First meeting of the Health Systems Development Advisory Group and Expert Panel: report on a WHO meeting: Copenhagen, Denmark, 10–12 December 2001

REGIONAL OFFICE FOR EUROPE ___________________________ EUR/02/5040745 ORIGINAL: ENGLISH UNEDITED E74963 FIRST MEETING OF THE HEALTH SYSTEMS DEVELOPMENT ADVISORY GROUP AND EXPERT PANEL Report on a WHO Meeting Copenhagen, Denmark 10–12 December 2001 SCHERFIGSVEJ 8 DK-2100 COPENHAGEN Ø DENMARK TEL.: +45 39 17 17 17 TELEFAX: +45 39 17 18 18 TELEX: 12000 E-MAIL: POSTMASTER@WHO.DK WEB SITE: HTTP://WWW.WHO.DK 2002 ABSTRACT Most countries in the WHO European Region are reviewing their health systems and their approaches to financing, organizing and delivering health services. While the last decade generated much debate, theoretical analysis urgently needs to be complemented by practical tools and processes to implement reform. The meeting reviewed the Regional Office’s achievements in health systems development over the last five years and planned new directions and ways of working. It convened an Advisory Group to guide the formulation of a vision and an action plan. It also established an Expert Panel that will implement the programme in countries, and trained its members in effective consultancy. The meeting finalized the programme’s business plan and agreed a number of activities, focusing on implementation of the country Biennial Collaborative Agreements. It advocated a more strategic approach to health systems development, taking the lead from Member States but working within the framework of WHO values and policies. Keywords DELIVERY OF HEALTH CARE – trends – economics ORGANIZATION AND ADMINISTRATION HEALTH CARE REFORM HEALTH PLANNING EUROPE © World Health Organization – 2002 All rights in this document are reserved by the WHO Regional Office for Europe. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. For the use of the WHO emblem, permission must be sought from the WHO Regional Office. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. The Regional Office would appreciate receiving three copies of any translation. Any views expressed by named authors are solely the responsibility of those authors. This document was text processed in Health Documentation Services WHO Regional Office for Europe, Copenhagen CONTENTS Page 1. Introduction.........................................................................................................................................1 Structure of this report ........................................................................................................................3 2. Report of the First Meeting of the Health Systems Development Advisory Group and Expert Panel ...............................................................................................................................4 Health systems development in the WHO European Region .............................................................4 How WHO supports health systems development..............................................................................5 Regional Office priorities .........................................................................................................6 Relevant Regional Office programmes.....................................................................................6 Health Systems Organization and Management (HSM).....................................................................6 Building on the past ..................................................................................................................7 Health Systems Organization and Management Mission Statement ........................................7 Health systems business plan....................................................................................................7 Resources..................................................................................................................................8 Health Systems Development Advisory Group ..................................................................................8 Expert Panel ......................................................................................................................................10 The purpose of WHO consultancy..........................................................................................10 Effective consultancy..............................................................................................................11 Support for the consultant.......................................................................................................12 Implementing Biennial Collaborative Agreements for 2002–2003........................................13 3. Next steps..........................................................................................................................................14 Annex 1. The WHO Country Cooperation Strategy (CCS) – product, principles, process....................17 Annex 2. Organigram of the WHO Regional Office for Europe............................................................19 Annex 3. Health Systems Organization and Management Programme (HSM) Business Plan 2002–2003 .....................................................................................................21 Annex 4. Health Systems Development Advisory Group......................................................................31 Annex 5. Participants .............................................................................................................................32 EUR/02/5040745 page 1 1. Introduction Many countries are reviewing their health care systems and the suitability of their existing approaches to financing, organizing and delivering health care services. Pressures to achieve better cost control and/or greater productivity and efficiency need to be balanced against deeply rooted moral imperatives to maintain universal access to necessary care, and to improve the equity with which services are distributed across social classes and groups (1). Reform measures will be judged not only by short-term savings to public budgets, but also by their ability to promote health and to generate health gain for the entire population in line with WHO’s HEALTH21 (2). Since the early 1990s, the WHO Regional Office for Europe has conducted an extensive programme of activities in support of reform development and implementation. When the winds of change swept through the Region and many newly independent countries became for the first time Member States, WHO was one of the first organizations to give active support. Today, many other agencies are active in the health field. If its interventions are to be complementary rather than competitive, WHO must focus its efforts where it can add value and make a difference, exploiting its unique strengths and relationships. While the last decade generated much analysis and discussion of health systems reform across the Region and indeed worldwide, this has not yet been matched by the development and use of practical, country-friendly tools and processes to help translate these intellectual insights into action and to close the policy-practice gap. WHO’s analyses and policy recommendations need to be refined and operationalized, and countries equipped with practical tools to improve their health services in a fast-changing world. Honesty is needed in sharing experience of what works, and inventiveness is needed in creating and using tools for change. Under the leadership of the Regional Director, the Office is now refocusing on more intensive work with individual countries, building stronger partnerships to underpin more consistent, longer-term strategies for health improvement. The world health report 2000 (3) which assessed how effectively and efficiently health systems were achieving their goals, highlights many challenges – and many variations in different aspects of their performance. Clearly, there is much that countries can teach and learn from each other. Looking more specifically at health care reform in Europe, the Ljubljana Charter on Reforming Health Care (4) identified a number of fundamental principles, taking account of the 1978 Alma- Ata Declaration on reorienting health services to primary health care. It says reform should be values driven, health focused, people centred, quality based, financially sound and orientated towards primary health care. Together the Declaration, Charter and Report set the parameters for the themes of the newly relaunched Health Systems Organization and Management programme (HSM), the focus of this report – highlighting why health systems matter, how well they perform, whether they are well organized, what resources are needed and where they come from, and how the public interest is protected. The Charter also outlined six principles for delivering these changes. These continue to provide a crucial frame of reference to guide the new programme’s work, while acknowledging the need to move with the times and remain abreast of recent developments in this rapidly changing EUR/02/5040745 page 2 scenario. The programme’s business plan, described later in this report, sets out specific proposals to put the principles into practice:
 Develop health policy – health care reform should be part of overall health policy;
 Citizen’s voice and choice – making a significant contribution to shaping care;
 Reshape health care delivery – a radical re-examination of systems and strategies;
 Reorient human resources for health care – a broader vision of roles, functions and practice;
 Strengthen management – functions, structures and individual capacities;
 Learn from experience – promote national and international exchange. While the last decade generated much analysis and discussion of health systems reform across the Region and indeed worldwide, this has not yet been matched by the development and use of practical, country-friendly tools to help translate these intellectual insights into action and to close the policy-practice loop. The lack of such tools may have contributed to the unduly slow progress of reform in some countries. The programme will therefore focus on delivering change, applying theory and implementing policy – developing ways of harnessing the experience and expertise in health care systems and coordinating access to the lessons learned. It will also be mindful of the many organizations and agencies already active in this field, and strive to complement rather than duplicate their work using the unique strengths of WHO. Taking its lead from the philosophical underpinnings described above, employing a bottom-up approach based on lived experience, and aiming to practise what it preaches, the programme’s preferred ways of working will focus on “how to do it” as well as “what should be done”. These methods and approaches will include the following:
 Local expertise. The programme will work with experts from health systems in all parts of the Region. The experience of colleagues working in systems in transition will be particularly important.
 Connecting stakeholders. Building effective networks of these colleagues so they become self-sustaining and not dependent on central resourcing from the WHO Regional Office for Europe will be a feature of the work.
 Feedback loops. Much of the work programme depends on consultation with the field, securing feedback and acting on the advice of those who work daily on improving health systems in. A variety of approaches will be used to enlist this crucial advice and support.
 Supporting the leaders of change. Systems and resources will be developed to allow those leading change to understand, assess and extend their abilities, knowledge and development needs.
 Translating experience. Experts will be identified to help interpret the experience of these local colleagues and help them become more effective change agents.
 A bank of resources. Resources and tools will be identified and catalogued to support change in health systems, for example approaches to the dissemination of evidence-based practice. These are usually initiated for local use but may well have international value.
