Dr. Lambo's health reform agenda for Nigeria - Part 2
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A policy analysis: Part II - Critique
[Warning: This critique is unavoidably lengthy]
Key messages
Dr. Lambo's health reform proposal for Nigeria is laudable and
contains many worthy and fundamental elements for policy change.
The formulation and structuring of the reform agenda is sound,
though top-down. Ownership does not belong to the intended bene-
ficiaries and a social construct and contract would be benefi-
cial. Heavy doubts must be entertained about the institutional
capacity to implement the reform as proposed. These are but few
policy limitations worthy of further consideration.
Objective
This is a good faith critique of Dr. Lambo's health reform pro-
posals for Nigeria. It examines the motivation, ownership, fun-
damental objective principles (if any), structure, implementa-
tion plan (where known), goal(s) and outcome measures (if any)
of the proposed reform.
The objective is to broaden the base of inputs to the proposed
reform by shedding light on its elements and purpose, elucidat-
ing its strengths and weaknesses and doing a reality check as to
whether the outcome of reform will serve the greatest good of
the greatest number of people of Nigeria into the long term.
In the process, questions will be raised for open debate and
dialogue. Additional reform proposals will be advanced and rec-
ommendations offered for further policy consideration.
Definition
First, a clarification; Health Sector Reform (HSR) and Health
Reform (HR) are used interchangeably in this piece as if they
both have the same scope and meaning. This is not truly so. But
whatever differences there are between the two terms really do
not impact significantly on the purpose of this discourse. Con-
sequently, the terms are used interchangeably as if they mean
the same in scope and details.
At this stage, a definition of health sector reform (HSR) with
special reference to developing countries is required to set the
stage for the critique.
The literature on this subject is replete with a plurality of
definitions. These are well reviewed by Baru (1) in his presen-
tation on "A policy analysis of health sector reform process in
India".
Whereas health activists, idealists and purists view health sec-
tor reform as a broad process for streamlining vision, legisla-
tions, programmes and projects in health towards improving effi-
ciency, access, financing, quality and equity; national public
health leaders and officials commonly propound a politically
jaundiced view of health sector reform that oftentimes includes
an admixture of barely integrated health programmes and projects
driven and tied to specific internal or external agenda and ad-
dressing issues of limited scope and sometimes questionable
benefits.
In developing countries, the triumvirate of donors, multilateral
and bilateral organisations commonly expresses health sector re-
form as a project to "rationalize health programmes, emphasise
basic and population health, promote economic efficiency and
rein in public sector spending while promoting increasing priva-
tization".
Cynics, academics and researchers (in and out of developing
countries) on the other hand, see health sector reform as as-
sortment of actions and programmes dictated by donors and multi-
lateral financial institutions (e.g. World Bank) and accepted by
national governments in order to obtain loans to overcome fiscal
crisis, without any substantial vision or inputs from the na-
tional government.
A definition of health sector reform with global application
that closely aligns with the idealistic view expressed above is
offered by Cassels (2) as "a fundamental rather than an incre-
mental change (in a health system) which is sustained rather
than one-off and purposive in nature". This is the gold standard
against which Dr. Lambo's reform agenda will be tested
According to Cassels, the components of a fundamental HSR in-
clude the following:
* Decentralisation of power and resources
* Improving function of national health ministries
* Improving the performance of civil service (and managers)
* Broadening health financing mechanism
* Introducing managed competition
To these, may be added,
* Guaranteeing access, redressing equity and pro-poor orienta-
tion
* Broadening ownership and impact
Health Sector Reform as Change Advocacy
Since health sector reform is not implemented 'in vacuo' or
where nothing previously exists, all attempts at HSR invariably
boil down to Change Advocacy. Dr. Lambo recognizes this admira-
bly; hence his talk about working with "carefully chosen 'Change
Agents'" to accomplish his proposed reform. Pertinent questions
to ask at this point are; what level of inclusiveness has Dr.
