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Known, Affordable and Effective Interventions

Responses from Featured Experts

Question 1: (Philippines)

The topic I want to explore with the resource persons is how they view the convergence of health sector reform with other sectoral reforms such as agrariam reform, budget reforms, educational reforms, etc. The development of health programs and projects have been usually sector specific or at best with token representation of partner sectors, only to realize towards the end that 'things could have been better' if a convergence approach was utilized.

Edwin Bolastig Response:
The issue you have raised highlights the limitation of SWAps as a sector-specific approach. This is a valid concern and this has been raised in the past by some quarters critical of SWAps. While SWAPs are sector-specific, this should not stop governments from integrating health systems reforms with reforms in other sectors through a convergence approach, knowing fully well that there are a number of health determinants such as education, housing, water and sanitation, employment, poverty, etc., that have an impact on people's health and well-being.

My concern, however, is the feasibility and efficiency of doing a national-level type of convergence considering the complexities of making these various large bureaucracies work in a fairly coordinated and effective manner. What I know is that, at the sub-Cabinet level in the Philippines, there is a coordinating committee involving the Social Cabinet cluster (Health, Education, Social Welfare and Development, Youth, Labor, and other sectors) that regularly meets at the National Economic Development Authority (NEDA). It is this Committee that harmonizes the reform programmes of the various agencies before these would reach Cabinet for policy direction and approval.

In the case of the Philippines, what I find to be more effective in such convergence approaches is doing it at the level of the local government (provinces, cities and municipalities) to whom the responsibility of delivering basic health care, social welfare services, agrarian reform, etc., have been devolved. The Local Government Councils are well-represented by all these sectors and the implementation of these reforms are much closer to these councils, thus they are more attuned to what are going on in the field. However, of course, this subjects the process to a highly politicized environment.

A pilot project we have launched in Dauis, Bohol, Philippines in the late 1990s under the Education Research Programme (ERP) of the University of the Philippines Center for Integrative Development Studies (UP-CIDS) known as the Comprehensive Education and Community Development Programme (CECDP) involved a multi-sectoral approach that included components such as education (functional literacy, including technical skills development), eco-tourism, primary health care, family-based farming systems, and small-to-medium enterprise development, among others. In this model, we have seen an increased interaction among the different sectors and increased participation in the governance of these programmes through the local government council, engaging politicians in the governance of a municipal-wide integrated development programme, using a convergence approach.

On another front, the Local Health Systems Component of the original Health Sector Reform Agenda (HSRA) acknowledges this reality, and has, in fact expanded the concept into 'Inter-Local Health Zones' or convergence sites where adjacent local governments would collaborate and share common resources for the implementation of these health reforms. The challenge for these ILHZs, however, is how to integrate agriculture, education, social welfare and other sectors with health in a seamless manner. A new type of governance model would need to emerge to address integration and coordination at this level.

In Trinidad and Tobago which is a relatively smaller twin-island country with a population of roughly 1.3 million people, it is relatively much more feasible to integrate reform efforts into one national programme, and this could be captured in the T&T government's Vision 2020 where a vision of 'Nurturing a Caring Society' is articulated, together with Developing Innovative People, Enabling Competitive Business, Investing in Sound Infrastructure and the Environment, and Promoting Effective Government.

Vision 2020 does not only envisage economic development for this country by the year 2020. National development objectives for all sectors, such as health, education, energy, tourism, environment, infrastructure development, agriculture, manufacturing, labour and small and micro enterprise, information and communication technology, etc. have likewise been identified. (For more details, see Vision 20/20 Operational Plan 2007-2010 in http://vision2020.info.tt/)

Vision 2020 represents a convergence of sorts at the national level, although of course, the seamless coordination and integration of efforts of the various executive agencies remain a challenge. To ensure the sustainability of the process, the T&T government has attempted to put in place institutional arrangements to manage and evaluate the implementation process. The above-mentioned document reports that a Programme Management Office has been established at the Ministry of Planning and Development 'to guide and manage the implementation of Vision 2020 activities in the public sector.'

I completely agree with the idea of integrating health with other sectors that have an impact on health, and vice-versa, over and beyond the scope of the SWAPs, through a convergence approach, but what needs to be determined for each country is the level in which such convergence should happen, whether national, sub-national, regional, provincial, local, inter-local, etc., considering the realities and exigencies existing in each country.

Grace Murindwa Response:
There are indeed similarities between health sector reforms with other sectoral reforms. Many of the health sector reforms and indeed other sectoral reforms are aimed at streamlining and improving the management and organization of these sectors. The problems affecting the health sector and indeed other sectors are similar and they include among others under-funding, inadequate and poor coordination of the development assistance, weak and bureaucratic management and organizational systems, low pay and poorly motivated workforce.