 Case studies. The programme will locate and highlight examples of good practice, and indeed initiatives which have not worked, publishing them as case studies that can act as catalysts or sources of information. EUR/02/5040745 page 3
 Events. The programme will hold seminars, workshops and other events to meet a number of objectives, including building skills, sharing information and perspectives, clarifying issues for and by those in the field, identifying case studies, qualitative evaluation and consensus-building. Health Systems staff, advisers and country partners agree that these approaches will best work to meet the spirit as well as the letter of WHO’s overarching policies. In particular, the programme will be needs-led, and those needs will be identified by those best qualified to do so – and those directly working to develop health systems that will best serve their local populations. In taking this innovative and therefore more risky approach, all concerned with the programme acknowledge that it represents an enormous set of challenges. At times they will appear daunting, but it is also recognized that the scale of changes needed to solve Europe’s health problems is so great that the safer traditional approaches are no longer effective. We are all embarking on a change journey that requires us continually to develop new skills, expertise and insights in ourselves as well as those we aim to support and serve. The stakes are therefore high, but so are the potential rewards. Structure of this report This report from the new programme has several strands. First, it describes the first meeting of the Health Systems Development Advisory Group and Expert Panel, held in Copenhagen on 10–12 December 2001. It then sets out the Health Systems Business Plan, revised in the light of discussions at the meeting, which gives details of the programme’s aims, objectives and context. It then outlines the next steps to be taken. Finally, it lists references and resources and contains annexes intended to supplement the report and provide a guide for further investigation. Like our other programme activities, this report is intended to stimulate debate and to represent work in progress rather than tablets of stone. Comments, criticisms and suggestions on any aspect of it will be warmly welcomed. Ainna Fawcett-Henesy, Regional Adviser, Health Systems, and Unit Head, Health System Policies, WHO Regional Office for Europe EUR/02/5040745 page 4 2. Report of the First Meeting of the Health Systems Development Advisory Group and Expert Panel The first meeting of the Health Systems Development Advisory Group and Expert Panel held in Copenhagen on 10–12 December 2001 had two main strands. One was the first meeting of the newly constituted Health Systems Development Advisory Group. Comprising experts from and observers from WHO headquarters and other key agencies, it guides the formulation of the programme’s vision, direction and action plan. The other main strand was a meeting of a new Expert Panel of consultants with a range of expertise in health systems reform. They will not only help shape the vision and direction of the programme, but will implement it in countries. The expected outcomes of the meeting were:
 Shared understanding of the vision and overall direction of the programme;
 Agreement on how to help countries to further develop their health systems;
 Agreement on the next steps to be taken as the programme moves into implementation of its Biennial Collaborative Agreements (BCAs) with countries;
 Shared understanding of the programme’s purpose and methods;
 Creation of team spirit and commitment to the programme. Health systems development in the WHO European Region The WHO European Region contains some of the world’s richest and poorest countries. According to the preliminary findings of the European Health Report (5), poverty has become more widespread in the eastern part of the Region in the past decade, contributing to a widening east-west health gap, while major inequalities persist within western countries. This diversity is reflected in the Region’s many and varied approaches to the design and management of health systems. There are major differences in financing methods, the degree of centralization, the balance between prevention and treatment, the balance between primary, secondary and tertiary health care, the attention given to evaluation and the strength of patients’ rights. Member States regard the development of their health system as a high priority, as they try to match the growing demand for more and better health care with stable or diminishing resources. Recent experience is dominated by two observations. First, market-oriented policies for health systems, such as privatization and purchaser/provider competition, have shown their limitations in terms of their impact on equity and their capacity to achieve efficiency gains. Nevertheless, the private sector can be an effective service provider as long as the government takes its Stewardship function seriously and all institutions and activities in the health system as a whole are regulated by national standards, and levels of quality guaranteed. Second, the convergence of different health systems that some predicted has not happened. Although many problems are common to all systems, and a few technical solutions enjoy wide popularity, the broad features are not evolving into a single model and many different solutions are being tried. However, the strengthening of the social dimension of the European Union (EU) and the accession of new Member States to the EU suggest that convergence is a likely future development – with WHO set to play a key role in advising on the key characteristics of a common European health systems model. EUR/02/5040745 page 5 Several trends are noted in the transformation of health services. Countries are seeking a better balance of sustainability and solidarity in financing. They are focusing on strategic purchasing in allocating resources to service providers, in order to maximize health gain. They are seeking greater efficiency in health service delivery. Finally, evidence is growing that effective government stewardship is central to success. How WHO supports health systems development Four presentations by WHO staff set the scene by outlining how the organization supports health systems development. Ainna Fawcett-Henesy explained that this work is carried out within the framework of WHO’s overall objective, summarized in its constitution as “attainment for all people of the highest possible level of health”. WHO aims to make the greatest possible contribution to world health through increasing its technical, intellectual and political leadership. It pursues four main strategic directions to achieve its goals of building health populations and fighting illness:
 reduce excess mortality, morbidity and disability;
 promote healthy lifestyles and reduce the risks from environmental, economic, social and behavioural causation;
 develop health systems that improve health outcomes, respond to people’s legitimate demands and are financially fair; and
 develop an enabling policy and institutional environment in the health sector, while promoting and effective health dimension to social, economic, environmental and development policies. WHO has six core functions to pursue these strategic directions: to articulate policy and advocacy positions; to manage information, and set the agenda for and stimulate research and development; to catalyse change through technical and policy support; to promote national and global partnerships; to set and validate norms and standards; and to stimulate development of technologies, tools and guidelines. Its current organization-wide priority areas are malaria, HIV/AIDS, tuberculosis, maternal health, mental health, tobacco, cancer, cardiovascular disease, diabetes, food safety, safe blood, health systems and investing in change in WHO. The Organization is moving to new ways of working worldwide. It aims to adopt a broader approach to health within human development (making clear links between health and poverty); to play a greater role in national/international consensus-building on health policy, strategy and standards by managing the generation and application of research, knowledge and expertise; to encourage more effective actions to improve health and reduce inequities; and to encourage strategic thinking, global influence, prompt action, networking and innovation. The development of a corporate, more strategic approach to WHO’s work with countries, central to these new ways of working, was presented to the meeting by Carole Landon of the Country Analysis and Support Unit at WHO headquarters. The WHO Country Co-operation Strategy (CCS), the strategic frame outlining what WHO will do (key content areas) and how it will do it (key functions) over the medium term is a key instrument in that approach (see Annex 1). Each CCS is based on a rapid policy analysis covering the country’s health and development challenges, WHO’s current involvement, the contributions of other external partners, and global and regional priorities. The process, involving WHO staff in a cohesive CCS team, is as important as the product – the CCS document that sets out the agenda of work in and with the EUR/02/5040745 page 6 country for the entire WHO secretariat. The approach has been tested in four non-EURO countries and is being extended to 20 more, including Armenia and the Russian Federation. In subsequent discussion, the approach was broadly welcomed. Participants pointed out the need for cooperation to go beyond the traditional partnership between WHO and Ministry of Health, and to be based on a broader consensus involving a much wider range of internal stakeholders as well as other external agencies. It was also stated that WHO’s intercountry work should not be neglected in the stronger focus on countries, and should be developed hand in hand with its country work. Regional Office priorities Under the leadership of Dr Marc Danzon, Regional Director, the Office is refocusing on more intensive work with individual countries, building stronger partnerships to underpin more consistent, longer-term strategies for health improvement. Its overall aim is to support Member States in developing their own health policies, health systems and public health programmes; preventing and overcoming threats to health; anticipating future challenges; and advocating public health. Its basic value is solidarity and its strategic principle is a multisectoral approach to health involving care, prevention, lifestyles and determinants (see Organizational Chart of the WHO Regional Office for Europe in Annex 2). Dr Josep Goicoechea, Director Division of Country Support, gave a brief overview of the Office’s strategy for helping countries to improve their health systems so they could have a positive impact on health. There was a need to focus more strongly on how to make change happen in real places with real people, rather than on theory. The Biennial Collaborative Agreement (BCA) between the Office and a country sets out the priorities for cooperation, based on thematic areas proposed by the Member State (such as communicable diseases, or health promotion), and outlines the policy measures, systems development measures and technical interventions to be implemented in each thematic area. A budget is allocated to each area in the agreement, covering the current implementation period 2002–2003. Relevant Regional Office programmes A number of different Regional Office programmes contribute to health systems development. Complementing the Health Systems Programme, the main focus of this meeting, there are technical units such as the Safe Motherhood programme, and a Health Systems Finance programme to be established in the near future. There is also the European Observatory on Health Care Systems, a partnership between the Regional Office and other important institutions and governments. Dr Josep Figueras, Head, WHO European Centre for Health Policy, outlined the work of the Observatory, which supports and promotes evidence-based policy-making through comprehensive and rigorous analysis of the dynamics of health care systems in Europe. It collects, analyses and disseminates information on the current state of health systems in specific countries, published in the Health Care Systems in Transition (HiT) country profiles (6). It also collates and comments on the range of policy options available, providing an invaluable intellectual foundation for BCA implementation and other health systems interventions. Health Systems Organization and Management (HSM) Introducing the Regional Office Health Systems Organization and Management Programme, Ainna Fawcett-Henesy emphasized the importance of continuity as well as change. The Regional EUR/02/5040745 page 7 Office had already done important work on health systems development, not least via the old Health Services Management programme. However, as WHO globally and in Europe entered a new phase of stronger support for countries, it was an opportune moment to assess achievements to date and plan new directions and new ways of working. Building on the past
 The 1996 Ljubljana Charter on Reforming Health Care was an important milestone. Endorsed by European Ministers of Health or their representatives, it articulated a set of principles – emerging from the experience of countries introducing reforms and from the European health for all targets – that were an integral part of current health care systems or could improve health care in all Member States. Although the Charter had not been followed up in a systematic way, and much had changed in the intervening five years, its principles were still highly relevant and should form the foundation of the new HSM programme.
