WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA
ORGANISATION MONDIALE DE LA SANTE BUREAU REGIONAL DE L'AFRIQUE
ORGANIZAÇÀO MUNDIAL DE SAÚDE ESCRITORIO RtGIONAL AFRICANO
REGIONAL COMMITTEE FOR AFRICA
AFR/RC52/12 12 February 2002 ORIGINAL: ENGLISH
Fifty-second session Harare, Zimbabwe, 8–12 October 2002 Provisional agenda item 8.5
IMPLEMENTATION OF HEALTII SECTOR REFORMS IN THE AFRICAN REGION: ENHANCING THE STEWARDSHIP ROLE OF GOVERNMENT Report of the Regional Director EXECUTIVE: SUMMARY I. The forty-ninth WHO Regional Committee for Africa examined and adopted the document entitled "Health Sector Reform in the WHO African Region: Stains of Implementation and Perspectives". The document defined the framework for implementing health sector reform in the African Region. The same meeting adopted resolution AFR/RC/49/R2 which gave orientations on the relevant ways of accelerating the implementation of the said reform. 2 Countries of the Region have undertaken reforms of their health sectors with enthusiasm and have achieved some significant results. But due to some constraints, they have not fully met the people's expectations. The weak stewardship role of government was highlighted as one of the main factors that have compromised implementation of health sector reforms in the countries. 3. Countries of the Region are continuing to seek solutions to the many problems they face in improving the performance of their health systems. If ways cannot be round to make reform efforts more successful, there is a real danger that the search for new ways of improving health systems performance will be abandoned. There is therefore a pressing need to revive and refocus reform efforts, mainly on the enhancement of the stewardship role of government. Policy debate and research should also focus on improving this role in future. 4. The purpose of this document is to provide orientations on how the health sector reform process can focus attention on improving the stewardship role of government and on the anticipated roles of the different partners and stakeholders in strengthening implementation of the reforms. Il also provides perspectives for deepening the reflection on the different dimensions of stewardship and its measurement. 5. The Regional Committee is invited to review and adopt the orientations contained in this document.
CONTENTS Para gra ph s INTRODUCTION.................................................................................................................................. 1-3 SITUATION ANALYSIS ................................................................................................................... 4-14 FRAMEWORK FOR ENHANCIM STEWARDSHIP .................................................................. 15-31 Health sector refonns and stewardship ............................................................................... 15-17 Cornponents of stewardship ................................................................................................ 18-27 Responsibility for stewardship ............................................................................................ 28-31 ROLES AND RESPONSIBILITIES................................................................................................ 32-35 Role of countries ......................................................................................................................... 32 Role of partners ......................................................................................................................... 33 Role of the World Health Organization .............................................................................. 34-35 CONDITIONS FOR EFFECTIVE STEWARDSHIP ......................................................................... 36 CONCLUSION .................................................................................................................................. 37-39 Annex Page Stewardship components ............................................................................................................................ 9
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INTRODUCTION I. The Regional Committee, at its forty-ninth session, noted that in order for health sector reforms to achieve their set goal of improving the health status of the population, they must first produce changes that lead to health systems development and strengthening. nese changes are prc:requisites for improving the performance of health systems. Resolution AFRJRC/49/R2 called upon Member States to ensure that govenunents assume leadership at every stage of the reform process and urged the Regional Director to "develop a framework that will guide Member States in designing, implementing and evaluating their health sector reforme.' 2. A broader version of the concept of leadership, termed stewardship, bas been identified in health development literature. Stewardship is defined as "the careful and responsible management of the well-being of the population" and has been described as "the very essence of good governante"? Stewardship goes beyond management of the state's role in the health system to taking responsibility for the health of the population. Health sector reform is defined as "a sustained process offundamental change in polie), and institutional arrangements, guided by government, designed Io improve the functioning and performance of the health sector and ultimately the health status of the population".3 It is evident, therefore, that the stewardship concept is not new. 3. The assessment of the implementation of health sector reforms in countries has revealed mixed results, with différent reasons given for failure to implement fully. Such assessments have pointed mainly to the weak leadership role of government. The purpose of this document is therefore to describe the role of the government as a steward of the health of the population in the implementation of health sector refonns. The document examines linkages between health sector reforms and stewardship and proposes a framework for enhancing the latter. SITUATION ANALYSIS 4. In the past ten years, most countries of the Region have developed and implemented health sector reforms. New concepts and ideas about health development and new challenges in disease patterns have diversely iniluenced the reform process. The burden of disease from malaria, HIV/AIDS, tuberculosis and complications related to pregnancy and childbirth and their wonying trends have influenced the development of strategies to address 'hese diseases by focusing attention on the building of capacity for holistic health sector responses to these challenges. Health for-all-policy for the 21st Century in the African Region: Agenda 2020, alongside New Partnership for Africa 's Development (NEPAD), provides guidelines for future health development in the Region. 5. Member States have shown significant enthusiasm in pursuing the health sector reform process. In Abuja, in 2000, heads of state and government agreed to allocate at least 15% of national budgets to health. Varions countries have started developing innovative approaches based on use of evidence for policy dialogue and decision-making. They have also realized the importance of monitoring the implementation of health sector reforms and have developed built-in indicators for this purpose.