There are also strong intersectoral and intrasectoral linkages between sectors especially social service sectors which provide synergies in reform or programme implementation. Weakness in one sector will adversely affect the delivery of services in other sectors. Therefore in order to make effective interventions widely available, there is need to strengthen the management and organization of many of the sectors at the same time.

In Uganda, many of reforms that have been implemented in the recent past were targeted at the key sectors of the economy. These reforms were therefore not limited to the health sector but were implemented across all government sectors. Some of the major reforms that have been undertaken include:

All these reforms were implemented across all government sectors including the health sector. Of recent Sector-Wide Approach reform which was first implemented in two sectors (Education and Health) has now been extended to other sectors but in a phased approach.

Uganda's experience of implementing similar reforms across all sectors has shown that such reforms provide a positive enabling environment for the implementation of sector specific reforms.

Question 2: (Bangladesh)

1.Why World Bank and Ministry of Health of developing country like Bangladesh, Pakistan took much longer time in tendering process. I know in Bangladesh few contracts led by WB and MoHFW took more than 2 years to be contracted (Management Support Agency, Program Support Office)?
2.What is the justification of involving expensive Management firms to manage such programme give our knowledge that these firms incurred too high overheads. Are they really inevitable to ensure high access by the poor countrymen?
3.How to sustain the Technical Assistance projects in the long run as because after the completion of the projects Govt has less interest and capacity to continue the efforts?

EB Response:
I cannot comment on the tendering process in Bangladesh and Pakistan, as I am not personally aware of what is actually going on there. But the problem you have identified is not unique to Bangladesh nor Pakistan.

Personally, from what I gathered in countries that have gone into SWAps, delays in certain processes, pre-SWAp, may be attributed to:

I could go on and on with postulated reasons, but the bottomline is that these, together with your two other questions, are some of the issues that the SWAps are trying to address.

One of the major goals of SWAps is to reduce inefficiency by avoiding the huge administrative costs of running multiple development projects whose objectives may overlap or duplicate those of similar initiatives but funded by a different set of donors or development partners. With the government actively managing the 'basket' of resources to implement commonly defined and agreed projects in a single programme that is based on a national framework, much of what you might call excessive 'overhead costs' will be minimized, if not avoided.

SWAps are seen as a means to sustain the gains of technical assistance projects, over and beyond the project's shelf life, since they are government-led, and thus ensuring ownership of the projects. Likewise, a national development framework is used to guide the implementation of the programme, as well as in the monitoring and evaluation of impacts on people's health. These TA projects should then be incorporated or integrated into the country programming for proper and continued monitoring and evaluation. In addition, accountability has to be ensured at all levels so that the initial gains would be sustained in the longer term.

GM Response:
Procurement of goods and services is one area in service delivery that is gaining prominence and The World Bank has been at the forefront of streamlining the procurement systems and processes in developing countries. Delays in the tendering processes, as was the case in Bangladesh, could have been due to weak capacity in procurement and bureaucratic delays usually experienced with government systems.

The process of procuring goods and services has several steps that must be followed. The initiating institution must first prepare a procurement requisition with clear specification and terms of reference. The institution must then confirm the availability of funds for undertaking the procurement. A review of the specifications and terms of reference, procurement methods and evaluation criteria must then be undertaken. The institution must then prepare bidding documents with instructions to bidders and terms and condition of service. Once the bidding documents have been approved, then an advertisement and invitation for bids should be placed in the media. International or local advertisement can be used depending on the value of the procurement. In Uganda for example, if the value of procurement is over US $ 35,000, then this calls for international advertisement which allows a 3 months period within which to receive the bids. Once the bidding documents have been received from interested firms, the institution should then arrange for opening of bids which must be done in presence of representatives from the bidding firms. The bids should then be evaluated using the evaluation criteria that were agreed earlier. A report of the evaluation should then be prepared, after which an award of the contract is given.

The process of procurement can therefore be long, but shouldn't take all that long as was the case in Bangladesh. Quite often poor planning is one of the main causes of delays in tendering and procurement process. Each stage of the procurement process must be properly planned, delay in one stage will obviously affect the whole procurement cycle. In some cases, especially when using donor funds like as was the case with World Bank in Bangladesh, Government often delays to honour its obligation of providing counterpart funding. Such a situation will automatically delay the tendering process. There are also bureaucracies within World Bank itself, which delays the procurement process. Failure to submit all the required information, especially when doing procurement with World Bank, causes delays in the tendering and procurement process. The bank will not proceed with that procurement until the required information has been provided.

