Are lessons from the education sector applicable to health care reforms? The case of Uganda

The decision by donors to use external aid for poverty alleviation in very low-income countries and the redefinition of development to include human aspects of society have renewed interest in education and health services. The debate about accountability, priorities and value-for-money of social services has intensified. Uganda's universal primary education programme (UPE) has within 2 years of inception achieved 90% enrollment. The programme has been acclaimed as successful. But the health sector that has been implementing primary health care and reforms for two decades is viewed as having failed in its objectives. The paper argues that the education sector has advantages over the health sector in that its programme is simple in concept, and was internally designed involving few actors. The sector received strong political support, already has an extensive infrastructure, receives much more funding and has a straightforward objective. Nevertheless, the health sector has made some achievements in AIDS control, in the prevention and control of epidemics, and in behavioural change. But these achievements will not be noticed if only access and health-status are used to assess the health sector. However, UPE demonstrates that a universal basic health care is possible, given the same level of resources and political commitment. The lesson for the health sector is to implement a priority universal health care programme based on national values and to assess its performance using the objectives of the UPE.     

Managing external resources in Mozambique: building new aid relationships on shifting sands?

The Mozambican health sector is recovering from war and general disruption. This massive endeavour is supported by several donor agencies, which contribute a substantial proportion of national health expenditure. The final years of the war and the transition period have seen an extreme fragmentation of the health sector. To correct it, serious efforts to coordinate the plethora of aid agencies and related external inputs have taken place. This paper reviews the actors present on the Mozambican health scene and their interactions. The existing aid management mechanisms are described and their effectiveness appraised. The factors affecting both the process and its outcomes are analyzed. Given the prevailing complexity, this research presents a number of tentative conclusions. First, the evidence suggests that coordination efforts have paid off. However, progress has required intense and sustained work. Incremental approaches, where donor demands are progressively raised as the system is strengthened, have been crucial. The initiative has come mainly from donors, with the Ministry of Health receptive and reactive. When the recipient administration has been able to take advantage of donor initiatives, success has ensued. Individual people have been crucial in shaping the process. Critical factors contributing to positive developments on both sides of the donor-recipient relationship have been frankness, risk-taking and a long-term perspective.     

Community-based health workers: head start or false start towards health for all?

Health service delivery programs using minimally-trained community-based health workers (CHWs) have been established in many developing countries in recent years. These programs are expected to improve the cost-effectiveness of health care systems by reaching large numbers of previously underserved people with high-impact basic services at low cost. The reported experience with these programs has been mixed, raising questions about whether the community health worker is an optimal vehicle for extending primary health care. This review of six large-scale community-based worker programs suggests that they have succeeded in some of their objectives but not in others. CHWs increase the coverage and equity of service delivery at low cost compared with alternative modes of service organization. However, they do not consistently provide services likely to have substantial health impact and the quality of services they provide is sometimes poor. Large-scale CHW systems require substantial increases in support for training, management, supervision, and logistics. The evidence suggests that, in general, their potential has not been achieved in large routine programs. Further development of these programs is needed to reinforce their successes and assure that they are adequately supported as an integral component of the basic health system.     

International NGOs and primary health care in Mozambique: the need for a new model of collaboration

In keeping with the neo-liberal emphasis on privatization, international aid has been increasingly channeled through non-governmental organizations (NGOs) and their expatriate technical experts to support primary health care (PHC) in the developing world. Relationships between international aid workers and their local counterparts have thus become critical aspects of PHC and its effectiveness. However, these important social dynamics of PHC remain understudied by social scientists. Based on three years of participant-observation in Mozambique, this paper presents an ethnographic case study of these relationships in one central province. The Mozambique experience reveals that the deluge of NGOs and their expatriate workers over the last decade has fragmented the local health system, undermined local control of health programs, and contributed to growing local social inequality. Since national health system salaries plummeted over the same period as a result of structural adjustment, health workers became vulnerable to financial favors offered by NGOs seeking to promote their projects in turf struggles with other agencies. It is argued that new aid management strategies, while necessary, will not be sufficient to remedy the fragmentation of the health sector. A new model for collaboration between expatriate aid workers and their local counterparts in the developing world is urgently needed that centers on the building of long-term equitable professional relationships in a sustainable adequately funded public sector. The case study presented here illustrates how the NGO model undermines the establishment of these relationships that are so vital to successful development assistance.     

Reinventing mass communication: a World Health Organization tool for behavioral change to control disease.

