VERHALLEN (MARIEKE) MANAGEMENT OF HEALTH DISTRICTS BY NON GOVERNMENTALORGANIZATIONS.
Item
- Title
- VERHALLEN (MARIEKE) MANAGEMENT OF HEALTH DISTRICTS BY NON GOVERNMENTALORGANIZATIONS.
- extracted text
-
Management
of Health Districts
by Non Governmental Organizations.
How can it be achieved?
June 1995
Marieke Verhallen
Management Involvement
of Non Governmental Organizations
in Health Care Districts
How can it be achieved?
Paper written to obtain
the Masters Public Health degree,
at the Netherlands School of Public Health.
Utrecht,
June 1995,
Marieke Verhallen
TABLE OF CONTENTS:
1.
2.
INTRODUCTION:
1.
PROBLEM DEFINITION:
2.
1.1. Background:
2.
1.2. The District Health System:
2.
1.3. Interests and Hesitations towards cooperation:
3.
1.3.1.
The Governments Perspective:
3.
1.3.2.
The Non-Governmental Organization's Perspective
4.
1.4. The Key Question:
5.
THE OBSTACLES TO SHARING RESPONSABILITIES IN
DISTRICT HEALTH -THE CASE OF TANGUIETA:
6.
2.1. The actual obstacles:
3.
2.1.1.
Political and legal constraints:
7.
2.1.2.
Organizational and structural constraints:
7.
2.1.3.
Resource Constraints:
7.
2.1.4.
Constraints related to attitudes, orientations and training:
8.
DISCUSSION:
Issues to be addressed:
4.
6.
8.
10.
)
A.
Policy formulating:
10.
)
B.
Legislation:
11.
)
C.
Organization and structure of the district management:
11.
)
D.
Resources:
12.
)
E.
Attitudes, orientations and training:
13.
)
F.
Support structure:
13.
CONCLUSIONS AND RECOMMANDATIONS:
14.
REFERENCES:
16.
ANNEXES.
INTRODUCTION:
At present many developing countries are undertaking health system reforms for a variety of
reasons. The envisaged reforms have stimulated a new debate on the role and place of health
care providers of church-related or social local non governmental organizations. (NGO’s) Only
too often their facilities are not an integral part of the public health care system.
The adopted 'District Health Care System' has to be a coherent and comprehensive delivery
system capable of answering the needs of a well defined population in the context of Primary
Health Care. 1,2 To achieve this all non-profit health care providers/facilities in the district have
to be part of the system.
The need for close cooperation between governmental and NGO providers and integration of
NGO facilities, in the context of the district health care system, has been well argumented in all
documents on the issue. 110 11 However, experiences show that achieving the cooperation
needed to establish a coherent district system, is not easy to realize. Governments are still trying
to manage and implement all health services while they are inadequately equipped and badly
placed to do this. NGO health facilities have the technical capacities to take more responsibilities
in a district but they are rarely being given these duties nor are they taking them. 3’4’5’6,7
Though both parties see the need for close cooperation, they are not finding the ways to
effectuate it. Up till now very little research has been done to determine how to install an
effective cooperation and which conditions can enable NGO facilities to take responsibility for
running (all) aspects of a health district or sub district.4,7
This paper lays out the need for health systems research into feasible strategies for Government
- NGO cooperation to assist policy makers, of both parties, in ensuring optimal use of all
available capacities and capabilities to strengthen the district health care delivery system.
I will first try to define the problem more clearly as I think that, at least, part of the difficulties
stem from unclear views on what the aim should be. At present the issue is considered merely
in the light of integration of the NGO facilities into the public delivery system. This raises
fundamental hesitations on both sides.
Subsequently I will study the obstacles as they pose themselves to a particular NGO hospital.
In chapter three I will try to determine the conditions that can remove the obstacles and enable
both parties to effectively share responsibilities and resources. In the conclusions and
recommendations I hope to give my ideas on how we can continue on this road.
The information and experiences, which form the basis of this study, mainly stem from SubSaharan Africa as my own experience lies there. The role of the NGO hospital in the district is
my main focus as it gives more opportunities to illustrate the issues at stake. But much of what
is being said is also applicable to peripheral units and sub districts.
1
1.
PROBLEM DEFINITION:
*.
1
Background:
At independence most new Sub-Saharan African governments (and their international partners)
interpreted their responsibility for health care delivery in such a way that they saw it as their
obligation to provide and manage all the services needed. This meant that non-governmental
providers were seen as temporary, or ignored and not integrated into the system.
Depending on the country or region, the NGO's now own and operate between 25 to 60% of
the available health facilities.
In some countries attempts have been undertaken, in the past, to integrate NGO health care
providers into the Governmental health care system, with limited success. The failures have
strengthened feelings of competition in many instances, and have sometimes even fostered
mistrust and hostility.
At present the issue is on the agenda again as a result of various changes in international and
national views regarding solutions for the problems of developing countries.
1.2.
The District Health System:
The main concern of the Primary Health Care concept (PHC) and the ensuing ’Health For All
by the year 2000’ strategy (HFA) is to ensure that prevention of disease and promotion of
health should get as much attention, if not more, as curative care. It’s revolutionary idea lies in
insisting that the population should be directly involved in shaping it’s own health and health
care.
*
The concept and the strategy is now the basis of health care programs and activities of
Governments and NGO’s in most Sub-Saharan countries
To facilitate community involvement and responsiveness to local health needs a reorganization
of the health care delivery system into health districts has been elaborated:
” A district can be defined in very general terms, as the functional unit of a decentralized health
care organization for a defined population’’.** Its optimum size is the result of two opposing
requirements: economy of scales and community participation.