In Uganda with the assistance and support of the World Bank, a number of procurement reforms have been undertaken to streamline the procurement process and also build capacity in procurement. An autonomous body called Public Procurement and Disposal of Public Assets (PPDA) has been established and an act of Parliament (PDDA Act) enacted to institutionalize it. The PPDA provides advisory function on public procurement, provides capacity building in procurement to both public and private institutions and also does audit function to public institutions. Procurement has been decentralized to sectors and Local Governments. A Procurement and Disposal Unit (PDU) has been created in each sector and Local Government. Technical officers in procurement have been appointed and deployed in all sectors to manage the procurement units. The Procurement and Disposal Unit is supposed to handle all the procurement in the respective sectors and Local Governments and must follow the laid down procedures and regulations.

Question 3: (Uganda)

Many times research is always carried out and gaps are always identified in the health system. How long or what stages should be followed to come up with an intervention that is affordable and available for consumption?

EB Response:
The issue you have identified is known as the 'know-do' gap and has been widely acknowledged in the health sector. Another HSAN colleague, Dr David Sanders from South Africa, has written extensively on the need for implementation research to address this gap. Implementation research is now a buzzword in the health circles.

Dr Tikki Pang of WHO writes: While many examples of the 'know-do' gap exist, getting research findings into practice is a difficult and complicated task. The main challenge is to translate knowledge into health decision-making and clinical practice in order to create an enabling environment for community benefits to accrue. Such an enabling environment consists of an effective health system that is able to link research to policy, put evidence into practice, and obtain the support of the public, communities, and society for the role of knowledge in improving health. Dr Pang has enumerated, albeit quite broadly, some steps in translating research into practice.

While there is no straight path from research to practice or implementation, I would like to adopt Dwayne Simpson's 4 phases involved in the process of implementing changes towards evidence-based practice, but modify it a bit with Dr Andrew Haines' (Director, London School of Hygiene and Tropical Medicine) steps in promoting the uptake of research findings:

PHASES

 STRATEGIES/ STEPS

 

 

EXPOSURE

 

Determine that there is an appreciable gap between research findings and practice
Review of research literature, best practices
Define the appropriate message (i.e., the information or evidence to be used)
Identify possible intervention for implementation
Consultation with experts

 

ADOPTION

 

Examine the fit of an intervention to the local setting (e.g. relevance, cost-effectiveness, replicability, acceptability)
Decide which processes need to be altered
Identify the barriers to change and decide how to overcome them
Adapt the intervention to the local setting
Conduct training in the delivery of the adopted intervention
Establish data collection and quality assurance mechanisms

 

IMPLEMENTATION

 

Involve the key players (e.g. people who will implement change or who are in a position to influence change)
Pilot test or run implementation trials
Develop policies and procedures to support implementation
Identify levers for change---that is, existing mechanisms which can be used to promote change (financing, regulations, incentives, etc.)
Monitor and evaluate implementation and changes in practice

 

PRACTICE

 

Incorporate intervention into over-all health programme
Sustain use of the intervention over time
Continuous two-way feedback

 

GM Response:
Health research is an important input in the development of evidence-based health policies and strategic planning. Unfortunately health research is not well exploited in many developing countries. Many researches have been conducted but are not appropriately used in policy formulation and decision making processes.

In Uganda a lot of research have been conducted which have produced very useful findings and information. Many of these researches however have not been used to inform health policy formulation and strategic planning. The problem in Uganda and perhaps many other developing countries, is that the research conducted doesn't respond to health sector priorities. Many times the research is donor driven and often aimed at answering the funding agency's interests. The research is also very poorly coordinated and there is no formal and organized system for disseminating the research findings. A lot of very good research findings may therefore be available in the country but not known by policy and decision makers.

In order to improve and streamline health research in Uganda, government has established an autonomous organization called the Uganda National Health Research Organisation (UNHRO) charged with the responsibility of coordinating all the health research in the country. The health sector in Uganda has also formed technical working groups; 9 in total (with membership from all the key stakeholders, key central government ministries, development partners, civil society organizations, private sector organizations, District Local Governments) to facilitate the participation of health sector stakeholders in the discussion of health sector issues. One of the technical working groups focuses on Research and Development and is chaired by UNHRO. The working group has already discussed and agreed on health research priorities for the sector over the next five years. These priorities should ideally guide any research in the health sector.

Any new intervention or proposal must first be discussed within the respective technical working group. The recommendations of the technical working group on the intervention or proposal are then tabled in the Senior Management Committee of the Ministry of Health and then later in the Health Policy Advisory Committee (a policy organ composed of government and development partners) for final approval and endorsement. The whole process may take up to three to six months, depending on the complexity and urgency of the intervention.

NKULU-ILY Shabo Yves Response:
Low and middle income countries account for 4.9 billion of the world's 6 billion people. Identifying research capacity for a specific field such as Health Policy an Systems Research in such a large context is daunting. Yet it is becoming ever more important to assess gaps and resource requirements, particularly for the low income regions of the world that are the targets of initiatives such as the GFAMT. Furthermore, the Commission on Health Research for Development proposed that governmens in low and middle income countries should allocate at least 2% of national health expenditures and 5% of externally funded programmes to research and capacity strengthening.

