117 CHAPTER SIX how is the Public nterest protected? Governments should be the"stewards"of theirnational resources, maintaining and improving them for the benefit of their populations. In health, this means being ultimately responsible for the careful management of their citizens well- being. Stewardship in health is the very essence of good gouernment. For every country it means establishing the best and fairest health system possible. The health of the people must always be a national priority: govemment responsi bility for it is continuous and permanent. Ministries of health must take on a large part of the stewardship of health systems Health policy and strategies need to cover the private provision of services and private financing, as well as state funding and activities. Only in this way can health systems as a whole be oriented towards achieving goals that are in the public interest. Stewardship encompasses the tasks of defining the vision and direction of health policy, exerting influence through regulation and aduo. cacy,and collecting and using information. At the international level, steward ship means influencing global research and production to meet health goals. It also means providing an evidence base to guide countries'efforts to improve the performance of their health systems
How is the Public Interest Protected? 117 CHAPTER SIX ow is the ublic nterest rotected? Governments should be the “stewards” of their national resources, maintaining and improving them for the benefit of their populations. In health, this means being ultimately responsible for the careful management of their citizens’ wellbeing. Stewardship in health is the very essence of good government. For every country it means establishing the best and fairest health system possible. The health of the people must always be a national priority: government responsibility for it is continuous and permanent. Ministries of health must take on a large part of the stewardship of health systems. Health policy and strategies need to cover the private provision of services and private financing, as well as state funding and activities. Only in this way can health systems as a whole be oriented towards achieving goals that are in the public interest. Stewardship encompasses the tasks of defining the vision and direction of health policy, exerting influence through regulation and advocacy, and collecting and using information. At the international level, stewardship means influencing global research and production to meet health goals. It also means providing an evidence base to guide countries’ efforts to improve the performance of their health systems. 117
HOW IS THE PUBLIC INTEREST PROTECTED? GOVERNMENTS AS STEWARDS OF HEALTH RESOURCES tewardship is the last of the four health systems functions examined in this report, nd it is arguably the most important. It ranks above and differs from the others service delivery, input production, and financing -for one outstanding reason: the ultimate responsibility for the overall performance of a countrys health system must always lie with government Stewardship not only influences the other functions, it makes possible the attainment of each health system goal: improving health, responding to the legitimate expectations of the population, and fairness of contribution. The government must ensure that stewardship percolates through all levels of the health system in order to maximize that attainment Stewardship has recently been defined as a"function of a government responsible for the welfare of the population, and concerned about the trust and legitimacy with which its activities are viewed by the citizenry"(1). It requires vision, intelligence and influence, pri marily by the health ministry, which must oversee and guide the working and develop ment of the nations health actions on the governments behalf. Much of this chapter, therefore, addresses the ministrys role. Some aspects of stewardship in health must be assumed by government as a whole Affecting the behaviour of health actors in other sectors of the economy, or ensuring the right size and skill mix of the human resources produced for the health system, may be beyond the ministrys reach. The government ought to ensure coherence and consistency across departments and sectors, where necessary by an overall reform of public administra Outside of government, stewardship is also a responsibility for purchasers and provid ers of health services who must ensure that as much health as possible results from their spending. And stewardship in health has an international dimension, relating to extemal But government remains the prime mover. Today in most countries the role of the state in relation to health is changing People,s expectations of health systems are greater than ever before, yet limits exist on what governments can finance and on what services they can deliver. Governments cannot stand still in the face of rising demands. They face complex dilemmas in deciding in which direction to move: they cannot do everything. But in terms of effective stewardship, their key role is one of oversight and trusteeship -to follow the advice of“ row less and steer more"”(2,3)
How is the Public Interest Protected? 119 6 HOW IS THE PUBLIC INTEREST PROTECTED? GOVERNMENTS AS STEWARDS OF HEALTH RESOURCES tewardship is the last of the four health systems functions examined in this report, and it is arguably the most important. It ranks above and differs from the others – service delivery, input production, and financing – for one outstanding reason: the ultimate responsibility for the overall performance of a country’s health system must always lie with government. Stewardship not only influences the other functions, it makes possible the attainment of each health system goal: improving health, responding to the legitimate expectations of the population, and fairness of contribution. The government must ensure that stewardship percolates through all levels of the health system in order to maximize that attainment. Stewardship has recently been defined as a “function of a government responsible for the welfare of the population, and concerned about the trust and legitimacy with which its activities are viewed by the citizenry” (1). It requires vision, intelligence and influence, primarily by the health ministry, which must oversee and guide the working