Analysing Disrupted Health Sectors by malj


									Supporting the Recovery of the Iraq Health Sector
A preliminary exercise of mapping key issues, constraints, policy options, lessons learned and urgent steps for health reconstruction

                                                                                          Policy options (not             Relevant experiences
                                                                                                                                                      Urgent measures to be
  Area / Issue               Situation                         Remarks                     always mutually               from other countries in
                                                                                                                                                      taken until end of 2004
                                                                                              exclusive)                       transition
 Policy              No overarching policy             strong                          adopt a modest,                 radical sector reforms        the improvement of
 formulation          documents available,               political/ideological            incremental approach             stand little chance of         the information basis
                      beside the statement of            control exerted by the           to policy formulation:           success during or in the       and analysis in
                      the right to health of all         central government on                strengthen the              aftermath of a serious         priority areas
                      citizens stated in the             the policy-making                     information basis           crisis: weak sectors do        (financing, network,
                      Constitutions                      process                               and the capacity of         not cope well with             HR, drugs, etc) is the
                     progressive legalisation of       the poor information                  analysis before             shock treatments. At           first step. Studies
                      private practice and               basis is the main                     addressing                  the same time, post-           should be
                      introduction of user-fees in       constraint to rational,               systemic policy             conflict openness to           commissioned to
                      the late 1990s, reflecting         evidence-based policy                 issues                      change offers                  address the main
                      reduced revenues and low           formulation                          establish a
                                                                                                                           opportunities to               information gaps
                      priority in resource              the lack of participation             genuinely inclusive
                                                                                                                           introduce structural          set up / strengthen (if
                      allocation to social sectors                                                                         reforms                        already in place) a
                                                         of stakeholders has                   discussion forum to
                     priority access of elites          created a culture of                  review problems            Kosovo is the only             central policy unit with
                      and the military to health         passive acceptance of                 and policy options          post-conflict example of       adequate skills and
                                                                                                                           ‘big bang’ approach
                      care represented the pillar        central guidelines; re-              identify priority
                      of unwritten policies              activation of capacity of             areas where there
                                                                                                                           (under much more              invest in competency
                     resource allocation                analysis and decision will            is sufficient
                                                                                                                           favourable conditions).
                                                                                                                           Results registered to
                                                                                                                                                          building in the area of
                      patterns reflected a soviet-       take long time                        evidence for policy                                        administration,
                      style, central planning           the OFFP's focus on                   decisions and
                                                                                                                           date are at best mixed         management,
                      model                              import of commodities                 resources for their        policy formulation is          planning, health
                     very poor information              strengthened the old bias             implementation              useless unless there is        economics
                      basis, aggravated by post-         towards hardware sector                                           capacity and                  share information
                                                         components and               Alternatively:                       willingness to                 widely among
                      war looting
                                                         centralised                     go for a
                                                                                                                           implement decisions            stakeholders, to
                                                         administration                   comprehensive and               a strongly politicised         encourage
                                                                                          radical, ‘big bang’              context can be                 participation, analysis
                                                                                          reform package                   conducive to                   and debate