In its simplest form the district health system (DHS) is an integrated three-tier system:
(1) community health care activities supported by (2) a first line health facility (dispensary or
health center) which in its turn is supported by (3) a district hospital.
In summary: the first line unit is the pivot of the health service delivery system, (curative care,
prevention and promotion) The district hospital provides referral care and support to the first
* This policy was inspired by the work of three NGO hospitals.
** Abbreviated definition as used by MMI in 5; see 2 for more extensive definitions.
2
line units. The District Health Management Team is responsible for the management,
strengthening and coordination of all services in close cooperation with the district health
governing board and the hospital staff. *
This concept facilitates the division of tasks and responsibilities between health professionals,
representatives of the population and all other parties concerned.2,4,6’8’9’10
1.3.
Interests and hesitations towards cooperation:
1.3.1.
The Government’s perspective:
The governments of the Sub-Saharan countries are going through a transition phase. Under
national and international pressure political changes towards democracy are being initiated. The
Structural Adjustment Programs of the International Monetary Fund and the World Bank favour
a different view on the role of government. Governments should not want to cater for
everything but restrict themselves to setting policy guidelines, ensuring access to social services
for the poor, regulation and research.3,11
This means the government has to delegate the execution of tasks and duties to other parties.
Privatization and decentralization are strategies envisaged to achieve this aim.
In health care governments face enormous budgetary constraints, lack of capacity and
capabilities as well as organizational problems. The World Bank and WHO stimulate
governments to concentrate on: 3
- financing and implementing public health interventions;
- financing and ensuring delivery of a package of essential clinical services;
- improving cost-effectiveness.
Private providers can ensure clinical services for the wealthy and might contribute to cost
effectiveness and quality of services through competition. Public health tasks and access for the
poor will only be taken on by private providers if special subsidy measures are taken by the
government. 12 In many areas, the population has no choice of providers as no other health
facility is available. Privatization can thus not contribute to comprehensive and equitable PHC.
The district health system, as a form of decentralization, aims at ensuring equal access while
delegating the responsibility for execution of essential clinical services and public health tasks to
local authorities and parties.
The international policies, and their translations by individual governments, are not clear with
regard to the role and place of NGO’s in these strategies.3,13
As private providers and competitioners, their contribution to alleviating the
* Annex 1 shows the national public health system and annex 2 the organization of the district.
3
governments burdens can only be quite limited. In practice some governments seem to favour
this option as it retains their complete authority and autonomy to determine policies and control
the execution of public duties from the central level down to peripheral workfloor.
As part of the district system, a solution has to be sought, to ensure that the NGO’s can
take up the appropriate district tasks and responsibilities. Integration is often proposed
2*4.5,6,7,8
most governments appear to shy away from it. The probable reason is that it
would increase governmental responsibilities instead of diminishing them.
Delegation of tasks gives the government the possibility to diminish its executive
responsibilities while retaining its constitutional obligation to ensure access to health care. This
option is new to most governments. Some are studying the implications, advantages and
disadvantages.
Most of the proposed changes still have to be translated into the laws and bylaws of the
countries but also into guidelines for local implementation. Experience within governmental
bodies, at all levels, to share decision making and to share responsibilities with- or delegate
tasks to non governmental parties is minimal. There is a reluctance to shed direct control and
current unfamiliarity with the NGO’s together with past rivalries give rise to resistance to such
cooperation.
1.3.2.
The Non-Governmental Organization’s perspective:
The NGO’s, thought of here, are autonomous local organizations. Their original aim is to
support the poor. They mostly finance their running costs from local income, (fees for services
and contributions) Dependence on international support is mainly for investment costs.
The developments at national level provide new challenges to contribute in other ways to the
improvement of services. They also open up possibilities to support popular movements in
search of a more just society.4,15
In health care the NGO’s present isolation from the system limits their possibilities to provide
comprehensive PHC. Their financial constraints limit their possibilities to realize their
commitment to the poor, particularly in situations where they are not sharing in public funding.
NGO’s are often quite aware of the needs and have-the.capabilities and experience to assist in
strengthening the existing health care system. 3,5,6 Their assets are: an important network of
facilities; experience in community involvement and experience in providing health care under
economical constraints. Most NGO facilities are either first line centers or first line referral
hospitals. Overall geographical coverage can be largely improved if they are included in the
DHS.
On the other hand the tasks, that they have taken in the course of the years, are often wider or
4
more restricted then proposed in the DHS. Moreover, as they have to ensure their own running
costs, their fees may be higher than those of the surrounding governmental facilities.
The district health system offers, in their perception, great advantages for improvement of the
health care provision and to solve the inadequacies and duplications existing at present between
the various parties. 5,6,7
Full integration of the NGO facilities into the district health system is often seen as the most
suitable approach. 5,6,8 However many NGO’s feel that, by definition, this would mean that
they become one with the government system and thus loose their identity. It is felt to be in
contradiction with their wish for autonomy and independence. In their opinion these guarantee
their freedom to act in line with their original aim and retain their community based
character. 6»14*15»16
Their hesitations are strengthened by past experiences with government nationalization
policies. 18,19 The fact, that most NGO’s have not yet developed consistent policies in face of
the new challenges, complicates matters still further. 7,14,15
If NGO’s want to remain faithful to their original aims and play a positive role in society
building, they need to know what is at stake at community level as well as have influence at
policy formulating and implementing level to promote such interests. Remaining autonomous
and accepting delegated responsibilities in the district health system, as partner of the
government, would give them both. But it will also give obligations as their activities and
policies (for ex. essential drugs, cost sharing etc.) will have to be aligned. Inevitably this entails
a certain loss of independence but the advantages outweigh this price, according to NGO's
considering this option.