and development of the nation’s health actions on the government’s behalf. Much of this chapter, therefore, addresses the ministry’s role. Some aspects of stewardship in health must be assumed by government as a whole. Affecting the behaviour of health actors in other sectors of the economy, or ensuring the right size and skill mix of the human resources produced for the health system, may be beyond the ministry’s reach. The government ought to ensure coherence and consistency across departments and sectors, where necessary by an overall reform of public administration. Outside of government, stewardship is also a responsibility for purchasers and providers of health services who must ensure that as much health as possible results from their spending. And stewardship in health has an international dimension, relating to external assistance. But government remains the prime mover. Today in most countries the role of the state in relation to health is changing. People’s expectations of health systems are greater than ever before, yet limits exist on what governments can finance and on what services they can deliver. Governments cannot stand still in the face of rising demands. They face complex dilemmas in deciding in which direction to move: they cannot do everything. But in terms of effective stewardship, their key role is one of oversight and trusteeship – to follow the advice of “row less and steer more”(2, 3)
120 The World Health Report 2000 Stewardship has major shortcomings everywhere. This chapter examines some of them, then discusses important stewardship tasks. It considers the main protagonists involved, and strategies for implementing stewardship in different national settings. Finally, it brings together some of the messages from preceding chapters on policy directions for better- functioning health systems. WHAT IS WRONG WITH STEWARDSHIP TODAY? Ministries of health in low and middle income countries have a reputation for being among the most bureaucratic and least effectively managed institutions in the public sec tor. Designed and initiated in the early 20th century and given wide responsibility for fi nancing and operating extensive public hospital and primary care systems in the post-war period, they became large centralized and hierarchical public bureaucracies, with cumber some and detailed administrative rules and a permanent staff with secure civil service pro- tections. The ministries were fragmented by many vertical programmes which were often run as virtual fiefdoms, dependent on uncertain international donor funding"(4) The problems described above are familiar, in greater or lesser degree, in many coun ies today. The consequences are easy to see, but it is not always easy to see why the problems occur or how to solve them. Often that is because the stewards of health suffer Health ministries often suffer from myopia. Because they are seriously short-sighted, ministries sometimes lose sight of their most important target: the population at large Patients and consumers may only come into view when rising public dissatisfaction forces them to the ministrys attention. In addition, myopic ministries recognize only the closest actors in the health field, but not necessarily the most important ones, who may be in the middle or far distance Ministries deal extensively with a multitude of public sector individuals and organiza- Ofte P tovidinghealth services, many of which may be directly funded by the ministry itself. Often, this involvement means intensive professional supervision and guidance. But some times just beyond their field of vision lie at least two other groups with a major role to play in the health system: nongovemmental providers, and health actors in sectors other than health In their size and potential impact on achieving health goals, these little recognized indi- viduals and organizations may be more important than the public resources directed through the health ministry. Yet information about them may be scant, and a policy approach to- wards them is often lacking In Myanmar, Nigeria(5), or Viet Nam, for example, privately financed and provided medical care is three or four times as big in expenditure terms, as spending on public services. But the many different types of private providers in these countries are barely recognized in legislation and regulatic Some large health insurance schemes in India currently have no legal status(6). In Et rope and the Americas, road traffic accidents rank fourth in the total burden of disease.Yet the main involvement of the health ministry is often as a steward of accident and emer gency services, not as a force for prevention Services funded from public sources are ob onsibility of government. But private finance and the provision of all he actions clearly need to be within the focus of government as overall steward of the public ministries are also myopic in the sense that their vision does not extend far enough into the future Investment decisions new buildings, equipment and vehicles frequently
120 The World Health Report 2000 Stewardship has major shortcomings everywhere. This chapter examines some of them, then discusses important stewardship tasks. It considers the main protagonists involved, and strategies for implementing stewardship in different national settings. Finally, it brings together some of the messages from preceding chapters on policy directions for betterfunctioning health systems. WHAT IS WRONG WITH STEWARDSHIP TODAY? “Ministries of health in low and middle income countries have a reputation for being among the most bureaucratic and least effectively managed institutions in the public sector. Designed and initiated in the early 20th century and given wide responsibility for financing and operating extensive public hospital and primary care systems in the post-war period, they became large centralized and hierarchical public bureaucracies, with cumbersome and detailed administrative rules and a permanent staff with secure civil service protections. The ministries were fragmented by many vertical programmes which were often run as virtual fiefdoms, dependent on uncertain international donor funding”(4). The problems described above are familiar, in greater or lesser degree, in many countries today. The consequences are easy to see, but it is not always easy to see why the problems occur or how to solve