We should focus our actions on the three main goals for the health system:

1. Health: The health of the population should reflect the health of individuals throughout life and include both premature mortality and non-fatal health outcomes as key components.

2. Responsiveness: we should enhance the responsiveness of the health system to legitimate expectations of the population.

3. Fairness in financial contribution: To be fair, financing of the health system should address two key challenges. First, households should not become impoverished, or pay an excessive share of their income in obtaining needed health care. Second, poor households should pay less towards the health system than rich households.

Question 4: (Algeria)

Could you please indicate key resources for understanding and putting into practice health system decentralization?

GM Response:
Decentralization of health service delivery has been one of the major reforms most governments have undertaken to improve the management and delivery of health services. Decentralisation brings decision making processes in service delivery nearer to the benefiting communities. Decentralisation of health services can take many forms:

The form of decentralization the government in power will decide to take will depend on the objectives and motives of decentralization and the degree to which the central government is willing to let go.

In order to put health system decentralization into practice there are some key things that must be put in place:

In order to ensure equitable allocation of the district health services budget among the districts, the Ministry of Health developed an allocation formula which takes into account the district population, poverty levels, disease burden (use Infant Mortality Rate as a proxy for disease burden), topography and surface area, distance from the centre etc.

EB Response:
There is an ongoing debate on decentralization that deals with its various dimensions as it applies to health systems.

Systems experts tend to view decentralization as both a state and a process.

As a state, decentralization refers to both level (whether at systems level or organizational level) and degree of decentralization (such as varying degrees of combinations of decentralization at varying levels within the system or organization).

As a process, it deals with phases and steps on how decentralization is conducted to shift roles and responsibilities from a highly centralized set-up to more autonomous structures in the periphery.

In many countries, as in the case of Trinidad and Tobago, decentralization of health services was intentionally done as part of the whole health sector reform process. However, the case in the Philippines was such that the devolution of basic health services delivery came about as a political decision, on the part of Congress and the Senate, with the enactment of the Local Government Code of 1991. The law vested local government units greater autonomy and responsibility over health, together with social welfare and education, without much preparation to manage such greater powers. Thus, the Health Sector Reform Agenda (HSRA) that was launched years later (1999) had to respond, by default, to this changing context in health service delivery.

This led to identifying Local Health Systems reforms, as one of the pillars of the five-pronged, inter-dependent reform process, together with Public Health reforms, Hospital reforms, Health Regulatory reforms, as primarily driven by reforms in Health Financing. The early post-decentralization challenges faced then were: 1) how to motivate former centrally employed health employees to continue to submit reports and comply with national directives, in the face of a growing demoralization over disparities in salary scales and benefit packages, owing to the inability of some local governments to comply with the provisions of the Magna Carta of Public Health Workers, that assured health workers of certain basic entitlements; 2) how to implement and monitor national health programs, such as the Expanded Program on Immunization (EPI) where mobilization of staff and supplies has now become dependent on local government management and resources; and 3) how to make local governments accountable for the health of their constituents and share health resources and expertise within and beyond geopolitical boundaries, to name but a few.

Clearly, these complex challenges entailed the development of innovative strategies and a re-allocation or redistribution of health resources vertically from national to local through the Internal Revenue Allocations (IRA) which represents global budgets coming from national coffers for the over-all management of local government functionalities, based on a formula that includes population size and income class, as well as horizontally from local to local, through the convergence or Inter-Local Health Zone strategy.

In Trinidad and Tobago, the Inter-American Development Bank (IDB)-funded Health Sector Reform Programme (HSRP) that was started in 1996 and involved mainly the decentralization of service delivery to the RHAs, consisted of the following key components:

The above components will give you an idea of the resources needed to carry out the decentralization process. Another colleague, Grace Murindwa, expounds on a number of these resources in his response, in the Ugandan context.

Another way of understanding decentralization is by using a typology that deals with the degree of "decision space" or "range of choice." A research done by Partners for Health Reform (PHRplus) compares the decentralization process in Ghana, Zambia, Uganda and the Philippines. Below is a summary table showing the results of this mapping exercise. This map is intended to clarify the decentralization picture for a particular health system and identify sources of tension, current or potential capacity problems, and political and/or bureaucratic concerns.