1.4.
The Key Question:
The principles of PHC and the definition of the DHS implies that the district has to be an entity
with a coherent system of participative management and an equitable financing system
(including user-charges). Each health facility/provider has to be part of the system to ensure its
cohesion and comprehensiveness.
The definition does not imply that there has to be unilateral ownership. The responsibilities and
tasks for providers/ facilities are clearly defined/definable. This means they can be divided
amongst the parties, present, on the basis of location and capabilities.
The government has to remain responsible for ensuring that the population has access to the
health care it needs and that each person benefits to an equal share of the national health care
resources. Under the new policies it can delegate responsibilities and grant access to such
resources to other parties.
5
The NGO's want to keep their autonomy while contributing to the improvement of health care
delivery to the same population to which they have close links.
Full integration does then not serve the interests of either party concerned.
The key question therefore should be: 'how to share responsibilities and resources in such a
way that government and NGO’s complement one and other to achieve optimal functioning of
the district health system' Or: 'how can the government delegate responsibility and the
corresponding resources to the NGO’s and how can the NGO’s take them up?'
2.
THE OBSTACLES TO SHARING RESPONSIBILITIES IN
DISTRICT HEALTH - THE CASE OF TANGUIETA.
Policy guidelines, regarding how to achieve the sharing of responsibilities by Governments and
NGO’s, are lacking all around.4,7 To find solutions I propose to look at the obstacles as they
are perceived by a NGO which is invited to take on responsibilities in a health district. The
example chosen is exceptional in that little to no cooperation existed between the hospital and
the government in the past. It allows to show more clearly which issues need to be addressed.
St. John of God Hospital is situated in north Benin. It is geographically and functionally well
placed to take the role of district hospital for the Tanguieta district. It is owned by the catholic
diocese of Natitingou and run by the congregation of the Brothers of Saint John of God of the
African Province.
The Atacora Health department and the administration of the bilateral ’Dutch Support to Primary
Health Care Project' want St. John of God hospital to take the role of district hospital. The
ultimate aim is that the diocese and congregation provide for the management of the district by
leading the District Health Management Team. (DHMT) 16
I will limit myself here to the main obstacles.16,17 *
2.1.
The actual obstacles:
The obstacles can be regrouped in four categories: political and legal constraints; organizational
and structural constraints; resource constraints and constraints related to attitudes, orientations
and training.
* For an overview of the background information please be referred to annex 3,4 and 5.
The case information stems from:
a) the report of a study to determine whether and how the proposed reorganization could be achieved. The study
was commissioned by the Atacora Health department and the management of the Dutch Support to PHC Care
Project and executed by the independant consultant Dr. F. de Paepe, see 16.
b) the reports on the Round Table Consultation regarding the Health Sector, held under the auspices of the
Ministries of Health and Economic Planning, see 17.
6
2.1.1.
Political and legal constraints:
The legal context for the installation and functioning of a health district still has to be
elaborated. The mandates of the district governing bodies, to determine local policy and
resource allocation, have not yet been set. The private non-profit health facilities are not legally
recognized. Combined these legal obstacles mean that the execution of public duties by the
NGO, in the district, will have no legal basis. A law to recognize NGO’s is being proposed but
it does not mention delegation of public tasks to NGO's.
There are serious inconsistencies between the ministry's policy statements and actions.
Even at present the implementation of activities and interventions from central level to
peripheral level often bypass the regional and district authorities. In addition the interpretations
of the role of a district hospital differ between local level (referral care and strengthening of first
line units) and the ministry (only referral care). Determining the actual responsibilities is thus
hampered.
2.1.2.
Organizational and structural constraints:
There is no regional development plan all parties can refer to. A platform for consultation
within the health sector and with related sectors does not exist. The regional health department
is not yet taking the lead in organizing dialogue between all parties.
Community involvement at all levels still needs to be realized as well as coordination
between the operational levels and the main actors in public health.
The health system elements are not well interlinked. The district medical officer is not part of
the hospital management and the hospital management is not part of the DHMT.
The health information system is deficient and the referral system is not operational.
The present services of the hospital need to be reoriented but this can only be done if the
surrounding facilities become fully operational: first line tasks for the population of the town
have to be taken over by a first line unit in the vicinity; second line referral care has to be
ensured by the Atacora regional hospital.
2.1.3.
Resource constraints:
Financial:
The budget allocated by the government to health services, is very limited in comparison to
the needs of the population and the problems the health system faces. There are also
inefficiencies in the allocation of resources.
The funding of running costs and motivational allowances by the bilateral development
agency endangers the sustainability, after the project period, and may prevent the mobilization
of local resources. The same goes for the high degree of dependency on outside support of the
hospital.
7
The hospital’s high fees already raise fears regarding the actual accessibility for the poor. If
these have to increase, to fund new activities, the access for the poor to referral care may
become even more compromised.
Personnel:
The region has a great lack of competent and motivated staff for all the intervention levels. =
On top of this staff management problems, like unwarranted absences and low performance
rates, result in under utilization of first line units. It is not yet clear where, under who's
responsibility, staff management will be placed in the district health system.
The hospital lacks staff that is capable of initiating and guiding operational integration and
structural cooperation ( for ex. a public health officer ). Its staff lacks recent experience in PHC
supervision of first line units.
2.1.4.