 WHO has played a central role in countrywide reform initiatives, for example in the Manas project in Kyrgyzstan and the Lukman project in Turkmenistan. The successes and shortcomings of these initiatives provided invaluable experience from which other countries and WHO itself could learn much.
 WHO networks of people involved in health systems development, such as MIDNET and EASTNET, had stimulated thinking and debate, and attracted experts and change agents whose continuing input would be useful in future work.
 Tools already generated by WHO and others that might assist with health systems development should be reviewed for continuing value and relevance in the new phase of HSM work. Health Systems Organization and Management Mission Statement Ainna Fawcett-Henesy presented a draft mission statement for the programme and invited comments and changes. A number were proposed by participants in the course of the meeting and the text was subsequently finalized as shown in Box 1. The shared values underpinning WHO, as set out in various policies, provide the framework for this mission statement. Box 1. Health Systems Organization and Management Mission Statement To contribute to the continuous improvement of health systems in the countries of the European Region through capacity development, promoting best practice and innovation, and sharing experiences. Health systems business plan A draft business plan outlining the programme’s context, history, proposed goals and ways of working was presented to participants with an invitation to comment on desired changes. The Advisory Group reviewed it in depth and the revised version appears in full later in this report. It proposes the following underlying principles: EUR/02/5040745 page 8
 continued and sustained delivery against the aspirations of the Ljubljana Charter;
 take the thinking of The world health report 2000 and make it a reality in the European Region;
 adopt the WHO Global Country Co-operation Strategy approach in work with countries;
 implement the revisited headquarters-led Global Strategies on Primary Health Care;
 respond directly to priorities identified by Member States, and deliver a practical work programme that involves all relevant stakeholders. Five key areas of programme work were proposed, and broadly welcomed in discussion:
 compile an inventory of tools to assist with the improvement of health systems;
 develop a method for assessing and improving the competencies of decision-makers and managers working in health systems development;
 collect and disseminate examples of good practice in primary health care-led systems;
 produce a guidance framework/algorithm on the stewardship role of governments;
 draw up a framework and method to assess health system performance. Resources In planning the programme it was essential to be realistic about the human and financial resources available. For its intercountry activities in the 2002–2003 biennium, (including holding this meeting), the programme has been allocated US $110 000 from the WHO regular budget. Smaller additional sums are allocated for implementing the BCAs with countries, ranging from US $10 000 to US $60 000. Human resources are equally modest, with one regional adviser and one programme assistant. There is therefore a need to mobilize further resources, such as voluntary donations and staff secondments. Tools for implementing change were also needed, and the programme could start by assessing whether existing tools produced by WHO and others could be adapted for BCA implementation, thus saving time and money and avoiding duplication of effort. Following these scene-setting presentations and preliminary discussions, participants divided into two pre-selected groups which then met concurrently. One was the Health Systems Development Advisory Group, led by Ainna Fawcett-Henesy, and the other was the Expert Panel, led by Jane Salvage, Temporary Adviser. Their discussions are reported below. Following these sessions, the Advisory Group and Expert Panel met in plenary and reported back on their work. Many similar points had emerged in both groups and there was strong consensus. The mission statement was revisited and agreed, and the draft programme business plan accepted with the amendments proposed during the meeting. Health Systems Development Advisory Group The Advisory Group, comprising nine members and three observers from nine countries, one international association, the World Bank and WHO headquarters, discussed its composition, and agreed that the EU should be invited to send a representative. The importance of active representation from the Observatory was stressed both to inform the group’s discussions and to ensure the two programmes complement rather than duplicate each other (the Observatory’s primary focus is analysis while HSM’s primary focus is implementing change). Dr Mihaly Kökény, President of the Hungarian Parliament Health and Social Affairs Committee, Hungary, was unanimously elected as Chairperson. EUR/02/5040745 page 9 The draft terms of reference were discussed, and finalized as shown in Annex 4. In essence, the group’s role, individually and collectively, is to provide strategic advice; act as a sounding board for the Regional Office on health systems development; flag up important issues; and offer leadership on health care reform to. The group expects to work closely with the Expert Panel of consultants who will be implementing the programme in countries, creating an effective policy- practice loop within the programme through regular feedback between the group and the panel. The two-way communication should include presentation of papers for joint debate at future joint meetings, including case studies reporting on the panel’s work. Broadly speaking, the group will steer HSM policy while the panel works on implementation of that policy, though there may sometimes be overlap, particularly when an activity is carried out in a country that has an Advisory Group member. In this case the member is expected to support and advise on implementation. The group should position itself appropriately within WHO, and be regularly advised of all relevant WHO and related information. Members and secretariat should make full use of digital technology to maintain frequent communication. It was seen as very important that the programme aimed to be relevant to health systems Europe- wide, i.e. all 51 Member States, not only those of central and eastern Europe and the newly independent states (NIS). All countries were struggling with similar problems, but needed to be stimulated to be more receptive to WHO input. The 1996 Ljubljana Charter had been an important milestone but not enough had happened subsequently to put its principles into practice. Concern was expressed at the hasty introduction of free market principles and policies into European health care systems at a time when, with ageing populations and declining birth rates, the pool of workers in employment who could fund an insurance-led system was shrinking: WHO was urged to offer a clearer way forward on this. WHO was also asked to produce a clear Region-wide overview of the current status of health care reforms, and to consider the possibility of preparing a conference reviewing the current state of health systems development in Europe ten years on from the major political and social changes in the countries of central and eastern Europe and the NIS. It was noted that there an external evaluation is under way, commissioned by the Standing Committee of the Regional Committee (SCRC), of WHO’s work on health care reform in Europe following the Ljubljana Charter; the outcome of this work would be significant for Health System Development and would inform the Advisory Group discussions in due course. The analytical work of the Observatory was crucial and should be fed into the work of the Health Systems Development Advisory Group. There was concern at the possible impact of the current WHO Regional Office structure on the delivery of BCAs, particularly the challenges posed by the geographical and structural separation of the Health Systems Policy function in Copenhagen from the WHO European Office for Integrated Health Care Services in Barcelona, Spain. The potential importance of WHO collaborating centres in implementing the programme was highlighted; there are currently only two in this technical field, in Canada and Germany, and more need to be identified. Greater clarity was needed in the division of labour between different United Nations agencies and others, avoiding duplication and competition. The following recommendations were made:
 The programme should focus on all 51 Member States in WHO’s European Region.