Lambo adopted in tapping his "Change Agents" for reform? Did he
engage the diverse constituents and communities in formulating
his reform agenda? What role will the beneficiaries of the re-
form play in the various stages of the reform process? These
questions play to that other most important question; who owns
the reform; the Honorable minister, the Federal Government, or
the beneficiaries of the reform, i.e., the people of Nigeria?
Available information so far does not suggest that Dr. Lambo's
reform proposal is or would be owned by the people of Nigeria.
Models of Policy Advocacy for Change
The literature of health reform is replete with various models
of Change Advocacy. (3) The model that is adopted for use in
this discussion describes two broad approaches, viz: Influencing
policy change directly; or fostering/engaging the capacity of
others for policy change. From a practitioner standpoint, this
model is the equivalent of the problem focus vs. the outcome fo-
cus model of change advocacy (4,5) The particular approach used
by an Advocate for policy change invariably betrays the Advo-
cate's expectation of the impact of the change process on the
lives of the beneficiaries. Within the present limitations in
the knowledge of the details of Dr. Lambo's current HR agenda,
and given his privileged position and his antecedent as a dis-
tinguished health economist, it appears that he has consciously
chosen to adopt the approach of influencing policy change di-
rectly. This approach is obviously easier to design and imple-
ment as it is problem focused and not client/outcome focused.
The approach of influencing policy change directly for health
reform would most probably constrain Dr. Lambo's change expecta-
tions to that of achieving an incremental, one-off reform of Ni-
geria's health system, rather than a fundamental restructuring
that would produce sustainable and purposive impact on the bene-
ficiaries.
What evidence supports this sweeping conclusion? These are exam-
ined under the following four non-exclusive headings:
* Motivation for reform: Dr. Lambo is understandably disturbed
by Nigeria's appalling health indices. He recognizes systemic
weaknesses in policy, funding and managerial capacities. He is
motivated to see reversals in these elements .Although not yet
specified in measurable terms, he wants to see urgent improve-
ments in the performance of the system. Surprisingly, the im-
pression is garnered that he has formulated his outcome measures
for now, essentially in terms of bricks, mortars and hardware.
Is this a policy flaw or is it a pointer to one-off (white ele-
phants, project-driven) change?
* Fundamental objective principles: The fundamental objective
principles behind Dr. Lambo's reform agenda are unclear. This is
not to say that principles do not exist. One thing however is
clear; because the reform agenda has been formulated and is
structured from top-down with significant emphasis on effi-
ciency, cost effectiveness and performance of the delivery sys-
tems rather than the social development and outcomes (5); it is
haunted by a lack of broadly inclusive social construct and con-
tract with the beneficiaries. This is another significant policy
flaw. At this stage of Nigeria's development, such social con-
struct and contract are fundamental requirements for sustainable
reform in health. It would help to place ownership of the reform
in the beneficiaries, foster their participation and guarantee
sustainability.
* Ownership of reform: This matter has been briefly touched
above. Dr. Lambo's reform agenda as conceived is not owned by
the beneficiaries of the reform. This is a significant policy
flaw.
* Elements and Structure: Dr. Lambo's reform agenda fulfills
some of the elements of a HSR as defined by Cassels and itemized
above. His proposals hope among others, to improve functions of
national health ministries through rationalisation of PHC pro-
grammes for example. If accomplished, the performance of the
civil service (and managers) is expected to improve. Is this
likely without a social construct and contract for reform?
Probably not. An object lesson to consider is the sweeping and
militarized reform of the Nigerian civil service embarked on by
the Murtala-Obasanjo military administration of the early 70's.
The jury verdict among political scientists is that it did not
produce the envisaged efficiency in the civil service. If any-
thing, it is believed that the reform stimulated corruption and
worsened the efficiency and performance of the civil service to-
date. This sort of outcome is to be avoided at all cost.