Constraints related to attitudes, orientations and training:
The communities are not yet well informed on the changes in policy and lack understanding
of its objectives. The various committees, in which they should be involved, are only just being
installed. Health authorities and staff have little experience with participatory management, (for
ex. the communities have not been consulted regarding the role of St. John of God hospital.)
As the private social sector was never officially recognized and structural subsidies were
never allocated the NGO facilities operate in relative isolation. This and events in the past have
given rise to mutual mistrust and even hostility. The hospital and NGO fear loosing their
autonomy when becoming part of the district system. The health authorities are unsure of the
allegiances of the NGO: to the people or to the donor organizations.
The health authorities do not recognize the value of the NGO's achievements, nor of the
contributions they can offer to the health care system.
The fact that, the dialogue between the two parties has and is instigated and organized by
donors instead of the Ministry of Health, does not facilitate the establishment of an equal
working relationship.
At the level of the institutions there is a resistance to change: after such a long period of
central planning and management local staff have the habit of limiting their activities to daily
management and avoiding changes. At regional and district governmental level there is a
significant lack of management and planning capabilities. Together this strengthens dependency
on central level and outside support for determining the Public Health Policy.
3.
DISCUSSION:
The obstacles for the transfer of public duties to the NGO are numerous.
In order to enable St. John of God hospital to take the role of district hospital, at least, the
8
following issues need to be addressed:
- the legal embedding;
- clarification of tasks and responsibilities;
- operational relations with the DHMT and the regional health department;
- the health information and referral system;
- the funding of delegated tasks.
To enable the diocese/congregation to accept the responsibility to manage the district the most
important obstacles are:
- the inconsistencies in the policies;
- absence of a legal context;
- the absence of clear mandates for the governing and managing structures.
Decentralization has to be a well thought through policy: decentralization of functions without
the necessary resources and strengthening of the local management capacity will lead to failure,
frustration and discouragement at community level.13
From the policy documents 17 it is not clear whether this government sees involving NGO's in
district health in the perspective of decentralization or as a form of privatization.14
It is only on the basis of a correct interpretation of decentralization and delegation of public
tasks that the political, legal and financial constraints, can be addressed adequately.
Confidence in one and other can not be dictated but it can be stimulated by recognition and
guidelines/regulations based on mutual respect.
However there are experiences that prove that more can be achieved:
The third mail survey of Medicus Mundi Intemationalis, regarding NGO hospital's
involvement in the district health system, shows that important improvements are gained in
districts where the hospital is represented in the DHMT, the DHMT in the management of the
hospital and district authorities in the Board of Governors of the hospital.6
Examples can also be found, among these hospitals, where very successful cooperation
has been established, due to personal motivation and interests of individuals at government and
NGO level. The effects of changes in staff show how fragile these successes are.18,19
In the Brong-Ahafo region of Ghana, the NGO facilities have become an integral part of
the district health system, while remaining autonomous.19 This can be clearly attributed to:
- deliberate policies on both sides combined with clear implementation guidelines;
- delegation of the district medical officer function to the NGO hospitals;
- well qualified and highly motivated staff on both sides;
- staff allocation and an important financial incentive in the form of payment of seconded staff;
- a policy of regular auditing.
9
Zaire’s policy on district health is one of the clearest and simplest. The hospital, that is
in or near the district capital, of what ever denomination, is designated district hospital and its
owner is invited to become responsible for managing the district, including the financial
responsibility. The DHMT and the district health office are situated on the hospital compound
the DMO is part of the hospital team. NGO’s find this a useful basis to take up the
responsibility. It should be realized though, that, the present socio-economic crisis in Zaire,
does give all parties a high degree of autonomy as well as very important constraints. 20,21
Which essential issues need to be addressed:
The obstacles and experiences show that, in order to improve cooperation between
governmental and NGO health care providers, in district health, the following issues need to be
addressed:
)
A.
Policy formulating:
For the government and the NGO’s, the first step to an effective cooperation in social services,
is the elaboration of deliberate policies on the extent and forms of the cooperation. If the
government wants to delegate public duties it should also specify the criteria, conditions and
possible contributions they foresee. In turn the NGO’s. should specify their criteria, conditions
and contributions.
On the basis of these positions a dialogue can be undertaken to come to consensus in the
specific fields. In case no consensus can be reached each party has to clarify the implications
this entails for their relationship and the activities/services being considered.
The government has to formulate its policies on decentralization and privatization as well as
specify the operational consequences in such a way that they are consistent with the aims and
the interpretation indisputable.
The policy on district health also needs to be consistent and clear. Its translation into guidelines
and mandates for local implementation have to be practical and transparent. Certainly the
mandates regarding local responsibility for strategy, staff management, material and financial
resource allocation have to be consistent with the aims of decentralization.
To delegate tasks and responsibilities, to NGO providers, the organizational structure of the
district should be chosen in such away that decision mandates and actual execution of activities
remain close together. Also communication lines should be kept short and access to information
optimal. The Zairian or Ghanaian structure seem, to me, the more appropriate.
The issue of community participation, participation of NGO’s and other health related sectors in
the health districts governing bodies still needs consistent and practical translation in to the
policy and guidelines in most countries.
10
On the basis of the government’s district health policy and their own aims the NGO’s should
establish their own policy towards district health and the role they can play in it. They need to
determine under which conditions they are willing to take on responsibilities, to what extent
and how these can best be implemented.
This deliberate policy can then be the basis for a dialogue with the district, regional and national
authorities to arrive at a strategic agreement.
In any case all policy documents and guidelines need to be made public and circulated widely
so that all concerned are well informed and well aware of what is expected of each party and
actor.
)
B.