them. Often that is because the stewards of health suffer specific visual impairments. Health ministries often suffer from myopia. Because they are seriously short-sighted, ministries sometimes lose sight of their most important target: the population at large. Patients and consumers may only come into view when rising public dissatisfaction forces them to the ministry’s attention. In addition, myopic ministries recognize only the closest actors in the health field, but not necessarily the most important ones, who may be in the middle or far distance. Ministries deal extensively with a multitude of public sector individuals and organizations providing health services, many of which may be directly funded by the ministry itself. Often, this involvement means intensive professional supervision and guidance. But sometimes just beyond their field of vision lie at least two other groups with a major role to play in the health system: nongovernmental providers, and health actors in sectors other than health. In their size and potential impact on achieving health goals, these little recognized individuals and organizations may be more important than the public resources directed through the health ministry. Yet information about them may be scant, and a policy approach towards them is often lacking. In Myanmar, Nigeria (5), or Viet Nam, for example, privately financed and provided medical care is three or four times as big, in expenditure terms, as spending on public services. But the many different types of private providers in these countries are barely recognized in legislation and regulation. Some large health insurance schemes in India currently have no legal status (6). In Europe and the Americas, road traffic accidents rank fourth in the total burden of disease. Yet the main involvement of the health ministry is often as a steward of accident and emergency services, not as a force for prevention. Services funded from public sources are obviously the responsibility of government. But private finance and the provision of all health actions clearly need to be within the focus of government as overall steward of the public interest. Ministries are also myopic in the sense that their vision does not extend far enough into the future. Investment decisions – new buildings, equipment and vehicles – frequently
How is the public Interest protected? occupy the foreground, while the severe and chronic need to improve the balance between investment and recurrent funding fades into the hazy distance Tunnel vision in stewardship takes the form of an exclusive focus on legislation and the issuing of regulations, decrees, and public orders as means of health policy. Explicit, written rules have an important role to play in the performance of the stewardship function. But formulating regulations is relatively easy and inexpensive. It is also often ineffective, with ministries lacking the capacity to monitor compliance: there are seldom enough public health inspectors to visit all food shops and eating places or enough occupational safety inspectors to visit all factories regularly On the rare occasions when sanctions are invoked they are too mild to discourage illegal practices or to affect widespread disregard of regula tions Good stewardship needs the support of several strategies to influence the behaviour of the different stakeholders in the health system. Among these are a better information bas the ability to build coalitions of support from different groups, and the ability to set incer tives, either directly or in organizational design. As authority becomes devolved, delegated and decentralized to a wide range of stakeholders in the health system, the repertoire of stewardship strategies needs to move away from dependence on"command and control systems towards ensuring a cohesive framework of incentives Health ministries sometimes turn a blind eye to the evasion of regulations which they themselves have created or are supposed to implement in the public interest. A widespread example is the condoning of illicit fee collecting by public employees, euphemistically known as"informal charging". A recent study in Bangladesh found that unofficial fee payments were 12 times greater than official payment (7). Paying bribes for treatment in Poland is cited as a common infringement of patients'rights(8). Though such corruption materially benefits a number of health workers, it deters poor people from using services they need, making health financing more unfair, and it distorts overall health priorities In turming a blind eye, stewardship is subverted; trusteeship is abandoned and institu- tional corruption sets in. A blind eye is often turned when the public interest is threatened in other ways. For instance, doctors can remain silent through misplaced professional loy alty in the face of incompetent and unsafe medical practice by colleagues. A 1999 US study commented"whether care is preventive, acute or chronic, it frequently does not meet pro- Box 6.1 Trends in national health policy: from plans to frameworks National health policy docu- nancial realities and people's pref- economic transition, revised its 1991 nancing and provision ments have a long history, predat- erences Implementation problems policy in 1996 and again in 1998.. identifies policy instruments g but stimulated by international were common A shift is now occurring towards and organizational arrange- concern for promoting primary By no means all countries have more inclusive- but less detailed ments required in both the health care. In many centrally formal national health policies: policy frameworks mapping the di- public and private sectors to planned and developing econo- France, Switzerland, and the United rection but not spelling out the op- meet system objectives: mies, health policies were part of States do not; Tunisia has no formal erational detail, as in Ghana and sets the agenda for capacity a national development plan, with single national policy document; the Kenya building and organizational de- focus on investment needs. UK produced its first formal docu- A national health policy frame- velopment Some health policy documents des guidance for priori programme-specific plans. They whether there are fimo ends on identifies objectives and ad- zing expenditure, thus linking only a collection of project or The lifespan of a policy dep mental dresses major policy issues analysis of problems to deci- ignored the private sector and of- changes to the agenda: India is still defines respective roles of the sions about resource allocation. ten took inadequate account of fi- using its 1983 plan; Mongolia, in public and private sectors in fi- Cassels A. A guide to sector-wide approaches for health development. Geneva, World Health Organization/DANIDA/DFID/European Commission, 1997(unpublished document WHO/ARA/97. 12)