Dr. Lambo's reform also intends to achieve a broadening of health
financing mechanism and strengthen public-private partnering in
a yet undefined manner. Sure fallout of the enhanced public-
private partnering will be increasing privatization of health
services delivery in Nigeria. It is as yet unclear how the re-
form will introduce managed competition on a national scale into
the health system.
Another perceived significant policy flaw in the reform agenda
relates to the issue of decentralisation of power and resources.
Present impressions are that Federal influence in the control of
Nigeria's health system is not about to be relinquished. Without
plurality and decentralisation however, the beneficial impact of
reform will be limited across the length and breadth of Nigeria.
Strengths and weaknesses of present reform agenda
One of the greatest strengths of Dr Lambo's reform agenda lies
in the enthusiastic will of the chief advocate to embark on the
reform. This is a salutary and laudable position from which to
launch what is expected to be a gruelling and complex reform
process. Other strengths include comparatively better articula-
tion of the elements of the envisaged reform and possibly top
administration support. The weaknesses perceived in Dr. Lambo's
reform proposal are partly associated with the four linked sig-
nificant policy flaws as earlier elucidated, viz. top down for-
mulation, non-beneficiary owned reform, lack of social contract
and signals regarding decentralisation of control and resources.
The other part of the weaknesses identified has to do with an
unclear enunciation of the pre-reform analysis of the impact
that poor capacity to implement proposed reform would have on
the reform outcome.
Notwithstanding, that some of these weaknesses are remediable,
lessons learned from reality checks of HSR in many developing
countries including those from sub-Sahara Africa in the last ten
years, indicate a wide gulf between outcome as designed and out-
come as it unfolds with implementation. (6, 7, 8)
References and recommended readings:
1. Baru, R.: A policy analysis of health sector reform process
in India, India habitat Centre. March 2003
http://www.genderhealth.org/pubs/Baru.ppt
2. Cassels, A.: A guide to sector-wide approaches for health de-
velopment, concepts issues and working arrangements. Geneva:
World Health Organization. 1997
3. Change theories. The Communication Initiative.
http://www.comminit.com/change_theories.html
4. Labouchere, P.: Change theories - Problem focus or Outcome
focus. The Communication Initiative, Nov. 2001
http://www.comminit.com/ctheories/sld-4123.html
5. Making Change Happen: Advocacy and Citizen Participation,
Just Associates, Washington DC, March 2001
http://www.justassociates.org/MakingChangeHappen.htm
6. Social development priorities in health sector reform: Ex-
perience from Bangladesh and Cambodia. Option News Newsletter.
# 6. Jan. 2001 http://www.options.co.uk/newsletter6.pdf
7. Donaldson, D.: Health sector reform in Africa: Lessons
learned. Data for Decision Making Project, Department of Popula-
tion and International Health, Harvard School of Public Health,
Boston, MA. March 1994
http://www.hsph.harvard.edu/ihsg/publications/pdf/No-3a.PDF
8. Thomason, J.: Health sector reform in developing countries: a
reality check. Australian Centre for International and Tropical
Health and Nutrition. (1997)
http://www.acithn.uq.edu.au/conf97/papers97/thomason.htm
9. Kiragu, K. (2002). Improving service delivery through public
service reform: lessons of experience from select sub-Saharan
Africa countries (English). Paper presented at the Second Meet-
ing of the DAC Network on Good Governance and Capacity Develop-
ment, OECD, 14-15 February 2002. KK Consulting Associates.
Pages: 18. http://www.sti.ch/pdfs/swap150.pdf
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Recommended readings:
More extensive health sector reform resources especially in de-
veloping countries including Africa are available from the Web-
site of:
* The Partners for Health Reformplus:
http://www.phrplus.org/index.html and
* The World Bank SDC Health Sector Reforms:
http://www.sdc-health.ch/priorities_in_health/good_governance/health_sector_reforms
* Please share and feel free to enrich the critique with your
contribution
A. Odutola
Centre for Health Policy & Strategic Studies
Lagos, Nigeria
mailto:chpss_abo@yahoo.com
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