Table 1. Comparison of "Decision Space" in Decentralization: Ghana, Zambia, Uganda and the Philippines

Function

Degree of Decision Space

Narrow

Moderate

Wide

Financing

  • Sources of Revenue
  • Expenditures
  • Income from fees

 

Zambia

 

Ghana, Uganda
All four
Ghana, Uganda,
Zambia

 

Philippines

Philippines

Service Organization

  • Hospital Autonomy
  • Insurance Plans
  • Payment Mechanisms
  • Contracts with private providers

 

Ghana, Zambia
Ghana, Uganda
Ghana, Uganda

 

Uganda

Philippines

Zambia

 

Philippines
Philippines, Zambia
Zambia

Uganda

Human Resources

  • Salaries
  • Contracts
  • Civil Service

 

All four
Ghana
Ghana

 

Philippines
Philippines, Uganda, Zambia

 

Uganda, Zambia

Access Rules

Ghana

Philippines, Uganda, Zambia

 

Governance

  • Local Government
  • Facility Boards
  • Health offices
  • Community Participation

 

Ghana, Zambia
All four
Ghana, Phils
Ghana, Uganda

 

 

Uganda, Zambia
Philippines, Zambia

 

Philippines, Uganda

Source: Decentralization and Health System Reforms, Partners for Health Reform Plus, No.1, September 2002 (available online:  http://www.phrplus.org/Pubs/IS1.pdf )

Lastly, health system decentralization is generally carried out to improve health sector performance. However, Bossert, Beauvais, and Bowser (2000) have identified other objectives that may complement or conflict with each other, such as the following:

The table below identifies some of the current issues related to these objectives and corresponding strategies to put into practice health system decentralization, based on experiences from transitional economies in Europe:

Table 2. Current issues in health care systems and examples of decentralization strategies to address them


Health care needs

Examples of decentralization strategies

To increase long-term care services

Responsibility for planning, financing, delivery and organization of long-term care decentralized to local health care level

To integrate care services

Responsibility for the set of services made under a single decision-making authority

To implement efficient public
health interventions

Responsibility for interventions for hard to reach and high risk groups is transferred to local levels

Community public health actions in high risk areas

To increase accountability

Responsibility for health care costs allocated to sub-national levels

Unconditional block grants to local governments

New forms of management of health care
Organizations

To increase efficiency

Innovative forms of organizing health provision and institutions

Increased role of private sector (i.e. PPP, PFI, contracting out)

To improve mental health care
services

Targeted community-based programmes in high risk areas

Source: Bankauskaite, V. and Saltman, R. (2006) Central Issues in the Decentralization Debate, European Observatory on Health Systems and Policies (available online: http://www.euro.who.int/Document/E89891_Ch1.pdf )

Question 5: (Grenada)

In most Caribbean countries a high proportion of health services are paid
for Out-of-pocket in the private sector, bypassing the government financed "free" health services. Is Social Health Insurance an answer to addressing the inequitable nature of user fees?

GM Response:
Social Health Insurance (SHI) is a health care financing scheme where specific population groups are mandated to enroll and pay a contribution to the SHI fund. In turn, enrollees are entitled to a set of health care benefits. Both SHI and out-of-pocket payment therefore involves payment for health care. Premium payments for SHI are based on the income of the individual and are paid in advance while out-of-pocket payments are based on the amount of services one has consumed and are paid at the time of using the services.

Since the premium payments for SHI are based on the income of the individuals/families, SHI therefore is definitely an answer to addressing the inequitable nature of user fees. The premiums paid by both the rich and poor in SHI result in pooling resources to finance the cost of health care in times of sickness. Since the health care benefit package is the same for all the enrollees, the rich therefore subsidize the poor.

In Uganda, we are still in the preparatory stages of introducing SHI. Pilot implementation will start in July 2008 starting with all the formally employed workers in the regional capitals. Premium contributions have been fixed at 10% of the salary.

There are however on-going Community Based Health Insurance Schemes for mainly the rural populations. Some rural populations have been organized into groups of schemes for Community Based Health Insurance. There are so far about 10 schemes operating now. Many of these schemes have been able to mobilize the rural population to pay their premium contributions. The enrolled members of the society pay the same premiums and have equal access to the same benefit package. The premium contributions are usually paid at the time when the peasants have some disposal income like at the time of harvesting crops. Due to the low incomes of the rural population, the premium contributions were set low. The funds raised from such schemes are therefore not always adequate to meet the cost of health care. In such instances hospitals where such schemes are based or some organizations/donors act as guarantors for such schemes.

EB Response:
Your observation is true to a large extent. Data extracted from the National Health Accounts in WHO's Statistical Information System (WHOSIS) shows that out-of-pocket expenditures are very high even in countries where free government health services are available. The table below highlights the issue of inequity in a situation where high out-of-pocket spending exists, as access to care is defined by one's willingness and ability to pay, rather than need and universal access to care:

Table 1. Comparison of Health Expenditures Among Selected Caribbean Countries


Selected Countries in the Caribbean

Total
expenditure
on health (THE) as
% of GDP

 

2004

Government expenditure on health as % of THE

 

2004

Private Expenditure on health as % of THE

 

2004

Out of pocket expenditure as % of Private Expenditure on health
2004

Out of pocket expenditure as % of THE
(Note: This is extrapolated data)

