate populations of 10,000
  • Referral hospitals to offer Complementary Package of Activities to 150-200,000 population
  • Former District Hospitals and Commune clinics to be rationalised into new coverage plan
  • Workforce to be standardised, training of doctors contained, training of nurses and midwives upgraded
  • Vertical programs to be integrated into MPA
  • National Financial Charter to improve access to budget funds and to permit cost recovery at health centres and hospitals
  • Establishment of exemption schemes (subsequently equity funds) for the poor

The resources made available for reconstruction

  • Substantial donor contribution to physical rehabilitation of infrastructure (World Bank and Asian Development Bank loans, Bilateral donors)
  • Continuing multilateral and bilateral donor support for vertical programs
  • NGOs heavily involved in District level and PHC services
  • MOH maintained salaries, with increasing budget allocations (from US$ 15 Million in 1994 to US$ 31.8 million in 2000); actual expenditure increased in percentage as well, over the reform period

The constraints met

  • Further conflict in 1997, resulting in 25% fall in development assistance through sanctions
  • Total funding support (MOH and donors) inadequate to finance reforms
  • Human resource development not consistent with the demands of the Health Coverage Plan
  • Poor financial incentives for staff limited MOH leverage to redistribute workforce
  • Initial capacity within central MOH and at provincial and district level severely limited
  • Quality of services in government facilities poor
  • Cost recovery not sufficient to meet health workers expectations
  • Resistance to changes implicit in Health Coverage Plan, especially closure of commune clinics and downgrading of former District Hospitals

The long-term results

  • Positive
    • Physical infrastructure enhanced
    • Access to health services substantially increased
    • Effective drug procurement and distribution through Central Medical Stores
    • Better coordination of multilateral and bilateral donor and NGO activities
    • Commitment of key donors/banks to Sector-Wide Management
    • MPA delivery extending immunisation and antenatal coverage
    • Increased budget for health, increased revenue from cost recovery
    • Significant increase in MOH capacity and ownership of reforms
  • Negative
    • Human resource management lagged behind infrastructure
    • Limited Complementary Package of Activities implementation
    • Financial package not adequate
    • Regulation of private sector not achieved
    • Equity issues not systemically addressed

The lessons to be retained for other reconstruction processes

  • The financial package available determines the parameters of infrastructure reform available
  • Reinforcement of existing strengths – such as the provincial hospitals – needs to proceed before other initiatives are taken
  • Human resource development must keep pace with service delivery reforms, particularly where new hospital based technology is planned
  • Without effective regulatory controls, or salary incentives, the MOH is powerless to bring about the necessary redistribution of the health workforce
  • The private sector must be addressed as part of the reform process, particularly where they supply a significant proportion of primary medical services
  • In situations like Cambodia, in-service training faces a dual task: a) to re-orient health staff towards working in their new roles, in a cooperative team, and b) re-teach basic clinical skills not acquired during their original vocational training.

Analysing disrupted health sectors: a toolkit: 1,2,3,4,5,6,7,8

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