Most of the WHO's vertical programs, because they were ill-conceived, ill-designed, and defectively implemented, have fallen far short of expectations. These limitations have been doggedly ignored by the WHO, although the authorities in India have now realized that such vertical programs are expensive and not sustainable. Launching of Communication for Behavioral Impact (COMBI) appears to mark a desperate effort to revive their performance. It represents yet another deviation from the mandate given to the WHO. In 1983, the then director general warned against motivational manipulation of people to sell health ideas, but the WHO has now brazenly come forward to look for help from the private sector. COMBI uses the jargon and language of the market place to "market" health programs; it calls this "cause-related marketing." The WHO has been most a historical in conceptualizing COMBI, as it has not learned from the failure of UNICEF's earlier venture to market child survival by employing experts in social marketing to bring about "community mobilization." The WHO should have reviewed the large body of literature on work in the health social sciences, health education, and the many programs based on the concept of "information, education, and communication." The pointed neglect of such key issues raises serious moral, ethical, and human rights questions. The COMBI approach amounts to be a breach of trust--a threat to human dignity.     

“Enticing case study” or “celebrated anomaly”? Policy learning from the Cuban health system

Cuba is regarded as having achieved very good health outcomes for its level of economic development. It has adopted policies and programs that focus on prevention, universal access to healthcare, a strong primary care system, the integration of health in all policies, and public participation in health. It has also established a strong and accessible system of medical education and provides substantial medical aid and support to other countries. Why then, it may be asked, has the Cuban experience not had greater influence on health policies and reforms elsewhere? This article, based on a literature review and new primary sources, analyzes various factors highlighted in the policy transfer literature to explain this. It also notes other factors that have created greater awareness of Cuban health achievements in some countries and which provide a basis for learning lessons from its policies.     

Has donor prioritization of HIV/AIDS displaced aid for other health issues?

Advocates for many developing-world health and population issues have expressed concern that the high level of donor attention to HIV/AIDS is displacing funding for their own concerns. Even organizations dedicated to HIV/AIDS prevention and treatment have raised this issue. However, the issue of donor displacement has not been evaluated empirically. This paper attempts to do so by considering donor funding for four historically prominent health agendas--HIV/AIDS, population, health sector development and infectious disease control--over the years 1992 to 2005. The paper employs funding data from the Organization for Economic Cooperation and Development's (OECD) Development Assistance Committee, supplemented by data from other sources. Several trends indicate possible displacement effects, including HIV/AIDS' rapidly growing share of total health aid, a concurrent global stagnation in population aid, the priority HIV/AIDS control receives in US funding, and HIV/AIDS aid levels in several sub-Saharan African states that approximate or exceed the entirety of their national health budgets. On the other hand, aggregate donor funding for health and population quadrupled between 1992 and 2005, allowing for funding growth for some health issues even as HIV/AIDS acquired an increasingly prominent place in donor health agendas. Overall, the evidence indicates that displacement is likely occurring, but that aggregate increases in global health aid may have mitigated some of the crowding-out effects.     

International aid policy: public disease control and private curative care?

Integrating disease control with health care delivery increases the prospects for successful disease control. This paper examines whether current international aid policy tends to allocate disease control and curative care to different sectors, preventing such integration. Typically, disease control has been conceptualized in vertical programs. This changed with the Alma Ata vision of comprehensive care, but was soon encouraged again by the Selective Primary Health Care concept. Documents are analyzed from the most influential actors in the field, e.g. World Health Organization, World Bank, and European Union. These agencies do indeed have a doctrine on international aid policy: to allocate disease control to the public sector and curative health care to the private sector, wherever possible. We examine whether there is evidence to support such a doctrine. Arguments justifying integration are discussed, as well as those that critically analyze the consequences of non-integration. Answers are sought to the crucial question of why important stakeholders continue to insist on separating disease control from curative care. We finally make a recommendation for all international actors to address health care and disease control together, from a systems perspective.     