Antigua & Barbuda

4.8

70.6

29.4

100

29.4

Bahamas

6.8

50.1

49.9

40.3

20.1

Barbados

7.1

63.5

36.5

78.6

28.7

Belize

5.1

53.8

46.2

100

46.2

Grenada

6.9

72.8

27.2

100

27.2

Guyana

5.3

83.5

16.5

100

16.5

Jamaica

5.2

54.3

45.7

63.6

29.1

Trinidad & Tobago

3.5

38.9

61.1

88.5

54.1

Source: World Health Statistics 2007, World Health Organization Statistical Information System (WHOSIS)
(available online at http://www.who.int/whosis/whostat2007_6healthsystems_nha.pdf )

This phenomenon could be explained, in part, by the general perception of the public that private health care is superior to public health care, despite the fact that majority of physicians doing private practice may be the same physicians employed in public health facilities. There is a saying in Trinidad that says, "Cheap ting no good". This could further be demonstrated by the willingness of patients to wait in line in private clinics but complain about the same queuing system in public facilities.

In a number of Caribbean countries, it could also mean that the investments in health that the governments are making are not enough to support the delivery of adequate and quality health services, alongside inefficiencies in the system, such that people are forced to dig into their pockets to access what they might perceive as quality health care in the private sector.

In this situation, social health insurance provides a more acceptable alternative to financing the health system. Social health insurance is based on the concept of solidarity, where the well-off shares resources to benefit the worse off in society. Hence, social health insurance involves the pooling of risks in order to even out or spread across the broader population the financial burden of catastrophic illness that may leave an individual or family impoverished from the cost of dealing with that illness.

Certainly, social health insurance addresses the equity issue as far as equitable access to health services is concerned, and for as long as the premium schedules are progressive (increasing premium scales set according to increasing income levels). Regressivity, on the other hand, has to do with flat rate payments that do not take into consideration the income status of the paying member, disproportionately benefiting the rich.

However, it should be borne in mind that user fees, while inequitable in situations requiring high out-of-pocket expenditures, may play a role in checking abuse of the system by controlling the unnecessary or wanton use of health resources for minor, self-limiting illnesses (also known as patient moral hazard), i.e., if such fees are set at a level that would deter frivolous consultations but not prevent those who truly need medical attention from seeking care.

Question 6: (Mali)

How do you improve a community's participation in the management and deliver of health services. In Mali, the delivery of health care along with other social services has been decentralized to the districts, but many are still not getting the best care.

GM Response:
Community participation is very essential in the delivery of social services. Community participation increases the ownership and utilization of the social services by the population. The health sector in Uganda has realized that community participation in the planning and management of health services is the only way to increase the utilization of health services, change the behavior and life styles and eventually improve the health status of the population. The health sector in Uganda is therefore using the following strategies to improve community participation:

In the health sector, Decentralised District Health Services are required to prepare annual work-plans before accessing funds allocated to them. One of the key principles used in developing district annual work-plans is bottom up planning approach. Within districts, there are health facilities. Each health facility (service delivery point) is allocated a budget and is therefore required to have a work-plan before accessing funds. The process of preparing the District Annual Work-plan starts with individual health facilities. Each health facility is expected to involve the Heath Unit Management Committee (composed of community representatives), extension workers of other sectors (inter-sectoral collaboration), Community Based Organisations (CBOs) in the catchment area (or service area/area of responsibility) and the health workers of that facility in the process of developing the Annual Work-plan for the facility. The plans of all the health facilities in the sub-county are put together to form the Sub-county Health Work-plan. The Sub-county Health Work-plans are put together to form the Health Sub-District Work-plan. The Health Sub-District Work-plans are put together along with the plan of the District Health Team to form the District Annual Work-plan.

Through the bottom-up planning approach, the communities participate in planning for health service delivery for their areas.

Each health facility is required to have a Health Unit Management Committee. The Ministry of Health provided guidelines on the function, composition and procedure of Health Unit Management Committees (HUMC). The communities must be represented on the HUMC by a prominent public figure (to be the chair) and another 4 or 5 community members with high integrity (appointed by the Sub-county Council, preferably from different parishes of the catchment area, and taking gender responsiveness into consideration). The community members on the HUMC represent the communities in the planning and management of health services at the health facility and in the entire catchment area. The HUMC members are also required to gather views of the communities on health service delivery and health priorities for the area which should be addressed and included in the work-plans.

Uganda has established the Village Health Team strategy as an innovative approach to improve community participation and involvement in health service delivery. Each village in Uganda (estimated population of 5,000 people) is expected to select 9 members from its community to form a Village Health Team (VHT). The Ministry of Health provided guidelines on the functions and composition and selection of the VHTs. Existing Community Health Workers (CHWs) and Community Resource Persons (CORPs) are prioritized for selection into the VHTs. The selected VHTs are trained by Ministry of Health in collaboration with the District Health Teams on the roles and responsibilities and various health activities (mainly preventive and promotove health activities) they are expected to do in the villages.

