117 CHAPTER SIX how is the Public nterest protected? Governments should be the"stewards"of theirnational resources, maintaining and improving them for the benefit of their populations. In health, this means being ultimately responsible for the careful management of their citizens well- being. Stewardship in health is the very essence of good gouernment. For every country it means establishing the best and fairest health system possible. The health of the people must always be a national priority: govemment responsi bility for it is continuous and permanent. Ministries of health must take on a large part of the stewardship of health systems Health policy and strategies need to cover the private provision of services and private financing, as well as state funding and activities. Only in this way can health systems as a whole be oriented towards achieving goals that are in the public interest. Stewardship encompasses the tasks of defining the vision and direction of health policy, exerting influence through regulation and aduo. cacy,and collecting and using information. At the international level, steward ship means influencing global research and production to meet health goals. It also means providing an evidence base to guide countries'efforts to improve the performance of their health systems
How is the Public Interest Protected? 117 CHAPTER SIX ow is the ublic nterest rotected? Governments should be the “stewards” of their national resources, maintaining and improving them for the benefit of their populations. In health, this means being ultimately responsible for the careful management of their citizens’ wellbeing. Stewardship in health is the very essence of good government. For every country it means establishing the best and fairest health system possible. The health of the people must always be a national priority: government responsibility for it is continuous and permanent. Ministries of health must take on a large part of the stewardship of health systems. Health policy and strategies need to cover the private provision of services and private financing, as well as state funding and activities. Only in this way can health systems as a whole be oriented towards achieving goals that are in the public interest. Stewardship encompasses the tasks of defining the vision and direction of health policy, exerting influence through regulation and advocacy, and collecting and using information. At the international level, stewardship means influencing global research and production to meet health goals. It also means providing an evidence base to guide countries’ efforts to improve the performance of their health systems. 117
HOW IS THE PUBLIC INTEREST PROTECTED? GOVERNMENTS AS STEWARDS OF HEALTH RESOURCES tewardship is the last of the four health systems functions examined in this report, nd it is arguably the most important. It ranks above and differs from the others service delivery, input production, and financing -for one outstanding reason: the ultimate responsibility for the overall performance of a countrys health system must always lie with government Stewardship not only influences the other functions, it makes possible the attainment of each health system goal: improving health, responding to the legitimate expectations of the population, and fairness of contribution. The government must ensure that stewardship percolates through all levels of the health system in order to maximize that attainment Stewardship has recently been defined as a"function of a government responsible for the welfare of the population, and concerned about the trust and legitimacy with which its activities are viewed by the citizenry"(1). It requires vision, intelligence and influence, pri marily by the health ministry, which must oversee and guide the working and develop ment of the nations health actions on the governments behalf. Much of this chapter, therefore, addresses the ministrys role. Some aspects of stewardship in health must be assumed by government as a whole Affecting the behaviour of health actors in other sectors of the economy, or ensuring the right size and skill mix of the human resources produced for the health system, may be beyond the ministrys reach. The government ought to ensure coherence and consistency across departments and sectors, where necessary by an overall reform of public administra Outside of government, stewardship is also a responsibility for purchasers and provid ers of health services who must ensure that as much health as possible results from their spending. And stewardship in health has an international dimension, relating to extemal But government remains the prime mover. Today in most countries the role of the state in relation to health is changing People,s expectations of health systems are greater than ever before, yet limits exist on what governments can finance and on what services they can deliver. Governments cannot stand still in the face of rising demands. They face complex dilemmas in deciding in which direction to move: they cannot do everything. But in terms of effective stewardship, their key role is one of oversight and trusteeship -to follow the advice of“ row less and steer more"”(2,3)
How is the Public Interest Protected? 119 6 HOW IS THE PUBLIC INTEREST PROTECTED? GOVERNMENTS AS STEWARDS OF HEALTH RESOURCES tewardship is the last of the four health systems functions examined in this report, and it is arguably the most important. It ranks above and differs from the others – service delivery, input production, and financing – for one outstanding reason: the ultimate responsibility for the overall performance of a country’s health system must always lie with government. Stewardship not only influences the other functions, it makes possible the attainment of each health system goal: improving health, responding to the legitimate expectations of the population, and fairness of contribution. The government must ensure that stewardship percolates through all levels of the health system in order to maximize that attainment. Stewardship has recently been defined as a “function of a government responsible for the welfare of the population, and concerned about the trust and legitimacy with which its activities are viewed by the citizenry” (1). It requires vision, intelligence and influence, primarily by the health ministry, which must oversee and guide the working and development of the nation’s health actions on the government’s behalf. Much of this chapter, therefore, addresses the ministry’s role. Some aspects of stewardship in health must be assumed by government as a whole. Affecting the behaviour of health actors in other sectors of the economy, or ensuring the right size and skill mix of the human resources produced for the health system, may be beyond the ministry’s reach. The government ought to ensure coherence and consistency across departments and sectors, where necessary by an overall reform of public administration. Outside of government, stewardship is also a responsibility for purchasers and providers of health services who must ensure that as much health as possible results from their spending. And stewardship in health has an international dimension, relating to external assistance. But government remains the prime mover. Today in most countries the role of the state in relation to health is changing. People’s expectations of health systems are greater than ever before, yet limits exist on what governments can finance and on what services they can deliver. Governments cannot stand still in the face of rising demands. They face complex dilemmas in deciding in which direction to move: they cannot do everything. But in terms of effective stewardship, their key role is one of oversight and trusteeship – to follow the advice of “row less and steer more”(2, 3)