Health without wealth? Costa Rica's health system under economic crisis

The recent history of Costa Rica's health system is reviewed, emphasizing the health-related effects of the economic crisis of the 1980s. This economic crisis has stopped and in some instances reversed the marked health improvements Costa Rica realized during the decade of the 1970s. The effects of the economic crisis emerge in 4 areas: deterioration in health status, as poverty contributed to higher disease rates; reductions in the government's ability to maintain public health and medical services; increased reliance on foreign aid to finance the health system; and growing national debate over the role of the state in health care. The result of the economic crisis was a reduction in health services and a questioning of the Costa Rican health model. This occurred following the implementation of an expensive health infrastructure and at a time when people most needed health services. During the 1941-70 period, domestic initiative can account for much of the expansion of Costa Rica's social security system, but also at this time international agencies such as the US Agency for International Development (USAID) and the Inter-American Development began to assist in the expansion of the health system. In 1971 a plan was initiated to create a nationalized health system. By 1980 the success of the health sector reorganization was evident in the statistics: marked improvements in life expectancy, infant mortality, and infectious disease mortality had surpassed the goals set by the Pan American Health Organization (PAHO) and the Ministry of Health. Costa Rica's success was a vindication of both policy goals and funding priorities, for it has been "proved" that primary health care was capable of improving health indices, particularly where the agencies had the active and conscientious support of the national government. By 1977, foreign contracts for aid had expired, and the Ministry declared that the rural health program would be supported totally by the government. The Minister of Health continued in 1982 to champion self-sufficiency despite a changed economic climate, but by early 1984 Costa Rica had to abandon its plan to wean the health sector from outside aid. In 1982 the health sector became the center of a nationwide debate. Representatives of the large agricultural export sector, who usually support free-market solutions to economic problems, lobbied for "reprivatization" of medical care. Those committed to expansion of the welfare state argued from the other extreme. The government offered concessions to both groups. The debate did end in 1986, most likely because of the overall easing of the economic crisis. The government needs to maintain state control over the health system while not exceeding its austerity budget and not reducing health services.     

What difference does ("good") HRM make?

The importance of human resources management (HRM) to the success or failure of health system performance has, until recently, been generally overlooked. In recent years it has been increasingly recognised that getting HR policy and management "right" has to be at the core of any sustainable solution to health system performance. In comparison to the evidence base on health care reform-related issues of health system finance and appropriate purchaser/provider incentive structures, there is very limited information on the HRM dimension or its impact.Despite the limited, but growing, evidence base on the impact of HRM on organisational performance in other sectors, there have been relatively few attempts to assess the implications of this evidence for the health sector. This paper examines this broader evidence base on HRM in other sectors and examines some of the underlying issues related to "good" HRM in the health sector.The paper considers how human resource management (HRM) has been defined and evaluated in other sectors. Essentially there are two sub-themes: how have HRM interventions been defined? and how have the effects of these interventions been measured in order to identify which interventions are most effective? In other words, what is "good" HRM?The paper argues that it is not only the organisational context that differentiates the health sector from many other sectors, in terms of HRM. Many of the measures of organisational performance are also unique. "Performance" in the health sector can be fully assessed only by means of indicators that are sector-specific. These can focus on measures of clinical activity or workload (e.g. staff per occupied bed, or patient acuity measures), on measures of output (e.g. number of patients treated) or, less frequently, on measures of outcome (e.g. mortality rates or rate of post-surgery complications).The paper also stresses the need for a "fit" between the HRM approach and the organisational characteristics, context and priorities, and for recognition that so-called "bundles" of linked and coordinated HRM interventions will be more likely to achieve sustained improvements in organisational performance than single or uncoordinated interventions.     

Strengthening health systems in poor countries: a code of conduct for nongovernmental organizations

The challenges facing efforts in Africa to increase access to antiretroviral HIV treatment underscore the urgent need to strengthen national health systems across the continent. However, donor aid to developing countries continues to be disproportionately channeled to international nongovernmental organizations (NGOs) rather than to ministries of health. The rapid proliferation of NGOs has provoked "brain drain" from the public sector by luring workers away with higher salaries, fragmentation of services, and increased management burdens for local authorities in many countries. Projects by NGOs sometimes can undermine the strengthening of public primary health care systems. We argue for a return to a public focus for donor aid, and for NGOs to adopt a code of conduct that establishes standards and best practices for NGO relationships with public sector health systems.     

Has the Swap Influenced Aid Flows in the Health Sector?

The sector wide approach (SWAp) emerged during the 1990s as a mechanism for managing aid from the multiplicity of development partners that operate in the recipient country's health, education or agricultural sectors. Health SWAps aim to give increased control to recipient governments, allowing greater domestic influence over how health aid is allocated and facilitating allocative efficiency gains. This paper assesses whether health SWAps have increased recipient control of health aid via increased general sector‐support and have facilitated (re)allocations of health aid across disease areas. Using a uniquely compiled panel data set of countries receiving development assistance for health over the period 1990–2010, we employ fixed effects and dynamic panel models to assess the impact of introducing a health SWAp on levels of general sector‐support for health and allocations of health‐sector aid across key funding silos (including HIV, ‘maternal and child health’ and ‘sector‐support’). Our results suggest that health SWAps have influenced health‐sector aid flows in a manner consistent with increased recipient control and improvements in allocative efficiency. Copyright © 2015 John Wiley & Sons, Ltd.     

Health sector reform in the Occupied Palestinian Territories (OPT): targeting the forest or the trees?