The VHTs are used to mobilise communities to take responsibility for their own health. They educate the communities on preventive and promotive health activities. They collect vital information and statistics in the villages. They conduct home visits, distribute drugs (especially Homapack for malaria treatment), do DOTS for TB, follow-up on patients in the community and act as pregnancy monitors etc. VHTs are supposed to ensure that the expected living and performance standards at the community level (which have been defined as the Activity Package for VHT) are adhered to.

The VHT is not a physical structure but is considered as the lowest level of the health system. It acts as the interface between the HSD health care system and the population or communities. Health facilities are expected to supervise and support the VHTs in their catchment areas. Health facilities provide supplies such as Homapacks, ORS, ITNs, etc to the VHTs for distribution to the communities.

In areas where the Village Health Team strategy has been fully operationalised (about one-quarter of the country), it has been identified as key for effective community mobilisation and involvement in promoting their own health

EB Response:
I would like to draw my response from experiences on community participation in the Philippines. In a country that has ousted two corrupt Presidents through two peaceful, i.e., non-bloody People Power events, the Philippines is rife with community participation strategies where the voice of the people are heard and represented in various forms and fora.

Community participation can occur in different levels and there are various existing mechanisms to ensure community participation.

In the Philippines, an example of community participation at work in the grassroots level is in the form of the Community-Based Health Programmes (CBHPs), which may be affiliated to civil society groups, parishes or religious organizations, academic institutions, or local governments. CBHPs, are in large measure, dependent upon a whole backbone formed by a cadre of volunteer village health workers, locally known as Barangay Health Workers (BHWs). It is said that the history of pioneering CBHPs in the Philippines antedates the Alma Ata Declaration on Primary Health Care in 1978.

The experience of the University of the Philippines College of Medicine (UP-CBHP), for instance, speaks about the transformation of these BHWs from being plain housewives to implementers of health programmes such as TB-Directly Observed Treatment Shortcourse (TB-DOTS), to social mobilizers, to health educators, or to health advocates lobbying for inclusion of or increased health budgets in village and municipal governing councils. Some of them have also gained representation in these local councils, or even went on further to run for local elective posts.

Some of the methods to improve community participation, as identified by CBHP practitioners in the Philippines, involve people empowerment approaches such as the following:

CBHP practitioners believe that such methods, as described above, are replicable and could be tailored according to the particular needs and conditions of any given community.

Contributions from other HSAN members

Andrey Ostrovsky adds:

1. What are the major bottlenecks to making known, affordable and effective interventions widely available?

In my experience a major bottleneck is a lack of government recognition of groups of people as residents.  In 2002, the UN General Assembly Special Session on Children adopted the target of ensuring by 2010 the full immunization of children under one year of age at 90 per cent nationally, with at least 80 per cent coverage in every district or equivalent administrative unit.1 In 2005, 86 % of infants in the Dominican Republic were immunized with DPT3, the WHO recommendation for Pertussis immunization. And, 63 cases of pertussis were reported in that country the same year. Relative to the global 78% estimated DTP3 coverage, the Dominican Republic is above the global coverage rate.3 However, the Haitian sugar-cane worker population in the La Romana district of the Dominican Republic is an unrecognized population of Dominican residents that is not included in the calculation of health indices such as immunization coverage and if unvaccinated, can serve as a reservoir of pertussis for the greater Dominican population.

In an observational study, the Inter-American Commission on Human Rights, found that about 500,000 undocumented Haitian workers reside in the Dominican Republic. Most of them are faced with permanent residential illegality, which is inherited by their children. Consequently, the children cannot obtain Dominican nationality even if they are born in the country because they are not granted birth certificates. The children live mainly in villages for sugar-cane cutters (bateyes) in socio-population sectors outside of the political-administrative boundaries of the Dominican Republic. The bateyes are the property of the sugar cane companies which hire the Haitian labor. Due to the lack of legal status of the residents and absence of governmental programs in these areas, the Haitian workers are not included in routine surveillance for pertussis (or any other health surveillance), nor are they included in national vaccination programs.

2. What measures must be put in place to ensure that known, affordable and effective interventions are widely available?

Government acknowledgement of their responsibility to care for the bateye residents (many of which were born and have lived in the DR their entire lives).

3. How do we ensure the sustainability of such interventions?

This suggestion would have to be an entire mentality change by the DR government and health system reinforced by some sort of economic incentive. Such an incentive could be taxing the sugar cane companies "employing" the immigrants. These companies are essentially oligarchies that indirectly work with the DR government to exploit the Haitian immigrants.

4. What are the organizational and management reforms (or arrangements) that must be undertaken to ensure that known, affordable and effective interventions are widely available?

