Key issues guide on service delivery... (2)
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Dear Colleagues
I was interested to read a message from Ingrid Young of the DFID
Health Resource Centre, Institute of Development Studies at the
University of Sussex in the UK talking about Key issues guide
on service delivery in difficult environments. I followed the
link provided (http://www.eldis.org/healthsystems/sdde/index.htm)
and found some interesting material, but I did not find what I
was looking for.
I have reproduced below the overview table of contents... and
then the top level material on two issues of particular interest
to me.
Health sector financing and
Performance measurement
In my view service delivery (in the health sector) in difficult
environments is about physical capacity and financial capacity,
both of which are a huge challenge... so I therefore followed
the link to financing ( Health sector financing).
I am also interested in performance measurement so I followed
that link as well ( Performance measurement). With regard to
health sector financing... I am reminded of planning work I have
done in various parts of the world over a period of many years
and the challenge of public finance that meets maybe one tenth
of what is needed to satisfy priority needs at even the most ba-
sic level. But it is made even worse because most of the pro-
jects that the donors want to fund are not even priority needs
as seen by local leadership and local experts. Frankly I was
VERY disappointed at what I found (quickly) on the website...
and would challenge the responsible people to link the cost of
the work being done to prepare information for the website with
tangible value on the ground that really benefits the needy. Re-
cently the British NGO Save the Children has talked about "phan-
tom aid" that consumes (they suggest) perhaps 60% of official
relief and development assistance (ORDA)... I think this is an
example of "phantom aid", but if, in fact, it helps to deliver
more resources to practical valuable health initiatives that
benefit the needy, then I am wrong.
And when I went to performance measurement ( Performance meas-
urement) I found rather little about performance measurement...
at any rate the sort of performance measurement that I used to
expect as a corporate manager (CFO) of a US based international
company, and what everyone needs to get improved decision making
in the global health sector. What we need to be able to see is
costs and benefits both in total and on a per unit basis, or
some basis that allows comparative analysis. Because the ORDA
world does little more than measure how much it has spent, there
is rarely any useful performance measurement. This is 2005 not
1805. In the corporate world best practice in performance meas-
urement is now engaged in providing the management information
needed for a "real time" enterprise, which is an enterprise that
knows AHEAD OF TIME what is going to be the problem it must
solve. I did not find in this section much reference to the sort
of hard cost/results and community impact analysis and feedback
that is needed to get meaningful performance measurement, and
provide the foundation of management information needed for good
decision making.
I realise this is a very negative message... and I realise it is
very long. But somehow the mindset of academic study about re-
lief and development has got to be replaced by a management
mindset where there is a very high standard of management infor-
mation and effective decision making. Health professionals in
the "south" deserve a better chance to be adequately funded and
recognised for excellent work that gets results, and to the ex-
tent that academic analysis in the "north" gets in the way and
consumes resources then good "management information" in the
global health sector should be available to sort out the good
from the mediocre from the bad.
Sincerely,
Peter Burgess
Tr-Ac-Net in New York
Tel: +1-212-772-6918
mailto:peterbnyc@gmail.com
The Transparency and Accountability Network
With Kris Dev in Chennai India
and others in South Asia, Africa and Latin America
http://tr-ac-net.blogspot.com
--
Introduction Issues Case studies Recommendations
Health, poverty and vulnerability
Governance and health
Priority diseases
Health sector financing
Global initiatives and PPPs
Access to medicines and international issues
Health service delivery
Gender
Performance measurement
Transitional economies
Human resources
Health
HIV and AIDS
This guide is based on Improving the delivery of health and edu-
cation services in difficult environments: lessons from case
studies, written by Cindy Carlson, Jean Pierre de Lamalle, Suz-
anne Fustukian, Katy Newell-Jones, Mo Sibbons and Egbert Sondorp
for the Health Systems Resource Centre
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Health sector financing
Eldis quick guide to the issues
Health sector financing is a rapidly evolving policy area, where
important progress is occurring alongside inherent tensions. De-
spite the growth of vertical programmes (see Global initiatives
and Priority diseases sections of this resource guide), there is
also increasing recognition of the disadvantages of projects
that are of limited duration and often driven by funding agency
interests rather than country priorities. Research has shown
that without a conducive policy environment, the benefits of aid
may not be sustained. This has led to growing interest and ex-
perience in alternative aid mechanisms. One is sector wide ap-
proaches (SWAps). SWAps promote greater government ownership and
leadership of the health sector and more efficient use of the
resources available for health. Some donors are moving still
further towards general or direct budget support. Agreement on a
poverty reduction strategy and a related budget framework forms
the basis for un-earmarked funding that is then allocated and
used through the government budget. At the same time as donor's
policies are evolving, so to are national governments' own
health sector financing policies, including experimentation with
separating finance from service provision. Below we've selected
some of the key areas within this topic and have highlighted a
number of recommended readings for each. The accompanying search
links take you to more key documents in each area.