 A mapping exercise of the key stakeholders should be undertaken, in recognition of WHO’s key coordinating role in some countries. EUR/02/5040745 page 10
 Each country with a BCA should identify a local expert group to act as programme counterparts, and connect with Expert Panel members from that country. Its membership should include WHO country-based officials and partners, such as WHO Liaison Officers and collaborating centre representatives. The Advisory Group should meet the chair of the local group annually to exchange ideas and review progress.
 The programme should constantly be aware of the range of stakeholders in health systems development, and its implications for working beyond the traditional strong relationship between WHO and the ministry of health, invaluable as this continues to be. The intersectoral approach continues to be essential. Expert Panel The first Expert Panel met concurrently with the Advisory Group. It comprised ten experts from eight Member States with particular expertise in health systems development. Their role, individually and collectively, is to help implement the Health Systems Development programme, through country missions and other forms of advice giving and support. This first meeting is to be followed shortly by a second meeting, using a similar format, with another group of experts; the two groups together comprise the Expert Panel. The meeting began by agreeing its main purpose in the context of the new Health System Policies strategy. This was to explore the processes to be used in implementing the BCAs, to reflect on how to be an effective consultant, and to build the panel into a team. It also formulated a set of ground rules to guide its conduct, noting that the process of the meeting should model the way in which work in countries would be carried out. The ground rules were respect for language differences, including requests for repetition or explanation when necessary; trust and openness; tolerance and respect for the diversity of views and behaviours within the group; maintaining confidentiality; keeping to time; and having disciplined discussions with short, clear inputs. The purpose of WHO consultancy WHO’s traditional strength lies in sharing technical expertise, and consultants are chosen on the basis of this expertise. However, this focus on the content of the assignment (giving advice and information) needs to be complemented with expertise on how to help the client bring about change, based on a clear understanding of the consultancy process. These process skills are often assumed to be implicit in an assignment, but it was acknowledged that many consultants with great technical expertise have never learned process skills and that WHO had rarely facilitated such learning. Participants welcomed the opportunity to reflect on the consultancy process and use their membership of the Expert Panel to exchange ideas and experiences. It was also recognized that clients and partners in countries needed to gain mastery of process skills as they tackled their change programmes, and that WHO consultants could play a valuable part in teaching and modelling the skills during their assignments. Panel members who had already undertaken WHO assignments had valued the experience but not always found it satisfactory. Consultants were too often expected to visit countries at very short notice and little opportunity for advance preparation or dialogue about what the client wanted and expected. Visits were often very short and might achieve little unless the consultant could negotiate the aim and agenda of the visit from the outset, and avoid distractions. Coordination with other WHO consultants, let alone other agencies active in the country, might be non-existent, leading to confusion, fragmentation and duplication of effort. This situation was frustrating for consultant and client alike, and a waste of scarce human and financial resources. EUR/02/5040745 page 11 Nevertheless WHO consultancy could be satisfying and effective. WHO was generally highly regarded and provided an effective entry point to important organizations, contacts and networks. Working within the framework of WHO principles and policies provided an ethical, equitable foundation for the work and generated mutual trust. Being a WHO consultant was different from many other assignments participants had carried out, in that the WHO consultant is expected to advocate WHO values, policies and guidelines. This may bring the consultant into conflict with clients who wish to pursue goals incompatible with those values and policies. Indeed, there is a tension in clarifying who the client actually is – the first step in effective consultancy. Is the client WHO itself, the Member State’s government, the ministry of health, another stakeholder or interest group, or the population as a whole? Effective consultancy The Panel worked through three papers (7–9) prepared and briefly presented by Jane Salvage, Temporary Adviser, on the consulting process, consultancy skills and cultural issues. These working papers, intended to provide the basis of guidelines on effective consultancy that may be useful to HSM and other WHO programmes, are available from HSM on request and comments on them are warmly welcomed. The consulting process
 The consulting process should build a healthy relationship between WHO/consultant/client; increase the client’s readiness to change and adapt; build a firm basis for implementing technical and social change; and develop the client’s confidence and capacity. It cycles through a number of separate yet related phases: gaining entry, data collection, making a diagnosis, bringing about change, evaluation and stabilization. The consultant’s awareness of what phase of the process she or he is in can enable clearer thinking and more appropriate action. This in turn can lead to a more effective interaction with the client. Many of the most common difficulties, such as offering a solution to a client when they are not ready to listen to it, can be eliminated by using the model to guide action. Being effective
 To consult effectively is to join another human being in a quest for some clarity or course of action that is currently hidden from him. Where he is in that quest and what help he needs will vary from person to person and situation to situation. The consultant’s responsibility is to bring to the client knowledge, skill and a range of behaviours through which that knowledge becomes useful. Being an effective consultant therefore requires mastery of process skills as well as mastery of a technical field. To be of maximum value to the client, the consultant must be prepared to provide a wide range of functions, because each client is different and each problem is different. There is no single right way to help another person or organization solve a problem. There is a time to listen and a time to prescribe; a time to probe and a time to recommend; and also a time to withdraw from the relationship. Cultural issues
 Acting as a consultant in a foreign country brings special challenges. Each one of us is conditioned by cultural influences at a variety of levels: family, social group, geographical region, professional environment and so on. These can exert a powerful influence over how we think and behave. When working as a consultant in another country, it is essential to be aware of our own cultural bias and ensure that it does not damage relationships with our clients. Understanding the client’s culture also helps us to develop a more productive relationship. EUR/02/5040745 page 12 WHO consultants often work in a second language or through an interpreter. Likewise the client may be working through an interpreter or in a language that is not his mother tongue. This requires extra care and hugely increases the risk of misunderstanding and misinterpretation. Non- verbal communication, an extremely important but underestimated form of communication, may assume even greater importance when linguistic communication is restricted and should also be closely studied. Finally, the historical and political context will have a strong impact on a project. Within the European Region, many countries have recently undergone rapid, dramatic and sometimes violent change, and the consultant needs to be as well informed about this as possible. Historical relationships between countries may also colour the consultant-client relationship, regardless of individual personality or attitude. Support for the consultant The panel outlined the support the consultant needed before, during and after missions in order to function as effectively as possible.
 WHO resource pack WHO should prepare a resource pack for consultants containing such information as background on the Regional Office; key WHO documents; recent World Health Reports; guidelines on speaking in international meetings; guidelines on running small groups; country information such as HiT profiles, Highlights on health, Health for all (HFA) statistical database; a standard set of overhead transparencies for use on assignments; guidance on health and safety; guidance on effective consulting; and a list of useful Web sites giving country data, weather reports, health data, etc.
 Feedback to/from WHO, Regional Office for Europe Regular feedback to and from the Regional Office is essential to keep the both parties informed of developments, ensure assignments are clearly understood and goals agreed and achieved, and changes tracked in. WHO should facilitate the Expert Panel to be a major source of continuity, feedback, mutual support and information.
 Tool kits for country work Consultants need a set of tools or guidelines to help them in their assignments. This helps ensure a consistent programme approach, provides countries with tried and tested solutions, and reduces duplication of effort.
 Learning opportunities Good consultants regard their assignments as learning opportunities and WHO should do more to support their learning and benefit from it, through such means as mentorship, learning sets and workshops. The learning should also be captured in reports and case studies that can be shared with clients and throughout WHO.
 Guidelines on effective consulting The consultancy know-how developed by the Panel should be distilled and disseminated throughout WHO and. Equally, WHO staff and consultants should be informed about current thinking on consultancy skills and approaches in international development and management circles. EUR/02/5040745 page 13 Implementing Biennial Collaborative Agreements for 2002–2003 The panel discussed in detail how the BCAs should be implemented. It devised the implementation process outlined in the following table. BCA implementation process, 2002–2003
 Consultant preparation – Consultant attends preparatory WHO workshop to clarify consultancy process and programme goals and policies, and to match consultant skills and preferences to country needs. – HSM Programme provides consultant with as much background information as possible about the country, the agreed goal(s) of the BCA, WHO policies, other agencies’ activities and any other relevant data. The consultant supplements this with personal research, from his/her home base. – Wherever possible, the consultant supplements this preliminary assessment with a visit to the country (although WHO funds are unlikely to be available for such visits). – Consultant, usually working with one or two fellow consultants from the Expert Panel, prepares preliminary proposal for BCA component implementation.
