Catalog

	Table of Contents
p. 18 of 27 BACK | NEXT Executive summary Introduction Regional health context The Bank’s involvementin the health sector Issues and options The health of the poor, women, and indigenous peoples Setting clear priorities Mobilizing resources for the public health sector Building managerial capacity Testing innovative approaches Introducing effective, new, and affordable technologies Focusing on functions which constitute public goods Increasing collaboration between public and private sectors The Bank’s health policy

Policy for the Health Sector : Issues and options

---

Building managerial capacity

Even with carefully selected priorities and sufficient resources, achieving results will require strong management. There is a broad consensus that a shortage of management capacity within DMC ministries of health has impeded the development of effective and efficient health care systems. Efforts to build such capacity need to differentiate between the two broad functions of the public sector: (i) service provision; and (ii) policy development, financing, regulation, monitoring, and evaluation. Analyzing the capacities of government institutions to carry out these two functions will be critical to successful management strengthening activities.

Strengthening the management of service delivery

Previous capacity-building activities have focused primarily on the service delivery function and have generally been limited to the provision of training. While training may be vital, its effectiveness has not often been evaluated. More importantly, the training activities do not address a fundamental problem. Ministries of health and the individual managers within them are rarely held accountable for the results of their efforts. There are few rewards for success, almost no sanctions for poor performance, and little incentive to increase efficiency. In this context, DMC governments need to ask fundamental questions about how they can modify incentive structures.

Improving the management of publicly financed health care delivery systems will require (i) consideration of innovative approaches that can increase accountability; (ii) the application of modern management techniques for particular functions such as supervision and logistics; and (iii) careful monitoring of the quantity and quality of services delivered. Increasing the responsiveness and accountability of the health system will require new organizational arrangements and approaches to management. Purchasing health or ancillary services from the private sector through contracting or other mechanisms may provide DMC governments with a means to increase efficiency and needs to be explored more widely. Granting greater managerial autonomy to staff closer to the actual site of service delivery will improve services as long as clear accountability for achieving results is assured. Another possible approach to improving management is the more widespread use of performance-based incentives. While these innovative approaches are currently being tested, there are a number of management techniques needed at the periphery that have already demonstrated their effectiveness. For example, a study in the Philippines demonstrated large benefits from regular and systematic supervision, and modern logistics management can improve the availability of drugs and supplies.

Regardless of who is responsible for their delivery, ensuring that services are being adequately provided at the periphery constitutes the bottom line for capacity strengthening activities. Hence, it is critical to assess the quantity and quality of health services. This can be done through the strengthening of management information systems by conducting health facility surveys, small household surveys, consultations with clients about their level of satisfaction, and diseases surveillance. Health facility surveys involve sampling relatively small numbers of peripheral facilities (typically 40 to 100) and collecting data on the availability of skilled staff, drugs and supplies, operating funds, adequate records, regular supervision, and other aspects of quality of care. Small household cluster surveys, typically involving a few hundred respondents provide crucial data on the quantity (coverage) of health services being provided. Client satisfaction surveys and focus group discussions are also vital to ensure that services are responsive to the needs of the community. Disease surveillance is required to provide policy makers and managers with usable information about patterns of disease occurrence.

Strengthening capacity in policy development, financing, regulation, monitoring, and evaluation

The capacity of DMC ministries of health to carry out the “steering” functions needs to be strengthened. Despite recent efforts to improve policy formulation, many ministries do not have the resources to analyze health sector needs. Many have not dealt with issues like decentralization or rationalization of the public health care system. A related problem is that most ministries of health do an inadequate job of assessing expenditures in the health sector, leaving managers at all levels with little accurate information about costs and the availability of resources. Evaluation of health care system performance is another role that DMC governments have had difficulty with. The reasons for the poor performance of these functions vary from country to country but often include (i) lack of attention from senior officials; (ii) shortage of personnel with specialist skills in these areas because many managers are doctors with only clinical training; and (iii) inadequate systems and structures for carrying out these functions.

Back Mobilizing resources for the public health sector	Next Testing innovative approaches