Donor policy: Sector-wide approaches (SWAps)
The sector-wide approach is a relatively new way of working be-
tween governments and donors. It is one with which a large num-
ber of donors are starting to favour, though it also has its op-
ponents. SWAps work differently in different countries but they
are typified by the following features: All significant govern-
ment and donor funding for the sector supports a single sector
policy and expenditure programme. Government leads the process
and its implementation. Common approaches are adopted across the
sector by all funding parties (government and donors). There is
progress towards relying on government procedures to disburse
and account for donor funds.
Recommended readings on SWAps:
The sector-wide approach: organising principle for bilateral de-
velopment cooperation Sector Wide Approach Support Group, Swiss
Tropical Institute / Swiss Tropical Institute (STI) , 2004
CIDA primer on program-based approaches Lavergne, R.; Alba, A. /
Canadian International Development Agency (CIDA / ACDI), 2003
A guide to sector-wide approaches for health development: con-
cepts, issues, and working arrangements Cassels, A. / World
Health Organization (WHO), 1997
Integrating vertical programmes into sector wide approaches: ex-
periences and lessons Brown, A. / Institute for Health Sector
Development (IHSD), 2001
Developing sector wide approaches in the health sector: an is-
sues paper for DFID advisers and field managers Walford, V. /
Department for International Development Health Systems Resource
Centre (DFID HSRC), 1998
For more information on SWAps, see the Swiss Tropical Insti-
tute/Swiss Agency for Development Co-operation's pages on The
Sector-wide Approach in the Health Sector. More recommended
readings on SWAps
Donor policy: Debt reduction
The development of many low income countries is slowed by heavy
external debts. Donors have launched policies to try to address
this problem, primarily the Heavily Indebted Poor Countries
(HIPC) Initiative. HIPC was announced in 1996, jointly by the
World Bank and the International Monetary Fund. It aimed to re-
duce to sustainable levels the external debt burdens of the most
heavily indebted poor countries. In 1999, modifications to the
HIPC Initiative were made, as many felt that it was failing to
deliver this goal. While this enhanced form of the HIPC Initia-
tive aims to provide 'faster, deeper and broader debt relief'
and has provided some countries with the opportunity to increase
spending in other ways, such as on health and education, it is
recognised that the initiative itself is not a panacea. Other
debt reduction policies include the 'swapping' of debt for vari-
ous policy investments, in health as well as in other fields.