 Country counterparts Meanwhile, HSM should ask WHO Liaison Officer and other relevant national contacts to establish a Country Project Group of stakeholders in health systems development. This group will work closely with the consultant(s) on BCA implementation, providing support, expertise, information, and a local powerhouse to ensure continuity between assignments, take ownership of the process and drive the changes forward. The group should elect a chair to maintain regular contact with HSP, the consultant(s) and the Advisory Group.
 Proposals to counterpart in country After checking preliminary proposals with HSM Programme, the consultant should discuss it with the WHO Liaison Officer and Country Project Group and agree an action plan. This dialogue is a negotiation to ensure the activity is feasible, desirable and consistent with the spirit and intention of the BCA (WHO and countries acknowledge that renegotiation of some parts of the agreement may be necessary if circumstances change). The action plan should include details of expected outcomes, activities proposed, parties to be involved, allocation of responsibilities, time schedule and draft budget. Copies of the final action plan should be held by the consultant, HSM, the WHO Liaison Officer and the country project group.
 Mission preparation and implementation Preparation for the mission, including all practicalities such as travel, accommodation and interpreters, should be carried out by HSM and the consultant with the support of the Liaison Officer.
 Report Following the mission the consultant should write a report of what was done, including an evaluation of its effectiveness, lessons learned for the future, the value of any tools used, and recommendations for follow-up including possible components of future BCAs or related WHO projects, both country and intercountry. This should be shared with all relevant parties. The consultant should be willing to discuss his/her experience with other Expert Panel members and the Advisory Group, and contribute on request to overall programme evaluation. EUR/02/5040745 page 14 The panel analysed the 2002–2003 BCAs and grouped the components for which HSM is responsible under broad thematic headings. This will enable HSM to match the consultants’ expertise with country needs, and lead to the establishment of consultant partnerships or small teams to work on a specific theme with an identified group of countries. It should help to minimize duplication, improve continuity, develop team spirit and a unified approach within the Expert Panel, and assist in the development or adaptation of tools for implementing reform. The topic areas identified were: review of the current health system; development of indicators of health system performance; strategies for health care management; health care financing; and health policy implementation. The terminology used in the BCA documents varies widely and is not always easy to interpret, so these thematic groupings must be regarded as provisional pending further discussion with the countries. The Expert Panel emphasized the importance of developing a toolkit of guidelines, approaches, methods and processes to support health systems development. Owing to resource limitations and to avoid duplication of effort, it was not seen as necessary or desirable to develop new tools. Rather, existing ones within and outside WHO should be identified and reviewed for suitability, and the best ones piloted and adapted in specific countries. 3. Next steps This list contains steps recommended during the meeting and others identified in subsequent discussions.
 Advisory Group meetings To be held in June and December 2002. Funds permitting, the Expert Panel will also be invited to the December meeting for an exchange of views and experiences of programme implementation.
 Expert Panel Second group of experts to be invited to Copenhagen workshop in February 2002, and integrated into the work programme drawn up by the first group. The Panel, and individual small groups/partnerships within it, will be kept up to date with developments by HSM, and will additionally maintain regular contact with each other on their own initiative.
 Maximizing consultant effectiveness Prepare WHO resource pack Feedback to/from WHO Tool kits for country work Learning opportunities Guidelines on effective consulting BCA implementation This should be started as soon as possible after the February workshop, according to the process recommended by the Expert Panel. A guidance note on BCAs should be drawn up. Inventory of tools HSM will prepare an inventory of existing tools/approaches/guidelines/processes for health systems development (and attempt to define the loose term “tool” more precisely). EUR/02/5040745 page 15 Country case studies HSM will conduct case studies of its work in selected countries, both to build a data bank of experience on which other countries can draw, and to contribute to evaluation of programme/WHO effectiveness. Programme profile The meeting recommended that HSM should publicize its new programme within and outside WHO using a web page and other suitable media, and acknowledged the value of participants’ individual roles in raising the profile. Resource mobilization The search for additional human and financial resources for HSM must begin as soon as possible. Ideas and assistance will be warmly welcomed. Programme monitoring and evaluation More consideration needs to be given to how this should be achieved. EUR/02/5040745 page 16 References 1. SALTMAN, R.B. & FIGUERAS, J. European health care reform. Analysis of current strategies. Copenhagen, WHO Regional Office for Europe, 1997 (WHO Regional Publications, European Series, No. 72). 2. HEALTH21: the health for all policy framework for the WHO European Region. Copenhagen, WHO Regional Office for Europe, 1999 (European Health for All Series, No. 6). 3. The world health report 2000. Health Systems: Improving Performance. Geneva, World Health Organization, 2000. 4. The Ljubljana Charter on Reforming Health Care. Copenhagen, WHO Regional Office for Europe, 1996 (document EUR/ICP/CARE 9401/CN01). 5. The European Health report – summary of preliminary findings. Copenhagen, WHO Regional Office for Europe, 2001. (document EUR/RC51/7). 6. Health Care Systems in Transition – Country Profiles (HiTs). European Observatory on Health Care Systems. Copenhagen, WHO Regional Office for Europe, various dates. 7. SALVAGE, J. Culture and communication. Unpublished paper, 2001. 8. SALVAGE, J. Effective consultancy. Unpublished paper, 2001. 9. SALVAGE, J. The consulting process. Unpublished paper, 2001. Resources
 For information about WHO worldwide – www.who.int
 For information about WHO/EURO – www.euro.who.int (information on country work http://www.euro.who.int/countryinformation)
 For information about the Observatory – www.observatory.dk
 For information about the European Healthcare Management Association – www.ehma.org EUR/02/5040745 page 17 Annex 1 THE WHO COUNTRY COOPERATION STRATEGY (CCS) PRODUCT, PRINCIPLES, PROCESS The CCS product: a crisp and concise document that:
expresses WHO’s corporate strategy at country level for the medium term (3 to 5 years)
represents a sound balance between country needs, regional orientations and global priorities
constitutes a framework for WHO cooperation in and with the country concerned, highlighting both what WHO will do and how it will do it (areas of work and functions)
is used as a common reference for country work throughout the Organization, influencing the programme budget and plans of action
clarifies WHO’s role at country level in supporting broad-based development approaches, poverty reduction and sector programmes
provides an input into other organizational change processes. The CCS is based on principles that need to guide WHO’s work in and with countries
moving towards greater internal coherence and responsiveness to country needs
being more selective, focusing on fewer priorities
fostering strategic thinking, putting more emphasis on our role as policy adviser, broker and convenor
distinguishing the performance of the WHO secretariat from that of our Member States
ownership by the entire Organization, guardianship by the WHO Representative (WR)
broadening and deepening the partnership at country level, with greater emphasis on advocacy and influence regarding overall policy and spending
working with other development agencies in a complementary way, based on our comparative advantage. Formulating and endorsing the CCS: a twenty-week process Six main stages
a preparatory phase covering preliminary analysis of key health and development issues, external aid (where relevant) and WHO current operations in the country concerned
a first mission of the CCS team to engage in dialogue with government and development partners, draft the situation analysis, undertake a preliminary formulation of the WHO strategic agenda and a first analysis of organizational implications
a six-week period for further consultation and review
a second mission to finalize the strategic agenda and complete the CCS draft document, to discuss them with government and partners, and to outline implications for WHO with relevant proposals for consideration
a two-week period to refine and edit the CCS
review and endorsement of the CCS by the Director-General and relevant Regional Director. EUR/02/5040745 page 18 Two features that foster internal coherence and staff development
a CCS team involving the WR and someone from his/her office, one representative from the Regional Office and one from headquarters, to ensure a united strategy