How is the Public Interest Protected? 121 occupy the foreground, while the severe and chronic need to improve the balance between investment and recurrent funding fades into the hazy distance. Tunnel vision in stewardship takes the form of an exclusive focus on legislation and the issuing of regulations, decrees, and public orders as means of health policy. Explicit, written rules have an important role to play in the performance of the stewardship function. But formulating regulations is relatively easy and inexpensive. It is also often ineffective, with ministries lacking the capacity to monitor compliance: there are seldom enough public health inspectors to visit all food shops and eating places or enough occupational safety inspectors to visit all factories regularly. On the rare occasions when sanctions are invoked they are too mild to discourage illegal practices or to affect widespread disregard of regulations. Good stewardship needs the support of several strategies to influence the behaviour of the different stakeholders in the health system. Among these are a better information base, the ability to build coalitions of support from different groups, and the ability to set incentives, either directly or in organizational design. As authority becomes devolved, delegated and decentralized to a wide range of stakeholders in the health system, the repertoire of stewardship strategies needs to move away from dependence on “command and control” systems towards ensuring a cohesive framework of incentives. Health ministries sometimes turn a blind eye to the evasion of regulations which they themselves have created or are supposed to implement in the public interest. A widespread example is the condoning of illicit fee collecting by public employees, euphemistically known as “informal charging”. A recent study in Bangladesh found that unofficial fee payments were 12 times greater than official payment (7). Paying bribes for treatment in Poland is cited as a common infringement of patients’ rights (8). Though such corruption materially benefits a number of health workers, it deters poor people from using services they need, making health financing more unfair, and it distorts overall health priorities. In turning a blind eye, stewardship is subverted; trusteeship is abandoned and institutional corruption sets in. A blind eye is often turned when the public interest is threatened in other ways. For instance, doctors can remain silent through misplaced professional loyalty in the face of incompetent and unsafe medical practice by colleagues. A 1999 US study commented “whether care is preventive, acute or chronic, it frequently does not meet proBox 6.1 Trends in national health policy: from plans to frameworks National health policy documents have a long history, predating but stimulated by international concern for promoting primary health care. In many centrally planned and developing economies, health policies were part of a national development plan, with a focus on investment needs. Some health policy documents were only a collection of project or programme-specific plans. They ignored the private sector and often took inadequate account of financial realities and people’s preferences. Implementation problems were common. By no means all countries have formal national health policies: France, Switzerland, and the United States do not; Tunisia has no formal single national policy document; the UK produced its first formal document in the 1990s, Portugal in 1998. The lifespan of a policy depends on whether there are fundamental changes to the agenda: India is still using its 1983 plan; Mongolia, in economic transition, revised its 1991 policy in 1996 and again in 1998. A shift is now occurring towards more inclusive – but less detailed – policy frameworks mapping the direction but not spelling out the operational detail, as in Ghana and Kenya. A national health policy framework:1 • identifies objectives and addresses major policy issues; • defines respective roles of the public and private sectors in financing and provision; • identifies policy instruments and organizational arrangements required in both the public and private sectors to meet system objectives; • sets the agenda for capacity building and organizational development; • provides guidance for prioritizing expenditure, thus linking analysis of problems to decisions about resource allocation. 1 Cassels A. A guide to sector-wide approaches for health development. Geneva, World Health Organization/DANIDA/DFID/European Commission, 1997 (unpublished document WHO/ARA/97.12)
The World Health Report fessional standards"(9). Ensuring probity in decisions on capital projects and other large purchasing decisions(equipment, pharmaceutical orders), where corruption may be par- Some recent developments create opportunities for better vision and more innovative stewardship. Greater autonomy in decisions relating to purchasing and service provision, example, shifts some responsibility away from central or local government. But it creates new tasks for government in overseeing that both purchasing and provision are carried out in accordance with overall policy. Accumulated experience of practices such as contracting is now available(10) and rapid technological advances enable the fast, inexpensive han- ding of huge amounts of information, thus making it easier in principle for stewards to visualize the whole health system. The notion of stewardship over all health actors and actions deserves renewed empha sis. Much conceptual and practical discussion is needed to improve the definition and meas- urement of how well stewardship is actually implemented in different settings But sev formulating health policy -defining the vision and direction, exerting influence-approaches to regulatic ing and using intelligence These tasks are discussed below HEALTH POLICY VISION FOR THE FUTURE An