Reduce government approval of sugar cane company exploitation of sugar cane workers and make the businesses and government mutually responsible for health administration. The financing for these reforms can initially be provided by and investment by the companies and government, and later the burden can shift to the healthier and higher paid sugar cane workers that can be taxed for health coverage.

Nkulu-Ily Shabo Yves adds:

1. What are the major bottlenecks to making known, affordable and effective interventions widely available?

While official documents continue to refer to primary health care as the strategy for implementing health policy, it is increasingly obvious from current trends that the problem currently facing the health system of DRC (Democratic Republic of Congo) is the lack of a common vision of the structure needed to address the overall health problems of the population.

This lack of vision prevents the different actors (those in the field, senior and middle managers at the Ministry of Health and donors) from establishing the link between primary health care and the health zone, which is defined as the operational unit whose development remains the prerequisite for implementing health policy. This fundamental link, which existed until around 1985, has disappeared over time to the extent that nowadays, the health zone has become a rather worn concept.

The health zone, which once was an integrated two-level health system, formed by a network of health centres and a general referral hospital, has now become a hotchpotch of actions and actors whose prime concern is to offer a high profile to donors rather than to meet the expectations of the target populations. In this way, the Minimum Package of Activities (MPA) has been sliced up into selected packages of activities, and the general referral hospital, which is considered as a "non-zone" facility, finds itself competing with the health centres. In addition, under the pretext of taking care closer to the population, a range of intermediate facilities have developed (community intermediaries, health posts and referral health centres) not all of which are necessary and many of which are harmful (health care of dubious quality, and competition with any attempt to rationalize the two levels).

The change in the political regime that took place in May 1997 raised hopes for the country's reconstruction. The preparation of the Master Plan for Health Development 1999 - 2008 (MPHD), needs to be seen in this context. In this respect, the audit of the health sector noted: "in order to set right the health situation that has prevailed in the country for several years, it is necessary to implement a health-development plan as an integral part of the national social and economic development plan and of the poverty elimination plan" (Health-sector audit, 1998).

The organization, in 1999, of the States-general for Health marked the starting point of a new agenda for the health sphere, with the adoption of four documents: - draft framework-law on public health; - draft organizational framework for the Ministry of Health; - draft health-sector policy statement and master plan for health development.
However, it was not long before the reform of the health sector in DRC and the different fora held after the States-General for Health (national SANRU 3 symposium: let's rebuild primary health care, round table on health, annual audits by the Ministry of Health, etc.) were seen as mere academic exercises, as pandering to a fashionable trend,  health sector reform.

2. What are the organizational and management reforms (or arrangements) that must be undertaken to ensure that known, affordable and effective interventions are widely available?

Strategic lines of action to be undertaken are:

Revitalization of the health zones and correction of the distortions that have developed at the peripheral level

The history of the health system of DRC is marked simultaneously by the use of ad-hoc programmes designed to address specific health problems and the introduction of health zones. However, in 1984, the synthesis of the different experience led DRC to define its health policy on the basis of primary health care with the health zone as the unit for planning and implementation.

Note: It is possible to envisage the development of health zones as a continuous process developing along five lines. These five lines are gradually reinforced with different levels of intensity, which vary depending on the level of development and specific needs of each of the zones. Two other criteria, which represent prerequisites, need also to be taken into account: funding and partnership.

Reorganization of the central and intermediate levels

Rationalization of health funding

Decentralization of the venue for negotiation of funding: Development of the capacity of the decentralized level to negotiate funding is to be considered as a process which, in the long run, should result in the decentralization from the central to the provincial level of the venue for negotiating funding, so as to set up provincial 'basket funding'.

Strengthening intra- and intersectoral partnership

It is also essential that institutions directly responsible for the quality of health care, such as training colleges for physicians and nurses, health-research establishments, facilities responsible for supplying quality drugs should be associated and thus become stakeholders in the reform process. Commitment by the State to help these institutions fulfill their key role in providing high-quality staff and inputs for health services is vital.

Development of human resources for health (HRH)

Development of human resources is one of the most important aspects of the strategy to reinforce the health system. This is so both because of what needs to be done in this area (better distribution of staff, improved and more diversified skills, creation of an environment that fosters a professional ethos, etc.) and of the way in which it needs to be done, which calls for the commitment of staff who, as we know, are often opposed to any idea of change. It would be simplistic to assume that health-system reform may content itself with changing structures without developing, first and foremost, an attitude capable of accepting, understanding and imagining what the reform actually demands.

Improving research into health systems

Such is the complexity of the situation in which the health system reinforcement strategy is to be implemented that action-oriented research is an essential line of action. This research will make it possible on the one hand to improve the quality of standard-setting activity and on the other to identify not only the bottlenecks holding back implementation of the strategy, but also alternative solutions.