Since the signing of the Oslo Peace Accords and the establishment of the Palestinian Authority in 1994, reform activities have targeted various spheres, including the health sector. Several international aid and UN organizations have been involved, as well as local and international non-governmental organizations, with considerable financial and technical investments. Although important achievements have been made, it is not evident that the quality of care has improved or that the most pressing health needs have been addressed, even before the second Palestinian Uprising that began in September 2000. The crisis of the Israeli re-invasion of Palestinian-controlled towns and villages since April 2002 and the attendant collapse of state structures and services have raised the problems to critical levels. This paper attempts to analyze some of the obstacles that have faced reform efforts. In our assessment, those include: ongoing conflict, frail Palestinian quasi-state structures and institutions, multiple and at times inappropriate donor policies and practices in the health sector, and a policy vacuum characterized by the absence of internal Palestinian debate on the type and direction of reform the country needs to take. In the face of all these considerations, it is important that reform efforts be flexible and consider realistically the political and economic contexts of the health system, rather than focus on mere narrow technical, managerial and financial solutions imported from the outside.     

Global public goods and the global health agenda: problems, priorities and potential

The 'global public good' (GPG) concept has gained increasing attention, in health as well as development circles. However, it has suffered in finding currency as a general tool for global resource mobilisation, and is at risk of being attached to almost anything promoting development. This overstretches and devalues the validity and usefulness of the concept. This paper first defines GPGs and describes the policy challenge that they pose. Second, it identifies two key areas, health R&D and communicable disease control, in which the GPG concept is clearly relevant and considers the extent to which it has been applied. We point out that that, while there have been many new initiatives, it is not clear that additional resources from non-traditional sources have been forthcoming. Yet achieving this is, in effect, the entire purpose of applying the GPG concept in global health. Moreover, the proliferation of disease-specific programs associated with GPG reasoning has tended to promote vertical interventions at the expense of more general health sector strengthening. Third, we examine two major global health policy initiatives, the Global Fund against AIDS, Tuberculosis and Malaria (GFATM) and the bundling of long-standing international health goals in the form of Millennium Development Goals (MDG), asking how the GPG perspective has contributed to defining objectives and strategies. We conclude that both initiatives are best interpreted in the context of traditional development assistance and, one-world rhetoric aside, have little to do with the challenge posed by GPGs for health. The paper concludes by considering how the GPG concept can be more effectively used to promote global health.     

Player or referee? Aid effectiveness and the governance of health policy development: Lessons from Viet Nam

Viet Nam is one of the brightest stars in the constellation of developing countries. Its remarkable achievements in reducing poverty and improving health and education outcomes are well known, and as a result it has enjoyed generous aid programmes. Viet Nam also has a reputation for taking a strong lead in disciplining its donors and pushing for more efficient and effective forms of aid delivery, both at home and internationally. This article discusses how efforts to improve the effectiveness of aid intersect with policy-making processes in the health sector. It presents a quantitative review of health aid flows in Viet Nam and a qualitative analysis of the aid environment using event analysis, participant observation and key informant interviews. The analysis reveals a complex and dynamic web of incentives influencing the implementation of the aid effectiveness agenda in the health sector. There are contradictory forces within the Ministry of Health, within government as a whole, within the donor community and between donors and government. Analytical frameworks drawn from the study of policy networks and governance can help explain these tensions. They suggest that governance of health aid in Viet Nam is characterised by multiple, overlapping 'policy networks' which cut across the traditional donor-government divide. The principles of aid effectiveness make sense for some of these communities, but for others they are irrational and may lead to a loss of influence and resources. However, sustained engagement combined with the building of strategic coalitions can overcome individual and institutional incentives. This article suggests that aid reform efforts should be understood not as a technocratic agenda but as a political process with all the associated tensions, perverse incentives and challenges. Partners thus need to recognise - and find new ways of making sense of - the complexity of forces affecting aid delivery.     

Player or referee? Aid effectiveness and the governance of health policy development: Lessons from Viet Nam

Viet Nam is one of the brightest stars in the constellation of developing countries. Its remarkable achievements in reducing poverty and improving health and education outcomes are well known, and as a result it has enjoyed generous aid programmes. Viet Nam also has a reputation for taking a strong lead in disciplining its donors and pushing for more efficient and effective forms of aid delivery, both at home and internationally.

This article discusses how efforts to improve the effectiveness of aid intersect with policy-making processes in the health sector. It presents a quantitative review of health aid flows in Viet Nam and a qualitative analysis of the aid environment using event analysis, participant observation and key informant interviews.