Legislation:
If cooperation, between governmental authorities and NGO’s, is desired official recognition of
the NGO’s in the general laws of each country is necessary. Specific criteria can be set to
determine which NGO’s warrant recognition.
All the above mentioned government policies and those determined in dialogue with other
providers need to be reflected by clear and consistent legislation, bylaws and regulations.
Contracts between government and NGO’s regarding delegation of tasks, responsibilities and
resources have to be drafted carefully and based on the general legislative frame work and upon
the published regulations, (such contracts are currently virtually non existent in the countries
concerned.)
All laws and regulations should be clear regarding litigation procedures. These have to ensure
independent and fair judgment.
)
C.
Organization and structure of the district management:
The first step to be taken, here, is that members of the management team of the hospital become
member of the DHMT and the district medical officer becomes member of the hospital
management team. The district health governing board and the hospital governing board should
include representatives of one and other. Both have to invite the communities to elect
representatives to join them.
The functional links between the district bodies/facilities and the regional health authorities have
to be clearly defined and operationalized.
The second step should be, the development and implementation of the health information
system, in a close cooperation between the government and the NGO’s. The third step is to
devise the two-way referral system together.
These two information systems are key elements for the assessment of needs and functioning
of facilities and thus form the basis for planning of services and activities.
The cooperation enables the staff of both parties get to know each other and have access to
feedback information to evaluate and adapt their functioning in line with the needs.
The next step should be the district diagnosis and the development of the district health plan
together with all parties concerned. The gradual transfer of tasks and responsibilities, to
NGO's, if relevant, has to be part of this district health plan. The process should be well
planned and phased, certainly if the gap between the prevailing situation and the desired district
health system is large. The ultimate goal has to be clearly defined and understood by all
concerned, from the beginning, and their participation ensured and maintained during the entire
process.
The business world uses an effective way to share tasks and responsibilities, between two or
more autonomous organizations, to realize a certain objective: subcontracting. An agreement is
signed between the parties determining which services or goods are to be delivered by one
party against which compensation of the other party.
In analogy, the government can contract NGO's to execute specific tasks or deliver specific
services and/or to be responsible for areas or sectors of public duties against certain
compensations.
The PHC approach demands that such contracts are agreements between the population, the
local government and the NGO. The contract should be drafted with care and in detail. It has to
fit into the policies and prevailing laws and bylaws as well as into the district health plan.
D)
Resources:
Allocation of responsibilities should go together with resource allocation. If governments wish
to delegate tasks and responsibilities to NGO's they will need to provide financial
compensation. Various forms of resource provision are possible but whatever form is chosen
equality between 'NGO districts’ and similar districts run by the local/district government
should be ensured.
These resource allocations should, on the other hand, not imply that the NGO's diminish their
contributions: in the partnership their resources have to be entered towards the common goal.
Personnel is an even more crucial resource for an effective functioning of the district health care
system. The district health board and the DHMT have to be allocated the necessary mandates to
ensure effective personnel management. Thus, if the NGO carries a leading responsibility for
12
the district, it should have a relevant responsibility for the management of staff at hospital and
first line units.
NGO’s often work with a minimal number of staff to keep running costs low. If they are to
realize, additional, delegated duties the government has to allocate the necessary personnel or
the funds to employ them.
E.)
Attitudes, orientations and training:
Communication and training are important tools to achieve the desired district health care. They
can also be important instruments to establish effective cooperation.
Each partner should invest in adequate exchange of information on its policies and activities
both formally and informally. The district health information and referral system are starting
points.
The district health system demands both new and different management capacities of health
staff. A management training program is an effective way to start the reorganization towards a
district health care approach. Staff of the public sector and the NGO’s should undergo the
training together. This shared experience and the inevitable exchange of views will certainly
contribute to changing attitudes and fostering cooperation.
Experience has proved that interest and motivation of key staff members can be conclusive in
establishing effective cooperation. Both the government and the NGO should select staff
accordingly. At coordinating positions staff should be'willing -and-capable of open
communication, building bridges and undertaking innovative approaches.
F.)
Support structure:
The actual delegation of tasks to achieve a coherent district health system has to be implemented
at district level between NGO, local authorities and communities. But to develop policy and
implementation guidelines the regional and national authorities need an interlocutor at these
levels. The NGO’s in a country should organize themselves in such a way that they can be a
dialogue partner for the government and support each other at these levels.
These regional and national coordinating bodies should aim at harmonizing policies and
facilitating local implementation.
In case of disputes between a NGO and local authorities the regional or national body should be
enabled to play a mediating role.
13
4
CONCLUSIONS AND RECOMMENDATIONS:
All Governmental and NGO health care providers recognize the possibilities and challenges that
the district health care approach represent towards improving the delivery of comprehensive
Primary Health Care. The basic willingness to cooperate to achieve the essential aims is
present.
However integrating the NGO health care providers into the governmental system is not a
feasible strategy. It ignores the right to a basic form of autonomy of the NGO's and adds to the
burdens of the government instead of diminishing them. It also ignores the value of continuous
dialogue between equal partners of different origin to shaping a democratic society.
Approaching the subject in the perspective of delegation of public duties and partnership
between Government and NGO’s respects , as much as possible, the autonomy of all partners.
More importantly it facilitates determining the extent, the conditions and methods required to
establish the necessary cohesion and comprehensiveness at district level.
In order to respect the autonomy of NGO providers and use their technical capabilities
optimally, delegation of the responsibility to manage a district or sub district seems the most
appropriate strategy.
The case study shows that there are important obstacles, for a NGO hospital to becoming
recognized district hospital and for the NGO to become responsible for the management of a
district. Removing these constraints will not be easy and demands important efforts of all
parties.