emphasis on facilitation: exercising a challenge and support function to ensure rigorous analysis in key discussions RDO Division of Country Support CS Division of Technical Support TS Division of Information, Evidence and Communication Division of Administration and Management Support EC AM Office of the Regional Director RDO Reducing Disease Burden and Promoting Health RDB
Communicable Diseases (CDS)
Family and Community Health (FCH)
Noncommunicable Diseases and Mental Health (NCD) Health, Environment and Sustainable Development HED
Health Impact of Environmental and Development Policies (HEV)
Health and Urban Environmental Quality (HUQ)
Investment for Health and Development (HDT)
Partnership for Environment and Health (PEH) Strategic Country Support
Core Country Support (CCS)
Comprehensive Health Policy Support (CHS) SCS Health Systems and Services HSS
Health System Policies (HSP)
Health Service Delivery (HSD) Evidence for Public Health EPH
Health Information (HIN)
Health-related Evidence (EVI)
European Observatory on Health Care Systems (OBS) Communication for Public Health COM
Communication and Public Affairs (CPA)
Health Documentation Services (HDS)
Support to Governing Bodies (GBS)
Strategic Budget, Planning and Evaluation (SPE)
Administration, Supplies and Conference (ASC)
Budget and Finance (BFI)
Informatics Support (ISS)
Human Resource Services (HRS)
Human Resource Development (HRD) Director’s Office Health Systems and Services Health System Policies • Health Systems Organization and Management (HSM) • Health Systems Financing (HSF) • Health Systems Technology, Pharmaceuticals and Quality (TPQ) • Legislation and Patients’ Rights (LPR) Health Service Delivery • Human Resources for Health (HRH) • Integrated HealthServices (IHB) HSP Strategic Country Support Core Country Support • Coordination of Country Support (COS) • Futures Fora(FFA) • Emergency Preparedness and Response (EHA) • External Cooperation and Partnerships (PAR) CCS DCS SCS HSD Barcelona HSS Brussels Barcelona Comprehensive Health Policy Support • National and Regional Policy Support (NRP) • Healthy Cities and Urban Governance (HCP) • Policy Assessment and Equity (PAE) CHS EUR/02/5040745 page 21 Annex 3 HEALTH SYSTEMS ORGANIZATION AND MANAGEMENT PROGRAMME (HSM) BUSINESS PLAN 2002–2003 The Health Systems Organization and Management Programme (hereafter referred to as “the programme”) lies within the Unit of Health Systems Policies, itself within the Division of Country Support of the WHO Regional Office for Europe. This paper outlines the programme mission, approach and deliverables for the 2002–2003 biennium. The mission of the programme, underpinned by the shared values espoused by WHO as set out in various policy statements, is: To contribute to the continuous improvement of health systems in the countries of the European Region through capacity development, promoting best practice and innovation, and sharing experiences. Programme foundations The programme pursues one of WHO’s four main strategic directions, “to develop health systems that improve health outcomes, respond to people’s legitimate demands and are financially fair”. An important and widely known expression of this is found in the 1978 Alma-Ata declaration on reorienting health services to primary health care, now being revisited in a global WHO review of primary health care strategies (1). In the European Region, in response to countries’ attempts to reform health services, the Ljubljana Charter on Reforming Health Care (2) identified fundamental principles for health care reform, which it said should be driven by values, targeted on health, centred on people, focused on quality, based on sound financing and orientated towards primary health care. The charter also outlined the following principles as keys to managing change effectively; these are being used by the programme as a framework for its action plan.
 Develop health policy;
 Listen to the citizen’s voice and choice;
 Reshape health care delivery;
 Reorient human resources for health care;
 Strengthen management;
 Learn from experience. These issues are further explored in WHO’s World Health Report 2000, Health Systems: Improving Performance (3). Together the Declaration, Charter and Report set the parameters for this programme, highlighting why health systems matter, how well they perform, whether they are well organized, what resources are needed and where they might come from, and how the public interest is protected. In deciding how to transform these aspirations into action, sensitivity to Member States’ diverse situations and needs will be maintained in various ways. Alongside its values and its theoretical base, the programme’s third foundation stone is information about its clients. Country data is collected by WHO and analysed by different programmes including our key internal partner, the European Observatory on Health Care Systems. This supports and promotes evidence-based policy-making through comprehensive and rigorous analysis of the dynamics of health care systems. The Biennial Collaborative Agreements (BCAs) with the countries of central and eastern Europe and the newly independent states also highlight country priorities. A further source of current information on country activities and priorities is the newly established Health Systems Development Advisory Group and Expert Panel. EUR/02/5040745 page 22 Programme infrastructure At the WHO Regional Office for Europe, Copenhagen The programme has a regional adviser and programme assistant based at the Regional Office. All other work is carried out by short-term consultants and staff on secondment from external organizations. The programme has been allocated US $110 000 from the WHO regular budget for its intercountry activities in the 2002–2003 biennium. Smaller additional sums are allocated for BCA implementation, ranging from US $10 000 to US $60 000 per country. Creativity and effort is therefore essential to secure the necessary extrabudgetary funds and other resources to enable delivery of the agreed programme outcomes. Health Systems Development Advisory Group An advisory group of leading health systems experts and policy-makers has been established to provide strategic advice; act as a sounding board for the Regional Office on health systems development; flag up important issues; and offer leadership on health care reform to member states. Members may also be asked to act as individual advisers to the programme, participating in missions related to their expertise, commenting on documents and issues, representing the programme at external meetings, and generally contributing to its development. They are committed to acting as advocates for the programme and disseminating its work in any suitable forum. Terms of reference have been agreed. The advisory group meets twice a year. Expert Panel The Expert Panel, comprising health systems development experts from within and outside the Region, has been established to help implement the programme, through country missions and other forms of advice-giving and support. It is developing an agreed philosophy and methods of work that will underpin the programme’s activities. Members are committed to acting as advocates for the programme and disseminating its work in any suitable forum. Other partners Partner organizations for this work already include the Observatory, WHO headquarters, the World Bank, the United Kingdom Department for Overseas Development, and the European Health Management Association. Other partners may be approached as appropriate. The programme works with existing WHO collaborating centres and will identify new ones from a range of countries, with a variety of missions. Ways of working Taking its lead from the philosophical underpinnings described above, the programme employs a participative, bottom-up approach based on lived experience. It will develop ways of harnessing the experience and expertise in Member States’ health care systems and coordinating access to the lessons learned. It will also be mindful of the many organizations and agencies already active in this field, and will strive to complement rather than duplicate their work using the unique strengths of WHO. Our ways of working will be as follows:
 Using local expertise. The programme will work with experts from health systems in all parts of the Region. The experience of colleagues working in systems in transition will be particularly important.
 Connecting stakeholders. Building effective networks of these colleagues so they become self-sustaining and not dependent on central resourcing from the European office will be a feature of the work. Information technology provides excellent tools. EUR/02/5040745 page 23
 Feedback loops. Much of the work programme depends on consultation with the field, securing feedback and acting on the advice of those who daily work on improving health systems in Member States. A variety of approaches will be used to enlist this crucial advice and support.
 Supporting the leaders of change. Systems and resources will be developed to allow those leading change in Member States to understand, assess and extend their abilities, knowledge and development needs.
 Translating experience. Experts will be identified to help interpret the experience of these local colleagues and help them become more effective change agents.
 A bank of resources. Resources and tools will be identified and catalogued to support change in health systems, for example approaches to the dissemination of evidence-based practice. These are usually initiated for local use but may well have international value.
 Case studies. The programme will locate and highlight examples of good practice, and indeed initiatives which have not worked, publishing them as case studies that can act as catalysts or sources of information.