       Draft – August 12 2003                                                                                                                                           1
                                                                                          Policy options (not              Relevant experiences
                                                                                                                                                         Urgent measures to be
 Area / Issue              Situation                          Remarks                      always mutually                from other countries in
                                                                                                                                                         taken until end of 2004
                                                                                              exclusive)                          transition
                                                                                                                             precipitous, ideological,
                                                                                                                             evidence-free decisions
Financing          the foreseeable financial          the estimated financing          maintain the present             restoring the pre-crisis        commission studies of
                    envelope might be in the            level could be adequate           health sector                     status quo is usually            health sector
                    range of $50-100 per                to cover recurrent                functioning and limit its         difficult or impossible          financing (formal and
                    capita in 2004; expected to         expenditure (ensuring             decline and de-                  the oil-induced                  informal)
                    increase quickly in the             the functioning of the            regulation, by allocating         perception of wealth            identify measures to
                    following years, as oil             sector in its current             adequate recurrent                and entitlement can              bring out into the
                    revenues grow                       status). The restructuring        financing                         encourage wrong                  open health care
                   the guess estimated                 of the sector (i.e.              invest substantially in           decisions, not only in           provision now under
                    private contribution to total       revamping the network,            restructuring the health          health (ex.: Angola)             ground
                    spending of 40% is rather           strengthening HRs, all
                                                        long-term investments)
                                                                                          sector, moving towards           to regulate a disrupted         advocate for restraint
                    large                                                                 PHC, diversification of           sector is intrinsically          in planning for
                   the current health sector
                                                        would require additional
                                                        financing, to be ensured
                                                                                          service provision,                difficult: sticks and            reconstruction:
                    seems to be inefficient                                               expanded access to                carrots must be used             available economic
                                                        by external assistance in         health care, etc
                    (hospital bias, low use,                                                                                simultaneously.                  forecasts point to
                    over-spending on drugs,
                                                        the short/mid-term and
                                                        by public sources
                                                                                         introduce / strengthen            Improved salaries will           modest improvements
                    oil-induced largesse, etc)                                            regulatory systems,               not correct informal             rather than booms in
                   there is a relatively strong
                                                       substantial efficiency
                                                                                          clarifying public and             privatisation without            the future
                    military health sector (31                                            private roles and                 associated adequate              performance of the
                                                        gains seem possible: to           partnerships                      sanctions                        economy
                    hospitals, unknown
                    number of health workers)
                                                        materialise this potential,
                                                        the radical re-structuring
                                                                                         integrate the military           imported blueprints             work out the financial
                    which integration into the                                            health sector into the            rarely thrive                    and organisational
                                                        of the sector is called for
                    public health sector (if                                              public health system                                               implications of
                    pursued) will need to be           private financing is              after an assessment of                                             radically restructuring
                    adequately reflected into           already considered                financial, organisational                                          the health sector
                    the budget                          substantial and unlikely
                                                        to grow as a share of
                                                                                          and HR development                                                identify existing
                                                                                          requirements                                                       inefficiencies and
                                                        total spending (due to
                                                                                                                                                             introduce temporary
                                                        cross-elasticity of
                                                                                                                                                             measures to address
                                                        demand in the presence
                                                                                                                                                             them (at least to
                                                        of improved public
                                                                                                                                                             some extent)
                                                        services). It should be

     Draft – August 12 2003                                                                                                                                                2
                                                                                              Policy options (not               Relevant experiences
                                                                                                                                                             Urgent measures to be
 Area / Issue                Situation                          Remarks                        always mutually                 from other countries in
                                                                                                                                                             taken until end of 2004
                                                                                                  exclusive)                         transition
                                                          regulated and captured                                                                                assess financial,
                                                          by national health                                                                                     organisational and
                                                          accounts                                                                                               HRD implications of
                                                                                                                                                                 integrating the military
                                                                                                                                                                 health sector into
                                                                                                                                                                 public health care
Infrastructures      reportedly hospital-               aggregate figures                  pending the formulation           uncoordinated                  to validate and
                      oriented, derelict, old;            suggest that                        of an investment plan,             rehabilitation tends to         expand the WHO
                     little investment over the          quantitatively the                  do not embark on                   privilege large hospitals       database of health
                      last 10-20 years.                   network, if restored to             heavy rehabilitation/              and areas with better           facilities as a first step
                      Maintenance neglected               acceptable functioning              construction; instead,             security and                    to develop an
                      due to insufficient                 levels, is fairly adequate          limit interventions to the         operational conditions;         investment plan
                      financing and other                 to offer universal access           functional rehabilitation          explicit measures to           to link investment
                      priorities; as a result,            to health care in a mid-            of existing facilities,            counter these                   decisions to those
                      substantial and expensive           sized country                       starting with a tight              tendencies are needed           related to HR
                      rehabilitation and                 available figures don't             selection of priority             uncoordinated, NGO-             development,
                      replacement are required            fully support the claim of          ones                               led reconstruction              financing, supplies,
                     network of almost 2,000             a heavy hospital bias:             identify and close down            usually results in              management;
                      health facilities, or 1 per        382 hospitals with 32,000           redundant facilities in            wastage of resources           define clear criteria
                      14,000 people (best ratio:          beds (average 83 beds)              over-served areas                 unplanned                       for rehabilitation in
                      Sulemanyiah =  4,000,              versus 1,570 PHC                   expand PHC facilities in           reconstruction tends to         consultation with
                      worst ratio: Baghdad =              facilities. The resulting 1 :       under-served areas                 strengthen or                   stakeholders; select
                       27,000). The three                4 ratio suggests a
                                                          modest advantage of
                                                                                             assess typology and                perpetuate pre-crisis           with them a first batch
                      northern governorates                                                   layouts of existing                flaws and biases                of facilities to be
                      enjoy better ratios than the        hospitals. Before
                                                          conclusions are drawn,
                                                                                              facilities and identify           reconstruction is often         rehabilitated and cost
                      rest of the country, due to                                             measures needed to                 disconnected by the             them
                      the inclusion of light              the share of tertiary
                                                          hospitals (number &
                                                                                              upgrade or restructure             projection of recurrent        review and
                      facilities, staffed by CHWs,                                            them                               funds, with implications        standardise layouts
                                                          beds) in relation to the
                      among health centres
                                                                                             progressively integrate            on future sustainability        and technical
                     hospitals beds seem fairly
                                                          total must be assessed.
                                                          Given the small average             military health facilities        area-based                      requirements for
                      distributed across                                                      (see urgent measures)              comprehensive                   health facilities
                                                          size, many 'hospitals'