The rare examples of effective delegation of tasks and responsibilities and positive cooperation
show that it is possible.
Particularly the approach of subcontracting seems very promising as a way to effectuate
delegation of tasks and responsibilities against an appropriate compensation. The government
can thus improve access to clinical care and public health interventions for the population while
retaining its influence and regulation power to meet its political obligation.
This approach needs to be tested in practice under close research conditions-so that its merits
can be clarified and practical implementation details can be elaborated. Also research into
different forms of subcontracting should be initiated.
Further operational research is required to establish appropriate ways, to create all conditions,
in full consideration of the wishes of the communities and the local situation.
Specific subjects are:
14
- in-depth analysis of positive experiences in public-private cooperation, in district health, to
establish the conditions which are decisive in ensuring this cooperation and to investigate
whether and how these conditions can be created elsewhere;
- how to translate transfer of public duties to NGO’s in the context of local democratic policy
and decision taking;
- how to ensure community involvement in the decision making with regard to the actual
transfer and in the gradual implementation and control there-of;
- investigate alternative staff management and training strategies to improve effectiveness of
health service delivery and the necessary support to the communities while taking the different
origins of the staff into consideration.
The origin, extent and the influence of negative attitudes towards cooperation should also be
researched, in each country, so that they can be taken into account and addressed in the
implementation strategies.
The district health system should not be made a goal in it self. It certainly cannot solve all the
problems in health care.
However it is, at present, the most promising means to achieve the goal: health for all in
cooperation with the communities.
This paper shows that there is still a lot to do to ensure clear translation into government
policies and implementation guidelines. Research and cooperation efforts should be
concentrated on this at present.
15
REFERENCES:
1)
World Health Organization, United Nations Children's Fund. Primary Health Care.
Report of the International Conference on Primary Health Care, Alma Ata, USSR, 6-12
September 1978. Health For All Series, no. 1: Geneva: WHO, 1978
2)
World Health Organization. The Challenge of Implementation: District Health Systems
for Primary Health Care. Geneva: 1988; WHO/SHS/DHS/88.1/Rev. 1
3)
World Bank. World Development Report 1993: Investing in Health. New York: Oxford
University Press; 1993.
4)
World Health Organization. Draft Background Document for a Study Group on
Integrated Health Care Delivery. Geneva: 1994. (unpublished)
5)
Leberghe L van, Balen H van, Kegels G. District and First Referral Hospitals in SubSaharan Africa. An Emperical Typology Based on a MMI Mail Survey. Antwerp:
Medicus Mundi Intemationalis, 1989
6)
Rypkema SM, Santing RCA. The District Health System: Cooperation between NGO’s
and Health Authorities at District Level. A Medicus Mundi Mail Survey. Brussels:
Medicus Mundi Intemationalis/Memisa, 1994
7)
Verhallen, MJP. Integration of church-related NGO facilities into district health systems:
Why not? MMI News letter 1994; 53: 5-13.
8)
Medicus Mundi Intemationalis. District Health Systems and the Health Care Revolution.
Conference Report International Colloquium. Brussels: 1989.
9)
Leberghe W van, Lafort Y. The Role of the Hospital in the District. Antwerp: 1990;
WHO/SHS/CC/90.Z
10)
World Health Organization. Strengthening District Health Systems Based on Primary
Health Care. Geneva: 1988; WHO/SHS/DHS/88.2
11)
World Health Organization. The Hospital in Rural and Urban Districts. Report of a study
group on the functions of hospitals at first referral level. WHO Technical report series
1992: 819.
12)
World Health Organization. The Public/Private Mix in National Health Systems and the
Role of Ministries of Health. Geneva: 1991; WHO/SHS/NHP/91.213)
Collins Ch, Green A. Decentralization and Primary Health Care: Some Negative
Implications in Developing Countries. International Journal of Health Services 1994; 24
14)
(3): 459-475.
Stefani A. Sustainability: the role of NGO’s World Health Forum 1995; 16: 42-46.
15)
Ritchie MA, Minsek M, Conner DW. NGO’s for Health: Roles and approaches of non
governmental organizations in health development. World Health Forum 1995; 16:36-41.
16
16)
Paepe F. La place de 1'Hopital Saint Jean de Dieu de Tanguieta dans la perspective de la
zone de Sanitaire de Tanguieta. Rapport de Mission d’Etude pour la Direction
Departemental de la Sant6 de F Atacora et le Projet Appui Nderlandais aux Soins de Sante
Primaires.(Institut Royal des Tropiques I Ministere de la Cooperation Internationale de
Pays-Bas). Tanguieta: 1993.
17)
Ministere de Sante et Ministere du Plan et de la Restructuration Economique de la
Republique du Benin: Processus de Table Ronde: Concertation sur le Secteur Sante.
Tome 1 : Diagnostique du Secteur et Enonces de Politique.
Tome 2: Politiques, Strategies et Prgrammation.
Benin: 1994.
18)
NN. Ten years Annual Reports of Church-related Hospitals in English-speaking Africa.
19)
NN. Ten years Annual Reports and Evaluation Reports of the six Hospitals of Sunyani
Diocese/ Brong-Ahafo, Ghana.
20)
Ministry of Health Zaire. The Convention between the Zairian Government and the
NGO’s regarding District Health Care implementation. Kinshasa: 1989.
21)
NN. Three years Annual Reports of Catholic Health Facilities in Zaire.
22)
Bureau Diocesain du Borgou pour le developpement. Promotion de Mutuelles de Sante
dans le Sud Borgou. Etude de faisabilite. Borgou: 1994; CIDR/BDBD.