 Events. The programme will hold seminars, workshops and other events to meet a number of objectives, including:
 building skills
 sharing information and perspectives
 understanding the issues
 identifying case studies
 qualitative evaluation, and
 reaching consensus. Programme outputs Working within the conceptual frameworks described above, the programme will focus on identifying models and practices contributing to the development of health systems that maximize their potential to promote health, reduce excess mortality and morbidity and disability; and that respond to people’s legitimate demands in equitable and financially fair ways. It will pay special attention to the stewardship function of governments. The activities are also grounded in an analysis of the current BCAs, that identify a range of issues Member States wish to address. The main areas of programme work are as shown in Box 1 – recognizing that there is no blueprint for change, but a wide range of useful initiatives and resources that the programme can identify and make accessible to those driving change, thus helping them improve their capacity to deliver efficient and equitable services. It is also recognized that some outputs may be modified and new ones added as the programme develops and responds to changing needs and circumstances. They will be developed or debated at intercountry level, tested in countries, used where appropriate in implementing BCAs, and the experiences fed back to intercountry fora, in an iterative cycle encompassing countries, regional and subregional groupings, WHO and other programme partners. Box 1: Main areas of programme work Tools for the improvement of health systems Sharing good practice in primary health care-led systems Developing the competencies of health decision-makers and managers Guidance on the stewardship role of governments Measuring health system performance EUR/02/5040745 page 24 These outputs are described in more detail below using the framework for change advocated in the Ljubljana Charter. Most of the activities enact more than one principle, and this cross-fertilization will be an important strength of the programme. Develop health policy Measuring health system performance Member States want help with assessing their health system’s performance. The programme will map out a mechanism, holding workshops at subregional level to discuss the management of routinely collected data and how it can contribute to the development of national performance indicators. This will be done in close cooperation with the Observatory, and build on the range of current work and thinking behind the World Health Report and in Member States. Listen to the citizen’s voice and choice Guidance on the stewardship role of governments WHO urges governments to accept accountability for providing an effective and equitable health care system, including public, private and non-profit services. An understanding of their stewardship function is key to this. The programme will develop guidance on raising awareness of the various components of the governmental role and understanding how to operationalize them. A series of workshops will then identify and construct a classification of stewardship-related activities in Member States, paving the way for specific work with countries to assess performance in the stewardship role, covering such issues as transparency, levels of corruption, accountability, predictability, and stability of policy. In the longer term a range of tools may be developed for these activities. Sharing good practice in primary health care-led systems As described below. Listening to the citizen’s voice and choice will be an important criterion for selection of examples. Reshape health care delivery Tools for the improvement of health systems There are currently few viable, tested tools or methods for developing health systems. The programme will trawl WHO and other organizations to establish an inventory of currently available tools which may be useful to Member States, and conduct a literature search. These tools will then be scrutinized, and the most suitable tested in Member States. Based on these findings, the tools can then be adapted and translated. They will be used by Expert Panel members in BCA implementation. Sharing good practice in primary health care-led systems Working in partnership with the Observatory, the programme will develop a portfolio of examples of good practice from primary health care-led systems. These case studies from Member States will include the development pathway and process followed as well as the outcome, and the methods used to evaluate effectiveness. The portfolio will enable countries to review others’ approaches and experiences, and encourage them to document their own. To encourage input and impose some rigour, guidance will be developed for those planning to submit examples for the portfolio. Guidance on the stewardship role of governments As described above, this will also help to reshape health care delivery. Reorient human resources for health care The primary responsibility for putting this principle into practice lies with the WHO European Office for Integrated Health Care Services, Barcelona. However, many of this programme’s activities will also contribute directly or indirectly. Strengthen management Developing the competencies of health decision-makers and managers Many of the people charged with leading, directing and managing change lack the right competencies – a major weakness in many health systems. Addressing this issue is fundamental to progress. As a starting EUR/02/5040745 page 25 point the programme will conduct a Delphi study in a number of Member States to identify the competencies required at each level of the health system. A guidance document will then be formulated describing how to develop an Assessment Centre that can judge the competencies of the players, piloted and amended accordingly. The study will also identify training modules and other ways to build the necessary competencies. Guidance on the stewardship role of governments As described above, this will also help to strengthen management. Learn from experience Examples of good practice in primary health care-led systems As described above, this will also help the programme and Member States learn from experience. Expert Panel The Expert Panel established by the programme provides an innovative way of learning from experience. Implementation of the BCAs will be evaluated through meetings and case studies, and experiences debated with the Advisory Group in a continuous feedback loop. The learning will focus on the effectiveness of implementation processes as well as technical content. It will also help panel members improve their individual effectiveness as they carry out their assignments. Where appropriate this learning will be shared more widely with other WHO programmes and organizations. Conclusion The programme will go some way towards:
 continued and sustained delivery against the aspirations of the Ljubljana Charter;
 building on The world health report 2000 and refining its methods and conclusions within the European Region;
 introducing the WHO Global Country Co-operation Strategy approach in work with countries;
 contributing to the WHO review of primary health care strategies;
 responding to the priorities identified by Member States, through a programme of work of direct and practical use that involves all relevant stakeholders. Making this happen depends on developing some new working approaches for the programme and taking others forward, with an emphasis on participation, continual review and adjustment based on robust feedback loops, and mutual learning. It is recognized that everyone involved, from advisers to programme staff to country partners, is on a change journey that may challenge us continually to develop new skills, expertise and insights in ourselves as well as those we aim to support and serve. This paper has outlined the work of the programme being initiated in the current biennium. Clearly, many if not most of the activities contribute to long-term health systems development that will take much more than two years to achieve, and the programme will be able to shape its long-term objectives as it gains experience in the short to medium term. The paper has provided an overview of the deliverables and the products, and identified the approaches to tackling this task that will best work to meet the spirit as well as the letter of WHO’s overarching policies. The programme will be needs-led, and those needs will be identified by those best qualified to do so – Member States and those working to develop the health systems that will best serve their local populations. References 1. The Ljubljana Charter on Reforming Health Care. Copenhagen, WHO Regional Office for Europe, 1996 (document EUR/ICP/CARE 9401/CN01). 