WHO/AFRO, Resolution AFR/RC/49/R2_ Health Sector Reform-in the African Region: Status of Implementation and Perspectives, RC49, 1999. 2 W110, World Health Report 2000. Health Systems: Improving Performance. Geneva, 2000. 3 WHO, Health Sector Reforms in sub-Saharan Africa, A review of experiences, information gaps and research needs. WHO/ARA/CC/97.2, Geneva, 1997. e
AFR/RC52/12 Page 2 6. A review of the implementation of health sector refonns in the African Region4-srevealed that health sector reform is a political process and that events from outside the sector can affect it. ft was found that the reform process tended to be incremental, non-linear and long-terni. Certain components of reform, like essential drags policy, health legislation and regulation, community participation and staff motivation were found to be very critical. 7. Ahnost ail the Member States have developed broad, medium-term health policies, strategies and plans. Policy frarnework documents from Member States atternpt to define the roles of various actors in health service provision, health financing and, to some extent, institutional arrangements. However, not ail of the Member States have prepared comprehensive health policy frameworks or budgets that reflect articulated priorities. In addition, matehirtg activities to available resources and the exact sources of financing still remains a problem. The majority of countries have developed an essential health package but have not costed it. S. Case studies on the health sector reform process from some Member States6 show improved quality of primary health care services, With increasing accountability. These countries are implementing the Sector Wide Approaches (SWAps) to varying levels as well as undertaking decentralization of health services. The case studies have shown that there are inadequate institutional and hurnan resource capacities to implement and manage the reforms. In addition, inter-sectoral activities seem to lag behind the other activities implemented in the reforms. 9. Countries of the Region have begun to implement SWAps in health as evidenced by the experiences shared between eight countries, maint); from eastern and southern Africa.' There is however still a gap in stakeholder dialogue. Consequently, coordination of partners in health development, which was expected na improve since the adoption of SWAps, remains weak in some countries. The flow of resources and coordination of action are still a problem as well. 10. Ministries of health and other ministries are important in influencing decisions. However, this ability has not been fully tapped. The high turnover among rninistry of health decision-makers remains one of the critical obstacles in policy implementation. In many cases, comprehensive national health policies have been formulated and resources mobilized. However, implementation bas been adversely affected by staff changes.
11. Wars, civil strife and natural disasters have comprornised health sector reforrn efforts in some countries. This situation, characterized by massive destruction of buildings and equipment, brain drain, increased numbers of refugees and displaced persans and increased demand for health care services, lias led to the collapse of national health systems.
WHO/AFR.0, Report on Health Sector Reform in the African Region: Status of Implementation and Perspectives, WHO, Regional Office for Africa, 1999. 51 1 10 - N EF, implementing Heahlt Sector Reforms in Africa: A review of eight country experiences. New York, 1999_ 6 WHOLAFRO, Case studies on SWAps implementation: Ghana, Malawi, Mozambique, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe_ WHO, Regional Office for Africa, 2001. 7 W110/AFRO, Report of a meeting on: Review of implementation of SWAps in the context of health sector reforms in Eastern and Southern Africa. WHO, Regional Office for Africa, 2001.