explicit health policy achieves several things: it defines a vision for the future which in turn helps establish benchmarks for the short and medium term. It outlines priorities and the expected roles of different groups. It builds consensus and informs people, and in doing so fulfils an important role of governance. The tasks of formulating and implement ing health policy clearly fall to the health ministry ome countries appear to have issued no national health policy statement in the last decade; in others, policy exists in the form of documents which gather dust and are never translated into action. Too often, health policy and strategic planning have envisaged unre Box 6.2 Ghana's medium-term health policy framework Forging linkages between private effective use of all available re- process of consultation, the follow- and public providers of health care logistics such as drugs sources from government, g strategies were identified as to ensure consensus and that all her consumables, equip- nongovernmental organiza- providing the means to better per- resources are focused on a com- ment, and vehicles at all levels of tions, and private, mission and formance in health the health system donor sources. Ways of mobilize Re-prioritization of health serv-.Expansion and rehabilitation of Strengthening the monitoring ing additional resources with a res to ensure that primary health infrastructure to increase and regulatory systems withi ealth care services(i.e. services coverage and improve quality the health service to ensure more ore accessible and affordable with maximum benefits in terms Strengthening human resource effective implementation of pro- will also be explor of morbidity and mortality re- Promoting intersectoral action uction) receive more empha ing as a means of providing and for health development, par retaining adequate numbers of communities to take more re- ticularly in the areas of food and The strengthening and decen- good quality and well-motivated sponsibility for their health nutrition, employment, educa- tralization of management health teams to provide the serv- .Improving the financing of health tion, water and sanitation within the context of a national ices care by ensuring the efficient and Source: Medium-term health strategy towards vision 2020 Republic of Ghana Accra, Ministry of Health, 1995
122 The World Health Report 2000 Box 6.2 Ghana’s medium-term health policy framework In Ghana, after an extensive process of consultation, the following strategies were identified as providing the means to better performance in health. • Re-prioritization of health services to ensure that primary health care services (i.e. services with maximum benefits in terms of morbidity and mortality reduction) receive more emphasis in resource allocation. • The strengthening and decentralization of management within the context of a national health service. • Forging linkages between private and public providers of health care to ensure consensus and that all resources are focused on a common strategy. • Expansion and rehabilitation of health infrastructure to increase coverage and improve quality. • Strengthening human resource planning, management and training as a means of providing and retaining adequate numbers of good quality and well-motivated health teams to provide the services. • Provision and management of adequate logistics such as drugs and other consumables, equipment, and vehicles at all levels of the health system. • Strengthening the monitoring and regulatory systems within the health service to ensure more effective implementation of programmes. • Empowering households and communities to take more responsibility for their health. • Improving the financing of health care by ensuring the efficient and effective use of all available resources from government, nongovernmental organizations, and private, mission and donor sources. Ways of mobilizing additional resources with a view to making the services more accessible and affordable will also be explored. • Promoting intersectoral action for health development, particularly in the areas of food and nutrition, employment, education, water and sanitation. Source: Medium-term health strategy: towards vision 2020 Republic of Ghana. Accra, Ministry of Health, 1995. fessional standards” (9). Ensuring probity in decisions on capital projects and other large purchasing decisions (equipment, pharmaceutical orders), where corruption may be particularly lucrative, is another frequent challenge to good stewardship. Some recent developments create opportunities for better vision and more innovative stewardship. Greater autonomy in decisions relating to purchasing and service provision, for example, shifts some responsibility away from central or local government. But it creates new tasks for government in overseeing that both purchasing and provision are carried out in accordance with overall policy. Accumulated experience of practices such as contracting is now available (10) and rapid technological advances enable the fast, inexpensive handling of huge amounts of information, thus making it easier in principle for stewards to visualize the whole health system. The notion of stewardship over all health actors and actions deserves renewed emphasis. Much conceptual and practical discussion is needed to improve the definition and measurement of how well stewardship is actually implemented in different settings. But several basic tasks can already be identified: • formulating health policy – defining the vision and direction; • exerting influence – approaches to regulation; • collecting and using intelligence. These tasks are discussed below. HEALTH POLICY – VISION FOR THE FUTURE An explicit health policy achieves several things: it defines a vision for the future which in turn helps establish benchmarks for the short and medium term. It outlines priorities and the expected roles of different groups. It builds consensus and informs people, and in doing so fulfils an important role of governance. The tasks of formulating and implementing health policy clearly fall to the health ministry. Some countries appear to have issued no national health policy statement in the last decade; in others, policy exists in the form of documents which gather dust and are never translated into action. Too often, health policy and strategic planning have envisaged unre-