2. Primary Health Care 21: ‘Everybody’s Business’. WHO/EIP/0SD/00.7 3. The world health report 2000: Health Systems: Improving Performance. WHO, Geneva, 2000. EUR/02/5040745 page 26 HSM workplan 2002 R B 20 02 –2 00 3 Ja nu ar y Fe br ua ry M ar ch Ap ril M ay Ju ne Ju ly Au gu st Se pt em be r O ct ob er N ov em be r D ec em be r Inventory of tools for health systems develop – 5038574 Trawl of all the regions on tools availability X Trawl of all relevant NGOs on tool availability X Literature search on tool availability X Desk assessment of each tool X Piloting testing and validation of the relevant tools identifies in at least 4 Member States Adaptation of the tools bases on the findings Translation of the tools into Russian Development of Frameworks and Assessment Tools and strategies for capacity building – 5038579 Delphi Study to be undertaken in a selection of Member States X Guidance document to be developed X Assessment Centre to be piloted in at least three countries Guidance document to be adapted accordingly Training modules to be developed on the outcome of the Delphi Study Portfolio of good practice on PHC-led National Health Systems Guidance framework to be developed X Examples to be sought from countries X Portfolio to be developed Country process to be elaborated in each example for the portfolio EUR/02/5040745 page 27 HSM workplan 2002 R B 20 02 –2 00 3 Ja nu ar y Fe br ua ry M ar ch Ap ril M ay Ju ne Ju ly Au gu st Se pt em be r O ct ob er N ov em be r D ec em be r Guidance framework/algorithm on the stewardship role of governments Seminar with a range of Member States to discuss the stewardship X Workshop to identify/classify stewardship related activities in Member States Specific work with a range of countries to assess aspects of stewardship performance Development of intermediate performance assessment methodologies for national use ? ? Workshop at subregional level Establishment of an Advisory Group for Health Systems Development Development of Terms of Reference and identification of Advisory Group membership DONE 12.01 Meetings of Advisory Group 10–11 X Action Plan to be developed by Advisory Group Evaluation of the work of the Programme Meetings of the Expert Panel 11–13 X The commencement of this work is dependant on securing a secondee from one of the Member States. EUR/02/5040745 page 28 HSM workplan 2003 R B 20 02 –2 00 3 Ja nu ar y Fe br ua ry M ar ch Ap ril M ay Ju ne Ju ly Au gu st Se pt em be r O ct ob er N ov em be r D ec em be r Inventory of tools for health systems develop – 5038574 Trawl of all the regions on tools availability Trawl of all relevant NGOs on tool availability Literature search on tool availability Desk assessment of each tool X Piloting testing and validation of the relevant tools identifies in at least 4 Member States X Adaptation of the tools bases on the findings X Translation of the tools into Russian X Development of Frameworks and Assessment Tools and strategies for capacity building – 5038579 Delphi Study to be undertaken in a selection of Member States Guidance document to be developed X Assessment Centre to be piloted in at least three countries X Guidance document to be adapted accordingly Training modules to be developed on the outcome of the Delphi Study X Portfolio of good practice on PHC-led National Health Systems Guidance framework to be developed Examples to be sought from countries Portfolio to be developed X Country process to be elaborated in each example for the portfolio EUR/02/5040745 page 29 HSM workplan 2003 R B 20 02 –2 00 3 Ja nu ar y Fe br ua ry M ar ch Ap ril M ay Ju ne Ju ly Au gu st Se pt em be r O ct ob er N ov em be r D ec em be r Guidance framework/algorithm on the stewardship role of governments Seminar with a range of Member States to discuss the Stewardship Workshop to identify/classify Stewardship related activities in Member States X Specific work with a range of countries to assess aspects of Stewardship Performance X Development of intermediate performance assessment methodologies for national use Workshop at subregional level Establishment of an Advisory Group for Health Systems Development Development of Terms of Reference and identification of Advisory Group membership Meetings of Advisory Group X X Action Plan to be developed by Advisory Group Evaluation of the work of the Programme X Meetings of the Expert Panel The commencement of this work is dependant on securing a secondee from one of the Member States. EUR/02/5040745 page 30 BCAs 2002–2003 Countries Ja nu ar y Fe br ua ry M ar ch Ap ril M ay Ju ne Ju ly Au gu st Se pt em be r O ct ob er N ov em be r D ec em be r Armenia Azerbaijan Belarus Bosnia and Herzegovina Czech Republic Estonia Kazakhstan Republic of Moldova Slovakia Slovenia Tajikistan Ukraine Uzbekistan Yugoslavia NB. Dates to be inserted when agreement reached between Regional Office/Consultants and Member State. Money allocation per country has not been approved yet. This information will be inserted as soon as possible. EUR/02/5040745 page 31 Annex 4 HEALTH SYSTEMS DEVELOPMENT ADVISORY GROUP Terms of Reference Background and context The Health Systems Development Advisory Group has been set up to underpin the development of strategy and approach of the Health Systems Programme. This Group, which shall meet twice each year, consists of experts from various Member States of the World Health Organization within the European Region. The Group will also include the Observatory and a number of Observers, for example the World Bank and DFID Resource Centre. WHO Geneva will also be represented. The Head of Health Systems in the Regional Office will act as the Secretary to the Group. Between meetings the Group will further be asked to contribute to the development of the thinking and approach of the Programme through regular e-mail contact. Overall objective The overall objective of the Group shall be to act as a reference group and advisory resource on Health Systems Development in the countries of the European Region. Specific objectives The objectives of the Group will be: 1. To help define the strategic direction for the Health Systems Programme, this to be guided by the overall direction set out in The world health report 2000 and the WHO Global and Regional Priorities. 2. To consider the relevant component of the country health priorities formulated by the Member States, as articulated in the Biennium Collaborative Agreements (BCAs), and provide advice and guidance on priorities for WHO cooperation. 3. To identify what tools and other resources are required to best deliver the overall objectives of the Programme. 4. To comment on the overall delivery of the work of the Programme each biennium. 5. To contribute to the roll out of the work of the Programme by acting as promoters of the work of the Programme within the Region. EUR/02/5040745 page 32 Annex 5 PARTICIPANTS Health Systems Development Advisory Group members Dr Philip Berman Tel. No.: +353 1 2839299 Director Fax No.: +353 1 2838653 European Healthcare Management Association E-mail: pcberman@ehma.org Vergemount Hall, Clonskeagh Dublin 6 Ireland Ms Ragnheidur Haraldsdottir Tel. No.: +354 5609700 Chief of Department Fax No.: +354 5519165 Ministry of Health and Social Security E-mail: ragnheidur.haraldsdottir@htr.stjr.is Heilbrigdis og Tryggingamalaradune Laugavegur 116 IS-150 Reykjavik Iceland Professor Jussi Huttunen Tel. No.: +358 9 474 41 Director General Fax No.: +358 9 4744 8552 National Public Health Institute E-mail: jussi.huttunen@ktl.fi Mannerheimintie 166 00300 Helsinki Finland Dr Danguole Jankauskiene Tel. No.: +370 87 27722 Social Medicine Centre Fax No.: +370 2 400474 Medical Faculty of Vilnius University E-mail: danguole_j@hotmail.com Seskines 24 - 311 2010 Vilnius Lithuania Dr Mihaly Kökény (Chairperson) Tel. No.: +36 1 4415101 President Fax No.: +36 1 4415969 The Hungarian Parliament, Képvisolöi lrodaház E-mail: mihaly.kokeny@mszp.parlament.hu Parliamentary Committee for Health and Social Affairs Szécsenyi rkp. 19 H-1054 Budapest Hungary Dr Sergey Shishkin Tel. No.: + 7 095 202 40 70 Research Director Fax No.: + 7 095 202 47 46 Independent Institute for Social Policy E-mail: shishkin@socialpolicy.ru 19a, Khlebnyi per., 121019 Moscow Russian Federation Ms Mai Vidali Tel. No.: +30 1 7011452 Researcher E-mail: maividal@otenet.gr Agras 25 Athens 11635 EUR/02/5040745 page 33 Greece Dr Rifat A. Atun (Observer) Tel. No.: +44 207 2532222 DFID Resource Centre for Health Systems Fax No.: +44 2075949160 27 Old Street E-mail: rifat.atun@ic.ac.uk London EC1V 9HL United Kingdom Ms Carole Landon (Observer) Tel. No.: +41 22 791 2706 World Health Organization E-mail: landonc@who.ch CH1211 Geneva 2 Switzerland Health Systems Development Expert Panel members Dr Juliette Bloch Tel. No.: +33 1 40 56 54 39 Direction Géneralé de la Santé Fax No.: +33 1 40 56 78 00 8, Avenue de Segur E-mail: juliette.bloch@sante.gouv.fr 75007 Paris France Dr Tim Ensor Tel. No.: +44 1904 433 639 University of York Fax No.: +44 1904 432 701 Heslington E-mail: te1@york.ac.uk York YO10 5DD United Kingdom Professor S. Ermakov Tel. No.: +7 095 1907906 Head, Public Health Institute Fax No.: +7 095 2193840 MEDSOECONOMINFORM E-mail: ermakov@aha.ru Epidemiological Department Moscow Russian Federation Mr Gintaras Kacevicius Tel. No.: +370 2 661364 Vilnius Territorial Sickness Fund Fax No.: +370 2 791424 Placeioji str. 10 E-mail: vidirektoriustlk@vlk.lt LT-2600 Vilnius Lithuania Dr Zbigniew Krol Mobile Tel No: +48 606 353324 Health and Management Organization Fax No.: +48 12 4295116 Sarego Str. 16/3 E-mail: Zbigniew.Krol@ziz.com.pl 31047 Kracow Poland Ms Rosalynde Lowe Tel. No.: +44 208 321 2345 Chief Executive, Hounslow and Spelthorne Community E-mail:ros.lowe@hscmhtr.nthames.nhs.uk and Mental Health Trust Phoenix Court 531, Staines Rd Hounslow Middx, TW4 5DP United Kingdom Professor Zafer Öztek Tel: +90 312 324 3975 Medical Faculty Fax: +90 312 311 0072 Hacettepe University E-mail: zoztek@hotmail.com Department of Public Health EUR/02/5040745 page 34 TR Ankara Turkey Professor Thomas A. Rathwell Tel. No.: +1 902 494 6579 Director, Dalhousie University Fax No.: +1 902 494 6849 School of Health Services Administration E-mail: thomas.rathwell@dal.ca Faculty of Health Professions 5599 Fenwick Street Halifax, N.S. B3H 1R2 Canada Dr Silvia Scintee Tel. No.: +40 1 638 4010 Institute of Public Health Fax No.: +40 1 312 3426 1-3 Dr Leonte str. E-mail: s.scintee@lycos.com 76256 Romania Dr Igor Sheiman Tel. 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