23)
United Nations Children's Fund. The Bamako Initiative. Proposal as presented by Mr.
James Grant, Director of UNICEF, in his address to the 37th session of the WHO
Regional Committee for Africa in Bamako/Mali: 1987.
17
National Public Health System
Levels
Health
Structures
Intersectoral
Structures
Health
Management
Sturctures
Health
Services
Training and
Research
National
National
MOH
National
Hospital(s)
University
Nursing
Schools etc.
Ministry of
Planning
Ministry of Local
Government
Others
P rovincial
Provincial
Prov. Dir.
Health
Provincial
Hospltai(s)
Strengthening
District
Health
Services
Sectoral
Delegations
District
District
DHMT
District
Hospital,
Other (NGO)
Hospitals
Strengthening
First line
Units
District Council
NGO's Sectoral
Programs
Sub-District
Sub-District
Health zone
Health Centre
Committee
Health
Centre,
Health Post
Strengthening
Communittee
Based Health
Care
NGO’s Sectoral
Programs
Village Health
committee
TBAs, VHW,
Other Health
Care
Providers
Village
Village
Development
committee
The National Health System.
Administrative
Annex 2.
Organization of the District Health System.
Tasks and responsibilities
of the health facilities:
First Line Centers:
The first line health institutes (dispensaries/health centers etc) role towards the communities in
their catchment area (service area or health ward = sub district) is:
- Providing first line curative and rehabilitative care and/or referring the patient to the next
most suitable level of professional care;
- Implementing prevention and promotion activities both on site as through outreach activities
at the level of the community and it’s institutions (homes, schools and workplaces);
- Supporting the health activities of the communities through health information/education,
stimulating promotion activities, training and supervision of village volunteers.
The first referral level: the district hospital:
The district hospital has two main functions:
- Providing referral curative and rehabilitative care/services for patients sent in by the first
line centers and referring patients back or to second or third line referral centers;
- Strengthening the functioning of the first lines centers
through:
* ensuring the two way referral system;
* ensuring the functioning of the health information system;
* training and supervision;
* management, procurement, transport and administration support.
Tasks and responsibilities of the management structures :
The Village Health Committee:
Representatives of the community and it's health care volunteers (village health workers and
traditional birth attenders) plan and manage their village health activities. They can call on the
health center staff to assist them.
The Health Center Committee:
Representatives of the communities in the catchment area of the health center together with the
staff of the health center plan and manage the activities of the health center.
The District Health Management Team (DHMT):
This team should be formed by the district health staff and representatives of the district
hospital. It is headed by the district medical officer (DMO). It's basic responsibility is to plan,
coordinate and manage the district health care program and representing the interests of the
district towards other sectors and higher echelons in the country's system.
The District Health Governing Board:
This council ensures policy formulating, decision taking, budget allocation and control for the
district. It is formed by the DHMT, representatives of the hospital, of the community, of non
governmental organizations active in health, of related sectors, and representatives of local
authority.
2
Annex 3
Benin.
DEPARTEMENT DE L’ATACORA
MINISTERE DE LA SANTE PUBUQUE
DIRECTION DEPARTE MANTALE DE SANTE
APPUI NEERLANDAIS AUX SOINS DE SANTE PRJMA1RES
PARC NATIONAL DE LA PENDJARI
3
0
10
20
30
X0
kx
Annex 4.
Socio-demographic and economical Indicators of Benin.
BP/inhabitant:
Total population:
Population density:
Rural population:
Urban population:
Male population:
Female population:
Children under 1 year of age:
Percentage of the population under 15 years:
109.221 CFA.
5.0 million.
45 inhab./kmz
59.4%.
40.6%.
49.1%.
50.9%.
4.5%.
47.4%
Percentage of women in the age of procreation:
Fertility rate:
Population growth rate:
Gross birth rate:
Gross mortality rate:
Mortality rate at 0-5 years
Maternal mortality rate:
Percentage of professionally assisted births:
Number of inhabitants per doctor:
Number of inhabitants per paramedical:
Life expectancy at birth:
Percentage of the national budget used for health:
Expenditure for health per inhabitant:
Percentage of the health budget spent on salaries:
Utilization rate of services:
Coverage rate for ante natal care:
Measles vaccination coverage:
44%.
6.4
3.1%.
49%o
138%O
147%O
11.7 per 1000 live births
35%
16.600.
1.750.
47 years.
4.9%
528 CFA.
80%
0.14 new visits/inhab./year.
47%
79%
Primary school enrollment:
Female primary school attendance:
Secondary school enrollment:
Adult illiteracy rate:
Percentage of the population with access to safe drinking water:
Percentage of population living below the poverty line:
52%
43%
16%
76.6%
54%
65%
Part of the national income from agriculture:
Part of the national income from commercial activities:
Part of the national income from salaries:
40.8%
50%
5.6%
Part of the household budget spent for nutrition:
Part of the household budget spent on traditional ceremonies:
Part of the household budget spent on clothing:
Part of the household budget spent on housing:
Part of the household budget spent on health care:
Household savings:
25%
17%
15%
11%
5%
< iU/o
[ Sources: Dep. Health Atacora 1992; Min. of Health 1988 and 1993; PNUD 1992;
UNICEF 1992; World Bank 1993]
4
Annex 5.
Background to the Case of Tanguieta.
1.
Country situation:
The hospital in question is situated in the northwest of Benin.
Benin is a French speaking Sub-Saharan African country.
The problems that the health care providers are facing are largely identical to those of most
developing countries.