      Draft – August 12 2003                                                                                                                                                    3
                                                                                          Policy options (not              Relevant experiences
                                                                                                                                                         Urgent measures to be
 Area / Issue             Situation                          Remarks                       always mutually                from other countries in
                                                                                                                                                         taken until end of 2004
                                                                                              exclusive)                          transition
                    governorates (range: lower         might be in fact large                                                planning promises              rise funding for civil
                    Tameem 0.65 x 1,000                health centres                                                        better results than             works to start in 2004
                    people, higher Baghdad:           overall, 1.2 beds x 1,000                                             selective planning
                                                                                                                                                            identify/set up a
                    1.81)                              people point to a limited                                             (such as planning PHC,
                                                                                                                                                             coordination forum of
                   no information available on        capacity & need for the                                               or hospitals, in
                                                                                                                                                             actors involved in
                    the capacity of the 31             future modest expansion                                               isolation from the rest
                                                                                                                                                             work on infrastructure
                                                                                                                             of the network)
                    military hospitals                 to improve service offer
                                                       in the least privileged                                             the investment needed
                                                                                                                                                            assess status and
                                                                                                                                                             capacity of selected
                                                       governorates                                                         to revamp an ageing
                                                                                                                                                             military health
                                                      (bed occupancy,                                                      and poorly maintained
                                                                                                                                                             facilities (see
                                                       reported as low in 1993,                                             network, with many
                                                                                                                                                             financing for the
                                                       improved under the OFF                                               facilities approaching
                                                                                                                                                             absorption of military
                                                       programme                                                            end of service, is better
                                                      the spatial distribution of
                                                                                                                            estimated using full
                                                                                                                            replacement costs
                                                       health facilities follows to
                                                                                                                            (instead of
                                                       a considerable degree
                                                                                                                            rehabilitation costs) as
                                                       population settling
                                                                                                                            the basis for projections
Workforce          composed of 13,000                the aggregate size of the         close down medical               without proper PHC-             carry out an inventory
                    doctors, 14,700 nurses,            workforce seems                    colleges and convert              oriented training,               of the workforce
                    2,000 pharmacists and              balanced (even slim) for           some of them into                 doctors & nurses tend           study deployment,
                    2,000 dentists; the ranks of       the network to be                  nursing schools                   to stick to the hospital         workload, job
                    other professionals and            operated                          freeze the enrolment of           model they absorbed              descriptions, skills,
                    ancillary professionals are       however, nurses and                medical doctors                   during their training            use of health workers
                    UNKNOWN. The number                possibly other cadres are         launch a two-pronged             during a protracted             develop a HR
                    of skilled workers per bed         under-represented (many                                              crisis, the skill stock of
                                                                                          in-service training                                                development plan,
                    should be in the order of 1-       foreign nurses left)               programme:                        the workforce suffers
                                                                                                                                                            assess the conditions
                    1.5 (i.e. rather low)
                                                      to stop or at least to                                              as much as the
                   poor training standards            reduce the production of
                                                                                              to improve the skills
                                                                                              of existing health
                                                                                                                                                             and the capacity of
                                                                                                                                                             the training network
                    seem an issue/concern              doctors could be                                                     Substantive re-training
                                                                                              workers,                                                       and identify measures
                   very large training network        politically difficult
                                                                                             to provide PHC
                                                                                                                            is always needed, as
                                                                                                                                                             to equip it to
                    composed of 17 medical            nursing training is an
                                                                                                                            witnessed in
                                                                                                                                                             implement the HRDP