The analysis reveals a complex and dynamic web of incentives influencing the implementation of the aid effectiveness agenda in the health sector. There are contradictory forces within the Ministry of Health, within government as a whole, within the donor community and between donors and government. Analytical frameworks drawn from the study of policy networks and governance can help explain these tensions. They suggest that governance of health aid in Viet Nam is characterised by multiple, overlapping ‘policy networks’ which cut across the traditional donor–government divide. The principles of aid effectiveness make sense for some of these communities, but for others they are irrational and may lead to a loss of influence and resources. However, sustained engagement combined with the building of strategic coalitions can overcome individual and institutional incentives.

This article suggests that aid reform efforts should be understood not as a technocratic agenda but as a political process with all the associated tensions, perverse incentives and challenges. Partners thus need to recognise – and find new ways of making sense of – the complexity of forces affecting aid delivery.     

Aid coordination for health sector reform: a conceptual framework for analysis and assessment

Recent widespread interest in health sector policy and institutional reform in lower income countries has coincided with heightened concern for aid coordination. Because the health budgets of many low income countries are highly aid dependent, donors are strongly placed to make aid conditional on health care reforms. However, given the growing number and heterogeneity of multilateral, bilateral and international non-governmental donors operating in many of these countries, there is concern that if external efforts are not coordinated, the aims of health care reform--namely improving efficiency, effectiveness and equity--will not be met. Evidence is mounting that without effective coordination arrangements, donors may weaken rather than improve fragile health systems, undermining attempts to reform those systems. This paper traces the factors fuelling current interest in coordination, in particular with reference to its contribution to the goals of health sector reform. Aid coordination is defined and its principles elaborated. A framework is developed by which to assess the variety of coordination mechanisms which are evolving at the county level. In light of this framework, a case is made for greater and more critical analysis of aid coordination arrangements. The paper concludes that if health sector reform is to be successful in low income countries, current enthusiasm for coordination needs to be harnessed. The framework offered here provides a way of assessing the variety of coordination mechanisms currently proliferating, which could be used to enhance health sector reform.     

Has HIV/AIDS displaced other health funding priorities? Evidence from a new dataset of development aid for health

In recent times there has been a sense that HIV/AIDS control has been attracting a significantly larger portion of donor health funding to the extent that it crowds out funding for other health concerns. Although there is no doubt that HIV/AIDS has absorbed a large share of development assistance for health (DAH), whether HIV/AIDS is actually diverting funding away from other health concerns has yet to be analyzed fully. To fill this vacuum, this study aims to test if a higher level of HIV/AIDS funding is related to a displacement in funding for other health concerns, and if yes, to quantify the magnitude of the displacement effect. Specifically, we consider whether HIV/AIDS DAH has displaced i) TB, ii) malaria iii) health sector and 'other' DAH in terms of the dollar amount received for aid. We consider this question within a regression framework controlling for time and recipient heterogeneity. We find displacement effects for malaria and health sector funding but not TB. In particular, the displacement effect for malaria is large and worrying.     

Community learning disability teams: the need for objective methods of prioritization and discharge planning.

As part of caseload management for community learning disability teams (CLDTs), it would appear reasonable that services would have a mechanism for prioritizing referrals and discharge planning. However, any formal mechanism in relation to these two aspects apparently is lacking within the literature. This theoretical article attempts to illustrate this evidence-base need, and demonstrate how a prioritization and/or discharge planning system would aid CLDTs. In light of the scarcity of material for the learning disability sector, information has been examined from other health domains such as mental health. The paper also presents a discussion on whether rationing of services is best done via explicit or implicit means. Issues related to setting referral criteria and the allocation of referrals are also considered. Although suggestions have been made for CLDTs, it is difficult to do so whilst the evidence base for this sector is so lacking.     

A potential role of anti-poverty programs in health promotion

Poverty is one of the most pervasive risk factors underlying poor health, but is rarely targeted to improve health. Research on the effects of anti-poverty interventions on health has been limited, at least in part because funding for that research has been limited. Anti-poverty programs have been applied on a large scale, frequently by governments, but without systematic development and cumulative programmatic experimental studies. Anti-poverty programs that produce lasting effects on poverty have not been developed. Before evaluating the effect of anti-poverty programs on health, programs must be developed that can reduce poverty consistently. Anti-poverty programs require systematic development and cumulative programmatic scientific evaluation. Research on the therapeutic workplace could provide a model for that research and an adaptation of the therapeutic workplace could serve as a foundation of a comprehensive anti-poverty program. Once effective anti-poverty programs are developed, future research could determine if those programs improve health in addition to increasing income. The potential personal, health and economic benefits of effective anti-poverty programs could be substantial, and could justify the major efforts and expenses that would be required to support systematic research to develop such programs.