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Irnplemereation of health sector reforms in the Region Iras also been impeded by weak institutional and human resource capacities, aggravated by the brain drain phenomenon, Jack of incentives and inefficient use of potential national expertise. This situation is worsened by the scarcity of resources in general and the poor allocation of interna] resources in particular. The sustainability of reforms is further undermined by the flegme and olten inconsistent changes in government policier, inadequate legislation, weak accountability and lack of transparency. 13. Governments have not maximized the use of international agreements and regulations for the benefit of public health. Recent developments surrounding efforts by countries to access antiretroviral therapy (ARV) show that World Trade Organization (WTO) regulations, in partieular the Trade Related Aspects of Int ellectual Property Rights (TRIPS) safeguards, could be used more to the benefit of the population. The Jack of awartness of global agreements bas sometimes been a disadvantage for the countries and has negatively influenced some relevant interventions. 14. Social and technical policy debates on how to accelerate efforts towards achieving good health outcomes have recently been held at different levels in the countries and by agencies and development partners. Some important questions have been raised about how to effectively integrate the Poverty Reduction Strategy Papers (PRSP), including use of resources mobilized through the IIighly lndebted Poor Countries (HIPC) Initiative, into health sector development perspectives; how to address equity issues; how economic refonns can be conducted without jeopardizing gains in the social sector, in particular for the very poor, how to address the issue of out-of-pocket/fee-for-service which has shown some adverse effects on service utilization; how governance issues affect health system development; what the role of govermnent should be in the context of increasing poverty, globalization, brain drain of skilled health personnel and market-oriented health services delivery; and, in view of the low institutional and human resource capacities, how should countries ensure a balance between the need to decentralize and responsibility for the provision of services. These questions are challenges that need to be properly addressed if countries are to improve implementation of health sector reforms. FRAMEWORK FOR ENHANCING STEWARDSHIP Health sector reforms and stewardship 15. The irnprovement of health systems performance depends on many factors one of which is the essential role of government in setting the direction for the health system, overseeing its opérations and leading inter-sectoral efforts to improve health.' 16. There are strong sirnilarities between leadership as defined in the context of health sector refonn and stewardship. Stewardship covers a broader perspective Chan leadership. Whereas leadership in health sector refonns has so far placed greater emphasis on areas directly under the jurisdiction of the ministry of health (stewardship in health), stewardship focuses on responsibilities and tasks for the strategic management of the health system (stewardship of heahh) and for factors in the broader social, political and economic environment within which the health system operates (stewardship for health). Government should ensure, in a coordinated manner, that the ministry of health and other key stakeholders are able to play their roles and assume their responsibilities in health development.
'WII0, World Ilealth Report 2000. Ileahh Systems: Improving Performance. Geneva, 2000.
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17. Even though the focus of leadership for health sector reform has been narrower Chan that of stewardship, it does not mean that some of the tasks and responsibilities outside the health sector have not been undertaken. Previous reviews of the implementation of health sector reforms' show that some attempts, albeit unsustained, were made at undertaking some of the stewardship tasks and responsibilities for and of health. However, these attempts have been piecemeal and inadequate. The framework for enhancing stewardship is aimed at strengthening government's role and responsibility in stewardship within and beyond the ministry of health. Components of stewardship 18. Four health system fonctions, namely stewardship, financing, service provision and resource generation have been defined." Stewardship is a fonction that impacts on ail aspects of health development. More specifically, it encompasses stewardship of health systems responsibilities that mainly fan directly under the jurisdiction of the ministry of health (stewardship. in health); stewardship in setting the direction of health development leading to the strategic management of the health system (stewardship of health); and stewardship of factors in the broader social, political and economic environment within which the health system operates (stewardship for health) (see annex). Stewardship in health 19. Stewardship in health is concemed with ensuring the effective undertaking of the other three health system fonctions. 1t includes stewardship in financing, stewardship in resource generation and stewardship in health service provision. 20. Stewardship in health financing is concemed with establishing and maintaining an organizational and regulatory environment in which effective and equitable financing can take place. Ils tasks include: defining policies on health financing, including the use of financial risk pooling,, sources of funding for specific services (benefits package and user fees policies) and approaches to revenue collection; regulating health insurance and other financial risk pooling schemes; defining approaches that detect and minimize the diversion of resources from their intended purpose; defining approaches that ensure the integrity of revenue collection schemes and those that ensure that individuals and organizations rneet their obligations to contribute; coordinating with other agencies involved in collecting revenues for health (tax authorities, employers and local government); collecting and analyzing information on coverage of insurance/pooling arrangements and their effectiveness; collecting and analyzing information on the impact and effectiveness of targeting and prioritizing initiatives; and monitoring where the burden of paying for health lies. 21. Stewardship in health resource generation is concerned with ensuring that activities such as human resources development, health intelligence, production, purchasing and distribution of pharmaceuticals and equipment and building and maintenance of infrastructure are effectively carried out. The tasks of stewardship in resource generation include: identifying current and anticipated future imbalances in the supply of and demand for key resources (manpower, consumables and capital); regulating resources deployed to ensure adequate quality and quantity-, monitoring the supply of and demand for key resources; developing and implementing incentives to address imbalances between the supply of and demand for resources; and overseeing organizations and institutions responsible for producing resources.