The former government was communist inspired. This meant a high degree of centralization and
no recognition for other social service providers.
Since 1989 Benin has undertaken a Structural Adjustment Program with the help of the
International Monetary Fund, the World Bank and it's other international development partners.
This was followed in 1990 by political changes favoring democratization.16,17
A new policy for health care has been devised in this period. The main aim is to improve health
care for the rural population through strengthening Primary Health Care, decentralization and
allowing private providers to practice. Cost sharing is being introduced under the
implementation of the Bamako Initiative 22,23Relations between the government and the NGO's are coloured by the past. The NGO's
covered their own running and investment costs by asking fees and raising donations from their
European counterparts. Mistakes and failures on both sides have given rise to mutual distrust
and sometimes even hostility.
The degree of organization among the NGO's is limited. The catholic church has a small
coordinating office. The 7 NGO hospitals of all denominations have formed an association to
harmonize their policies and facilitate their dialogue with the Ministry of Health. Recently this
association was invited to participate at a round table conference to discuss the country’s health
care decentralization policy. The invitation was instigated by the international donors of
Benin.17
2.
The Atacora Region:
This is the northwestern region.16 In comparison to the other regions it is the least developed
region. Living conditions are harsh and communications difficult. This means that well trained
staff does not want to work here.
There are three hospitals in the region, two NGO and one governmental. Apart from the NGO
hospitals the various institutes function far below their capacity.
A Dutch governmental development program has been active in the Atacora since 1983. It
started as a program to strengthen Community Based Health Care by improving Village Health
Worker performance. In the second and third phase of the program it became apparent that the
community activities needed to be supported by a well functioning health care system.
Therefore the fourth phase is directed at reorganizing and improving the performance of the
health care services. The approach chosen is to develop a district health care system.
For this reason the region will be divided into several districts each comprising three sub
districts. A district health team will be appointed for each district.
3.
Tanguieta district andTanguieta Hospital
, T
.
Tanguieta is one of these districts. This district counts about 150 000 people. It comprises 54
village health posts together with 54 village health committees; 13 first line centers and one
NGO hospital in Tanguieta town: St. John of God hospital.
.
The utilization of the first line centers is low (0.15 visits pp/py). The units have serious staffing
problems both in actual shortage as due to frequent absences. Supervision has been irregular up
The^aint John of God hospital at Tanguieta is geographically and functionally well placed to
take the role of district hospital. It is owned by the catholic diocese of Natitingou and managed
5
by the congregation of the Brothers of Saint John of God (Fatebenefratelli) of the African
Province.
The diocese and the congregation have the basic capability to take the responsibility to manage
the district.
From 1970 to 1994 St. John of God hospital grew out to a be a 190 bed hospital. At present it
considers the population of at least five surrounding sub districts as it's target population. (±
200.000) For this population the hospital provides first line, first and second level referral care.
It has taken on all these functions in answer to the team's views on care for the poor and in
response to deficiencies in the surrounding region. Patients have a considerable confidence in
the hospital they come from all over the region and the surrounding countries, (bed occupancy
is 70%)
The financing of the running costs is covered for 33% by patient fees. The remaining part is
contributed by the Milan province of the congregation. This is a high rate of outside
dependency, (in most other countries the level of outside support ranges around 20% mainly for
investments) The congregation wants to retain accessibility for the poor in this way. At present
it feels that the outside support can not be increased any more. At the same time the devaluation
of the CFA is driving up costs. The hospital is therefore forced to increase fees.
The hospital is well staffed with personnel [92] from the region and for the larger part trained
on site. The management is still totally in the hands of the expatriate members [6] of the
congregation. The population is not involved in the hospital board.
In the past the hospital had started two peripheral centers and outreach preventive activities.
These were handed over to the regional health authorities around 1987.
4.
What does the hospital have to offer the district?
The St. John of God hospital has much to offer to ensure the functioning of the district of
Tanguieta.
To ensure quality of care it has a large experience in management, permanent well qualified staff
and a stable supply of equipment and medicines.
The motivation and commitment of the staff, their listening attitude and their special interest in
the vulnerable are great assets towards acceptability by the communities. In order to stimulate
participation of the communities, it has the people's confidence. Also, due to it's long and
stable presence, it has accumulated a good knowledge of the actual field situation and the social
context.
It’s assets towards fostering responsibility at all levels are:
- a great interest and sufficient capabilities for training personnel and volunteers also beyond
the mere technical aspects;
- access to feed back information and the capacity to coordinate a health information system;
- the possibilities to install direct supervision;
- a basic willingness and experience to ensure progressive handing over of responsibilities to
key staff and other personnel.
St John of God hospital sees the following advantages in becoming district hospital:
It offers the opportunity to take charge of all the health related problems of a well determined
population.
First of all this will increase the possibilities to reach the poor. Secondly it will be able to plan
the activities in a comprehensive way so that it can improve delegation of tasks among staff,
optimize the use of resources and improve efficiency. Furthermore, supervision of first line
centers together with a key role in installing and maintaining a two-way referral system, give
the team much more scope to ensure continuity in care and services.
Due to the hospital's financial restrictions and in view of equity it hopes that taking the
responsibility for the district will give it access to government subsidy.
The leadership role and the subsidy will enable it to install more rational fee systems.
6
For the government the advantages of St. John of God Hospital as district hospital for
Tanguieta district correspond largely to those mentioned above. The ultimate aim, that the
diocese and the congregation become responsible for the management of the disUict and thus
for the running of the first line units, would constitute a considerable alleviation of the
responsibilities of the regional health department.
7
- Media
5432.pdf
Not viewed