Recommended readings on debt reduction:
Debt-for-AIDS swaps: a UNAIDS policy information brief UNAIDS /
UNAIDS (Joint United Nations Programme on HIV/AIDS) , 2004
Debt relief for the poorest: an OED review of the HIPC initia-
tive Gautam, M. / Operations Evaluations Division (OED), World
Bank , 2003
Heavily Indebted Poor Countries initiative: status of implemen-
tation IMF; World Bank / Debt Initiative for Highly Indebted
Poor Countries (HIPC), World Bank , 2002
Tracking of poverty-reducing public spending in heavily indebted
poor countries (HIPCs) International Monetary Fund (IMF); Inter-
national Development Association / International Monetary Fund
(IMF) , 2001
Donor policy: budget support
Budget support is a form of quick-disbursing programme aid which
is channelled directly to partner governments, uses local ac-
counting systems and is linked to sector or national policies
rather than specific project activities. It aims to promote pro-
poor growth through encouraging fiscal stability and more equi-
table and efficient allocation and use of public funds. It of-
fers the potential to address key cross-cutting issues such as
public sector reform, gender, and the environment in ways that
other aid instruments cannot, and also seeks to make maximum use
of local capacity
Recommended readings on budget support:
Poverty reduction budget support: a DFID policy paper DFID / De-
partment for International Development (DFID), UK , 2004
Aid and public expenditure: a guide Foster, M.; Fozzard, A. /
Overseas Development Institute (ODI) , 2000
Moving to budget support Justice, G. / Development Assistance
Committee (DAC), OECD , 2001
Budget support versus project aid: a theoretical appraisal Cor-
della, T.; DellâArricia, G. / International Monetary Fund
(IMF) , 2001
General budget support evaluability study phase 1: final synthe-
sis report Lawson, A.; Booth, D.; Harding, A.; Hoole, D.;
Naschold, F.; Overseas Development Institute / Oxford Policy
Management (OPML) , 2002
Donor policy: bilateral and multilateral analysis, policy and
strategy
Development agencies' policies and strategies evolve over time.
There is an unusual degree of consensus at present on the objec-
tives and focus of development efforts in the form of the Mil-
lennium Development Goals (MDGs) and the need to focus on pov-
erty reduction. There is also growing consensus on broad aid
policy and the need for harmonisation of aid mechanisms and re-
quirements. However the views of donors on different aid instru-
ments, such as SWAps and budget support, still vary widely.
Within health there is also broad consensus on priorities, but
also differences on issues like the role and advantages of
global health initiatives; the relative importance of systems
strengthening versus immediate health needs; the role and fund-
ing of hospitals. Listed here are a number health sector strat-
egy papers for bilateral and multilateral agencies.
Click on the Search Eldis link for more multilateral and bilat-
eral strategy papers, or for links to websites see the Aid Re-
source Guide page of donor agency websites.
Better health for poor people: strategies for achieving the in-
ternational development targets Department for International De-
velopment (DFID) / Department for International Development
(DFID), UK , 2000
USAID population, health, and nutrition strategy for 1998-2003
Center for Population, Health and Nutrition, Bureau for Global
Programs, Field Support, and Research, USAID / USA Agency for
International Development (USAID) , 1999
Policy for the health sector ADB / Asian Development Bank (ADB)
, 1999 Sector strategy: Health, Nutrition & Population Preker,
A. S.; Feachem, G. A.; De Ferranti, D. / World Bank , 1997
Performance measurement
Eldis quick guide to the issues
Evaluation - "a systematic way of learning from experience and
using lessons learned to improve current activities and promote
better planning by careful selection of alternatives for future
action", WHO 1994 - provides an objective basis for assessing
the performance of health projects, agency performance, global
programmes, and health policies and changes. Process evaluation
shows how a programme or change is implemented as planned; out-
come evaluation aims to find out the effects (and, longer term,
impact) of an intervention. Careful planning, clear identifica-
tion of questions to be asked, data (or proxy data) required,
and identifying who will conduct the evaluation (internal, ex-
ternal, collaborative) are pre-requisites of all evaluations.
Monitoring measures the continuous process of activity over time
(against a standard); with the introduction of SWAps, the need
to monitor PRSPs, and the new global programmes, sector monitor-
ing is increasingly important. Development partners are attempt-
ing to standardise evaluation methodologies - assessing inter-
ventions, country programmes, and developing sector and thematic
reviews. These will inform future health policy and interven-
tions. In 2000, the WHO World Health Report attempted, for the
first time, to evaluate and compare 191 health systems world-
wide. The methodology used requires refinement, but the results
will yield valuable data.
Recommended readings on performance measurement:
Evaluation tools and approaches The World Bank Operations
Evaluation Division / Operations Evaluations Division (OED),
World Bank , [2003]
Draft evaluation guidelines Department for International Devel-
opment (DFID), UK / Department for International Development
(DFID), UK , [2002 Monitoring global health: time for new solu-
tions Murray, C.; Lopez, A.; Wibulpolprasert, S. / British Medi-
cal Journal (BMJ) , 2004 ]