'Report of a meeting on: Review of Implementation of SWAps in the context of health sector reforms in Eastern and Sondem Africa. W110, Regional Office for Africa, 2001. ° WHO, World Ilealth Report 2000. Ilealth Systems: Improving Performance. Geneva, 2000.
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22. Stewardship in health service provision encompasses a variety of tasks that must be carried out to ensure that the type, quality and accessibility of services are in line with national policies and plans. Some of the tasks involved are developing policy on service provision; anticipating future needs and assessing the health system's ability to meet these needs; identifying service gaps and unmet needs; regulating and legislating on die provision of services and imposing sanctions and providing incentives to ensure appropriate service provision; and monitoring the performance of providers and services. 23. Whereas stewardship in health service provision is mainly undertaken by the ministry of health, stewardship in health fmancing and resource generation mils for close collaboration with the other anus of govenunent. Stewardship of health 24. Stewardship of health refers to the strategic management role and is concerned with developing a broad vision and setting a policy direction for health development as well as deciding how the health system should evolve to respond to the changing social, demographic and economic environment. It is also concerned with the establishment and maintenance of the health system's overarching organizational and institution) frarnework, and with issues such as the allocation of functional responsibilities to individuals and organizations within the system, including operationalization of district health systems. 25. Tasks that contribute to the strategic management component of stewardship include: developing and promulgating a meaningful vision and policy for health; defining the overall design of the health system, including roles, responsibilities and operating principles; developing and promulgating a strategic plan for health ami the health system based on the best available evidence and Wide consultation; developing and implementing laves and regulations Io ensure that the system operates as planned; establishing and managing partnerships within the system; providing the public with information on the system, on how it operates and on their rights and responsibilities as citizens and consumers; using networking, lobbying, influencing and advocacy to effect positive change within the system; monitoring progress in implementation of the strategic plan and the appropriateness of health system design; and collaborating nationally and internationally in the exchange of information on current and future challenges to health and possible responses. Stewardship for heahh 26. Stewardship for health deals with activities that go beyond the health system to impact upon the main determinants of health and with other issues that are extemal to the health system but which either foster or constrain its effectiveness. Stewardship in this area seeks to influence the broader environment in which the health system operates. There are factors external to the health system which have a direct or indirect influence on health or "a secondary, health-enhancing effect"." These include appropriate policies on education, environment, agriculture, employrnent and trade; the specification and enforcement of property rights; levels of corruption; and access to mass media. These factors clearly fall outside the boundaries of the health system but can significantly influence its performance.
1W110,
World Ilealth Report 2000, IleaIth Systems: Improving Performance. Geneva, 2000.
