Author: UNICEF NYHQ
During much of the 1980s and 1990s, health systems in many developing countries were under severe stress. In response, a number of countries embarked on efforts to reform and revitalize their health sectors. Though the individual technical components of these efforts have been widely studied, insufficient attention has been paid to understanding the overall process of reform -- how large-scale, system-wide changes were initiated and developed, and what approaches and strategies were used in practice.
Purpose / Objective
This report is directed at identifying the range of policy and implementation processes and strategies that have been used in a variety of country contexts. The report uses the experiences of these countries to understand how they initiated a programme of change at the national level and, relatedly, to identify lessons that can benefit all those who are involved in health sector reform. The report, however, is neither an evaluation of the success or impact of the reforms nor a description of an 'optimal' approach to reform.
The primary source of material for this report is the eight country case studies that were carried out from 1995 to 1997: Benin, Cameroon, Congo, Guinea, Mali, Mauritania, Senegal and Zambia. The eight countries were selected according to whether they had undertaken a nationwide programme of health sector revitalization or health reform. The country case studies were designed to primarily use qualitative research methods, including a desk review of existing literature and key informant interviews at various levels.
Key Findings and Conclusions
In bringing about system-wide changes, leadership is of crucial importance at both political and technical levels. Leaders need to be willing to take risks, to be able to recognize opportunities and to seize them, and to be skilled at compromise when it is needed to keep the reforms moving. They need to be able to articulate a mobilizing vision and to ensure a degree of coherence in what can be a tumultuous process, subject to political shocks and unanticipated obstacles.
At a technical level, leadership in the implementation of reform generally centres on a committed team of professionals, which very often operates as an ad hoc group especially in the early stages. Institutionalization of the reforms involves expanding this team and extending responsibilities to others, and eventually these ad hoc structures are formalized, often as part of a reorganization of the Ministry of Health (MOH). Key members of the implementation teams are often involved in the formulation of the reform policy, the design of implementation plans and strategies and the field follow-up to ensure start-up activities in the field. This type of involvement in all the key stages helps improve the quality of implementation through learning by doing, and also motivates the central team, and, by extension, their local-level counterparts.
In many countries, a particular idea or tool became a focal point for reform activities and was used to build alliances and to develop the confidence and skills of the promoters of change. Establishing an environment that encourages positive emulation and competition was an important means of stimulating implementation teams to learn from experience.
Typically, health sector reforms require skills not traditionally found in health ministries, such as economics, accounting, human resources management and community organization. A mix of short- and long-term strategies were used to meet these needs, including building MOH capacity directly, as well as collaborating with other institutions that could provide these skills.
New approaches to the training of health workers were developed in some countries, using experienced health personnel as resource persons for the development of materials and the conduct of training. Other approaches adopted included multi-skill training teams, on-the-job training and 'placement' schemes and regional exchanges for health workers and community committees.
Effective communication of the new policies to health sector staff and to the public has smoothed the process of implementation and ensured support at all levels. This was not, however, always given sufficient attention as the reform process progressed. New strategies for communicating were developed in a number of these countries. Building partnerships with the non-government sector and with local government has been a strategy in several countries.
'Going to scale' is a critical step in the implementation process. Strategies must be adapted, management tools simplified, and approaches harmonized. New skills (particularly facilitation, negotiation and compromise) are needed. Most of the experience has been in rural areas and small towns. Strategies have to be adapted to the very different conditions that prevail in large urban areas. The case studies describe a range of expansion strategies in these countries.
Moreover, the pace of expansion has varied, depending on the availability of internal and external resources, local capacity and the need to work at the speed of the community and 3 pressure from government and donors. Most of these countries used some form of phased geographic expansion. Zambia was a marked exception, beginning with nationwide implementation of certain reforms in all districts, but then taking longer to extend the reform to other aspects, such as staffing, where more preparation was needed.
Health sector reform is a political process. Health sector reform involves changing the prevailing patterns of authority and power. Though reforms can be initiated by a core group, support for these reforms has to be expanded. It is only when there is a broad base of support for the reforms that they can be successfully implemented and sustained. Moreover, the reform landscape is made up of many stakeholders involved in the process, whose roles may change over time -- at different times they will play the role of leaders, supporters of change or obstructors. Managers of reform must know the stakeholders and their positions, and develop strategies to build supportive alliances and to overcome resistance.
The context matters. Events outside the health sector can affect the reform process. They can either constrain possible actions or provide new opportunities. Although these factors are beyond the control of the managers of a reform process, reform managers need to be aware of the risks and opportunities that may develop.
The process of reform has tended to be incremental, non-linear and long-term. Reformers need to recognize the implications of these characteristics of the reform process and to structure their strategies accordingly. They should note the following:
- A clear vision is required to guide the process, particularly when reforms are taking
place on many fronts or when obstacles are encountered.
- Strategies must be flexible and adaptive, and they must be able to seize opportunities when they arise.
- Coordination and dialogue mechanisms should be established with their partners.
- The central level, usually together with donors, needs to support and nurture the reform process over an extended period of time.
Certain components of reform are critical. While all elements of reform cannot be in place at the beginning and there is no 'best' order for implementing the various components, the experiences of these eight countries show that certain programme elements -- drugs, legislation and regulation, community participation and staff motivation -- requires particularly close attention.
Donors have played an important role. Donors' contributions in finance, in concepts and in technical support have been significant. While some of their support is directly focused on the reforms, some is the result of past investments. However, donor actions can also obstruct reform. To make their assistance more effective in the future, donor agencies need to better understand the positive and negative impact they have on reform efforts.
A number of other problems, including equity and drug management, remain unresolved. Some of these are longstanding issues that have persisted despite considerable effort. Others have emerged as programmes mature. Reforms will be successful to the extent that they can respond to and overcome new challenges: Flexibility and adaptability are therefore vital.
Agencies need to adopt a more tolerant attitude towards initiatives that seem risky or uncertain. Because changes tend to be incremental, agencies need to be more flexible and to respond quickly to constraints and to changes in the external environment.
National ownership is only possible where agencies relinquish the driver's seat.
Donor support should focus on critical programme elements, such as regular drug supplies, development of the institutional framework, management information systems, social mobilization and community participation, and staff management and motivation.
Reforms create needs for new skills among both agency staff and government partners. The political nature of the process requires capacity in policy analysis, mapping, negotiation and building consensus. The content of the reforms generates needs in areas such as health economics, management and logistics, accounting, community development and personnel management. Careful thought must be given to how best to fulfil these staffing and training needs, both in ministries and in donor agencies.
Greater donor coordination will aid health reform efforts. Donors should seek ways to ensure both consistency and continuity in policy advice to governments. In addition, coordination of procedures in cases such as programme monitoring and reporting, and procurement, can improve the efficiency and effectiveness of resource management. Coordinating implementation can also help ensure that lessons about 'best practice' are learned and adopted quickly.
A broader range of national partners will be needed to implement health sector reforms, including other government departments, universities, non-governmental organizations (NGOs) and even local consulting firms.
Greater emphasis should be placed on promoting and learning from small-scale projects in the health sector. Agencies should provide greater support to promising initiatives and research, as well as for synthesizing and adapting experiences, to make them relevant to national circumstances.
To learn more about how countries managed and implemented reform, agencies should give greater support to documenting the reform process. This may include support for the development of policy analysis skills, such as qualitative research methods, and for institutional linkages with appropriate research centres to provide an environment in which this reflection on the implementation process can take place.
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