     Draft – August 12 2003                                                                                                                                                4
                                                                                       Policy options (not               Relevant experiences
                                                                                                                                                     Urgent measures to be
 Area / Issue               Situation                       Remarks                     always mutually                 from other countries in
                                                                                                                                                     taken until end of 2004
                                                                                            exclusive)                         transition
                     colleges, 4 nursing              absolute priority                    skills to health                Cambodia, Angola,            introduce incentives
                     colleges and 92 nursing         no information about                 workers deployed                Afghanistan                   to expand the ranks
                     schools                          deployment was found                 to provide PHC                strengthening the              of nursing students
                    most (or all?) health           the training network            import foreign nurses              workforce is a long-          introduce incentives
                     workers have received a          needs to be downsized,           from abroad as a gap-              term, labour and               to encourage the re-
                     hospital-oriented training       upgraded and redirected          filling measure                    resource intensive             deployment of cadres
                    unknown, but possibly            to expand in-service            strengthen and expand              endeavour, to be
                                                                                                                                                        assess number,
                     large, number of army            training capacity                the capacity of nursing            thoroughly planned and
                                                                                                                                                         distribution, profile of
                     health workers                                                    schools                            implemented
                                                                                                                                                         military personnel
                                                                                      update the salary scale,                                          (see financing for the
                                                                                       bringing on-salary the                                            absorption of military
                                                                                       many allowances                                                   health staff)
                                                                                       previously provided
                                                                                      progressively integrate
                                                                                       military health
                                                                                       personnel (see urgent
Pharmaceutical      a state company, Kimadia,       even if reduced over the        start a comprehensive             in Mozambique, the            ensure the availability
area                 was in charge of drug            years, the total financial       drugs policy review                state structure for drug       of essential drugs
                     procurement, storage and         allocation to drugs              process, backed by                 procurement and                (rigorously selected)
                     distribution, importing          seems adequate to                serious studies of the             distribution was               during the transition
                     about $500 million of            respond to the needs for         most relevant areas                preserved despite the          period
                     goods in 1989. Local             a mid-sized, under-used         meanwhile, maintain                overall trend towards         launch an in-depth
                     production covered 30% of        health sector                    basic functions of                 privatisation, with            study of the area
                     total consumption               the possibility of serious       procurement and                    excellent returns
                                                                                                                                                        start reviewing policy,
                    during the last years,           inefficiencies along the         distribution of drugs             heavy investment in            legislation,
                     under the OFFP, average          drug chain cannot be            dismantle the Kimadia              restoring local                regulations, drug list,
                     imports (of which drugs          ruled out                        structure, fully                   production might not be        rational use of drugs
                     represented the dominant        the Kimadia structure is         privatising the area, or           justified on purely
                                                                                                                                                        identify suitable
                     share) accounted for $373        so large and complex to          alternatively parts of it,         economic grounds
                                                                                                                                                         agencies to assume
                     million, or an yearly            call for an in-depth study       chosen because                    reintroducing regulatory       interim key tasks:
                     average of $17 per capita        before decisions are             considered not                     measures in a

     Draft – August 12 2003                                                                                                                                             5
                                                                                             Policy options (not             Relevant experiences
                                                                                                                                                          Urgent measures to be
 Area / Issue               Situation                           Remarks                       always mutually               from other countries in
                                                                                                                                                          taken until end of 2004
                                                                                                 exclusive)                          transition
                    the pharmaceutical area              taken about its future             appropriate to remain             disrupted, deregulated         procurement,
                     has moved towards                   reformulating and                  under public                      environment is a               distribution, quality
                     deregulation, with a ill-            strengthening regulatory           management                        challenging endeavour,         control, inspection,
                     documented expansion of              functions (including              outsource regulatory               likely to succeed only        etc
                     private operators                    quality control) seems a           functions to                      when adequately
                     (including about 20                  pressing priority                  independent public                resourced and backed
                     producers whose outputs             the national drug list is          agencies or to third              by firm commitment
                     are unknown)                         considered as                      parties                         given the nature of the
                    local production has                 inadequately selective            restore local production         pharmaceutical area,
                     dramatically declined.              after the last war,                (if it entails minor             fully-fledged
                                                                                                                              privatisation without a
                     Quality control functions            coordination of drug               interventions)
                     have suffered                                                                                            strong regulatory
                                                          donations has been
                    before the last war, the             overall problematic, due
                                                                                                                              capacity in place is
                                                                                                                              likely to worsen the
                     OFFP cumbersome and                  to the lack of an effective
                     slow procedures                      tracking system
                     negatively affected the             in the aftermath of the
                     supply chain. The                    last war, user-fee for
                     interruption of the OFFP,            drugs have been used to
                     war damage and looting all           supplement salaries,
                     contributed to cause drug            instead of replenishing
                     shortages                            stocks
Health service      strong tradition of public          The temptation to return          conceive and introduce          Kosovo offers a rich           start an in-depth
delivery             service provision, totally           to the old supply-side             a phased, long-term,             learning ground of the          study of health
                     subsidised by the public             model might be strong              comprehensive PHC                practical implications of       service provision at
                     purse, progressively                To take advantage of               programme                        introducing PHC into a          field level
                     eroded during the 90s                private (for-profit and not-      pilot contracting-out            hospital-oriented sector       start an exploration of
                    curative, high-tech, facility-       for-profit) providers, a           schemes to assess               Excessive expectations          private service
                     based services as                    dramatic upgrade of the            their feasibility in the         about the capacity of           providers and of the
                     dominant model. Referral             legislative and regulatory         present context and the          private providers to            potential they
                     systems described as                 framework is needed                requirements of their            ensure a substantial            represent
                     crippled.                           Reshaping the sector in            scaling up                       share of service               establish a forum of
                    PHC underdeveloped, as               favour of PHC implies             identify core segments           outputs might be                public and private