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27. An effective steward Will see• k to exert influence over these factors, even if decision-making powers lie elsewhere. Stewardship for health tasks include: contributing to the development of plans and policies in other sectors; using networking, lobbying, influencing and advocacy to bring about and enforce healthenhancing policies across society; coordinating the efforts of agencies outside the health sector whose activities impact on the sector's functioning; supporting individuals and organizations outside the health sector to implement health-enhancing policies and other initiatives; and monitoring changes in the key déterminants of health that lie outside the health system. Responsibility for stewardship 28. Despite ils broad focus and its central role in any health system, stewardship does not require the govemment or the ministry of health to become directly involved in financing, resource generation and service provision. Indeed, stewardship involves the govemment in the establishment and maintenance of an environment in which NGOs, private enterprises and individual health practitioners can operate effectively, efficiently and with minimum bureaucratie interference. A successful steward is one who strikes a balance between freedom and control, and between centralization and decentralization, and allows and encourages public and private service providers, govemment employées and others in the sector to be innovative and creative, while ensuring the safety and integrity of the health system. 29. One of the most notable changes in many African health systems in recent years has been the emergence of multiple players in the provision of health services. Aspects of service delivery that were undertaken by govemment and other public sector agencies in the past are now commonly assigned to private enterprises and NGOs. The multiple players, including international agencies and NGOs, often have more resources and may have values and policies different from those of the govemment. 30. Responsibility for the careful and responsible management of the well-being of the population and organized efforts in support of that function can only rest with govemment. It is the govemment that is ultimately accountable for the effective undertaking of the stewardship function in the whole country. Some tasks may be delegated. Special care would be required in ensuring that delegated stewardship tasks conceming public goods do not lead to their being compromised. Such delegation should be well defined and coherent. Government must maintain oversight over those it expects to carry out these tasks and must monitor how well they are being carried out and intervene where necessary. 31. While it is often assumed that responsibility for the stewardship function rests with the ministry of health, which clearly has a pivotai role to play, the govenament as a whole must create an enabling environment for the involvement of ail public and private sector agencies. The ministry of health should daim and take its rightful place in decision making on ail matters concerning health in the country. ROLES AND RESPONSIBILITIES Role of countries 32. Govenunents should integrate the new dimensions of the stewardship role outlined in this paper into the implementation of their health sector reforrns. The speed and success of implementation will depend mainly on the efforts of the govemments themselves and the priority they give to this important demain. Governments should sensitize ail stakeholders in health sector reforrn on the importance of stewardship and seek their support in undertaking the stewardship rote. Governments should ensure donor coordination and guide ail partners in supporting health within the context of national priorities, policies and plans.
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Role of partners 33. Partners should work closely with and under the guidance of the goverronent in the definition of national priorities and provide support to strengthen institutional and human resource capacities in different areas of health sector reform, including the implementation of research in health systems development. Partners should also leam to respect the position taken by the government and open up dialogue on areas where there are differences of opinion. Role of the World Health Organiz' ation 34. WHO should ptovide technical support to countries in undertaking their stewardship role and in the development of instiliitional and human resource capacities. As a first step, it is necessary to develop a cIearer understanding of the main tasks that contribute to the enhancement of the stewardship function. 35. In order to support governments in undertaking their stewardship role, WHO, in consultation with Member States, has already developed tools for monitoring and evaluating health sector reforms and the operationality of district health systems and is refining health systems performance assessment tools. It is also developing a methodology for the assessment of stewardship and stewardship monitoring indicators. These tools will be made available to countries. CONDITIONS FOR EFFECTIVE STEWAFtDSHIP 36. The following conditions must be met to enable governments to effectively undertake their stewardship rote: (a) peace and security; (b) continuity in health policies and personnel and institutional arrangements in ministries of health; (c) coordination and participation of partners in the implementation of health policies and plans; of public (d) participation of civil society in improving the design and implementation programmes; (e) (f) (g) evidence-based decision making; transparency and accountability, and inter-sectoral collaboration.
CONCLUSION 37. h is evident that stewardship is an essential prerequisite for a well performing health system. Good stewardship can make a positive difference in die performance of health systems, both as an important function in ils own right and as a means to enhance the effectiveness of the other three health system fonctions. In the absence of good stewardship, health systems will not perform properly, no malter how well resourced they are or how well the other three frictions of financing, resource generation and service delivery are carried out.
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38. Enharking the stewardship role of governments is critical in accelerating the health sector reform process that would result in the improvernent of the performance of health systems and, consequently, in the realization of the goal of the Ilealth-for-all policy for the 21st Century in the African Region: Agenda 2020. The ministers of health should Lake the lead in transforming their ministries and in influencing the other amis of govemment to undertake their stewardship roles. 39. The Regional Committee is invited to review and adopt the orientations contained in this document entitled Implementation of health sector reforrns in the African Region: Enhancing the stewardship role of government.
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ANNÉX S t ewardship romponents The figure below is a diagramrnatic presentation of the différent components of stcwardship. It shows that effective sterardship !culs to better implemcntation of bealth sector reforma, improved performance of the hcalth system and the realization of health systems goals.
Stewardship IN health
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