      Draft – August 12 2003                                                                                                                                                6
                                                                                     Policy options (not             Relevant experiences
                                                                                                                                                   Urgent measures to be
 Area / Issue               Situation                     Remarks                      always mutually              from other countries in
                                                                                                                                                   taken until end of 2004
                                                                                          exclusive)                        transition
                     least as an alternative         major changes in most           of the public health              deluded, particularly           service providers to
                     conceptual approach             organisational aspects,         sector to be retained by          when these actors are           discuss and
                    Private not-for-profit          including management            the MoH and others to             inexperienced and               harmonise delivery
                     providers not very              systems, training,              be privatised.                    without access to               models
                     developed / implanted.          allocative criteria,           regulate the charging of          capitals                       design a long-term
                    Grey areas of ownership,
                                                     advocacy with the public
                                                                                     service fees and clarify                                          programme to
                     responsibility, access to                                       the use of collected                                              improve quality of
                     resources abound               Outpatient contacts in          revenues                                                          care
                                                     2000 suggest remarkably
                                                     homogeneous patterns
                                                     of service uptake
Management          A heritage of vertical         The re-activation of           Try to resuscitate              The loss of memory              an improvement of
systems              bureaucracy, centralised        capacity of analysis and        existing management              induced by radical               information basis and
(to be               decision, scarce                decision will require           systems, study their             change may severely              analysis in priority
developed when       delegation of powers,           sustained efforts over a        weaknesses and                   arm management                   areas
                     passive acceptance of           long time (see also             strengths, and on the            systems, in this way            invest in competency
                     central guidelines              Policies, above)                basis of the obtained            delaying their recovery          building in the areas
available.. )
                    A culture of "non-             Possible clash of culture       results design a                Effective management             of administration,
                     information sharing"            and management style            comprehensive                    needs:                           management,
                     inherited by the previous       between Iraqi technicians       overhaul programme
                                                                                                                          Authority ( i.e.            planning, health
                     regime                          and newcomers, Iraqi                                                  policies and laws)          economics
                    Current instability of          Diaspora, contractors,      Alternatively:
                                                                                                                          Institutions ( i.e.        create appropriate
                     decision-making                 etc                                                                                               fora and mechanisms
                     structures, already            The purging of cadres          Consider existing
                                                                                                                           appropriate bodies,
                                                                                                                           clear reporting and         for balanced dialogue
                     weakened by years of            associated to the old           management systems                                                between policy
                                                                                                                           accountability lines)
                                                                                     irremediably crippled
                     public sector breakdown         regime might lead to the
                                                     loss of many competent          and introduce a new                  Plans, resources
                                                                                                                                                       makers, technicians
                                                                                                                                                       and managers
                                                                                     package (possibly                     and procedures to
                                                     and knowledgeable
                                                                                     inspired to models                    deploy them
                                                     managers, difficult to
                                                     replace                         drawn from comparable                Partners (i.e.
                                                                                     countries)                            openness and
                                                                                                                           coordination within
                                                                                                                           and around the

     Draft – August 12 2003                                                                                                                                         7
                                                                                       Policy options (not        Relevant experiences
                                                                                                                                           Urgent measures to be
 Area / Issue              Situation                        Remarks                     always mutually          from other countries in
                                                                                                                                           taken until end of 2004
                                                                                           exclusive)                   transition
                                                                                                                       sector; public
                                                                                                                       information, etc)
                                                                                                                       Reliable and
                                                                                                                        information, and
                                                                                                                        open dialogue
Equity              Differentials in investment      Despite these                                                                     
(to be               and in outcomes between           differentials, geographic
developed when       at least three zones              access seems fairly
relevant             (North, Centre and                balanced across country.
information          Baghdad and the South),           Economic, cultural and
becomes              fostered in different ways        gender factors might play
available..)         by the old government and         a more relevant role in
                     by the international              shaping user behaviour

     Draft – August 12 2003                                                                                                                               8

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