120 The World Health Report 2000 Stewardship has major shortcomings everywhere. This chapter examines some of them, then discusses important stewardship tasks. It considers the main protagonists involved, and strategies for implementing stewardship in different national settings. Finally, it brings together some of the messages from preceding chapters on policy directions for better- functioning health systems. WHAT IS WRONG WITH STEWARDSHIP TODAY? Ministries of health in low and middle income countries have a reputation for being among the most bureaucratic and least effectively managed institutions in the public sec tor. Designed and initiated in the early 20th century and given wide responsibility for fi nancing and operating extensive public hospital and primary care systems in the post-war period, they became large centralized and hierarchical public bureaucracies, with cumber some and detailed administrative rules and a permanent staff with secure civil service pro- tections. The ministries were fragmented by many vertical programmes which were often run as virtual fiefdoms, dependent on uncertain international donor funding"(4) The problems described above are familiar, in greater or lesser degree, in many coun ies today. The consequences are easy to see, but it is not always easy to see why the problems occur or how to solve them. Often that is because the stewards of health suffer Health ministries often suffer from myopia. Because they are seriously short-sighted, ministries sometimes lose sight of their most important target: the population at large Patients and consumers may only come into view when rising public dissatisfaction forces them to the ministrys attention. In addition, myopic ministries recognize only the closest actors in the health field, but not necessarily the most important ones, who may be in the middle or far distance Ministries deal extensively with a multitude of public sector individuals and organiza- Ofte P tovidinghealth services, many of which may be directly funded by the ministry itself. Often, this involvement means intensive professional supervision and guidance. But some times just beyond their field of vision lie at least two other groups with a major role to play in the health system: nongovemmental providers, and health actors in sectors other than health In their size and potential impact on achieving health goals, these little recognized indi- viduals and organizations may be more important than the public resources directed through the health ministry. Yet information about them may be scant, and a policy approach to- wards them is often lacking In Myanmar, Nigeria(5), or Viet Nam, for example, privately financed and provided medical care is three or four times as big in expenditure terms, as spending on public services. But the many different types of private providers in these countries are barely recognized in legislation and regulatic Some large health insurance schemes in India currently have no legal status(6). In Et rope and the Americas, road traffic accidents rank fourth in the total burden of disease.Yet the main involvement of the health ministry is often as a steward of accident and emer gency services, not as a force for prevention Services funded from public sources are ob onsibility of government. But private finance and the provision of all he actions clearly need to be within the focus of government as overall steward of the public ministries are also myopic in the sense that their vision does not extend far enough into the future Investment decisions new buildings, equipment and vehicles frequently
120 The World Health Report 2000 Stewardship has major shortcomings everywhere. This chapter examines some of them, then discusses important stewardship tasks. It considers the main protagonists involved, and strategies for implementing stewardship in different national settings. Finally, it brings together some of the messages from preceding chapters on policy directions for betterfunctioning health systems. WHAT IS WRONG WITH STEWARDSHIP TODAY? “Ministries of health in low and middle income countries have a reputation for being among the most bureaucratic and least effectively managed institutions in the public sector. Designed and initiated in the early 20th century and given wide responsibility for financing and operating extensive public hospital and primary care systems in the post-war period, they became large centralized and hierarchical public bureaucracies, with cumbersome and detailed administrative rules and a permanent staff with secure civil service protections. The ministries were fragmented by many vertical programmes which were often run as virtual fiefdoms, dependent on uncertain international donor funding”(4). The problems described above are familiar, in greater or lesser degree, in many countries today. The consequences are easy to see, but it is not always easy to see why the problems occur or how to solve them. Often that is because the stewards of health suffer specific visual impairments. Health ministries often suffer from myopia. Because they are seriously short-sighted, ministries sometimes lose sight of their most important target: the population at large. Patients and consumers may only come into view when rising public dissatisfaction forces them to the ministry’s attention. In addition, myopic ministries recognize only the closest actors in the health field, but not necessarily the most important ones, who may be in the middle or far distance. Ministries deal extensively with a multitude of public sector individuals and organizations providing health services, many of which may be directly funded by the ministry itself. Often, this involvement means intensive professional supervision and guidance. But sometimes just beyond their field of vision lie at least two other groups with a major role to play in the health system: nongovernmental providers, and health actors in sectors other than health. In their size and potential impact on achieving health goals, these little recognized individuals and organizations may be more important than the public resources directed through the health ministry. Yet information about them may be scant, and a policy approach towards them is often lacking. In Myanmar, Nigeria (5), or Viet Nam, for example, privately financed and provided medical care is three or four times as big, in expenditure terms, as spending on public services. But the many different types of private providers in these countries are barely recognized in legislation and regulation. Some large health insurance schemes in India currently have no legal status (6). In Europe and the Americas, road traffic accidents rank fourth in the total burden of disease. Yet the main involvement of the health ministry is often as a steward of accident and emergency services, not as a force for prevention. Services funded from public sources are obviously the responsibility of government. But private finance and the provision of all health actions clearly need to be within the focus of government as overall steward of the public interest. Ministries are also myopic in the sense that their vision does not extend far enough into the future. Investment decisions – new buildings, equipment and vehicles – frequently
How is the public Interest protected? occupy the foreground, while the severe and chronic need to improve the balance between investment and recurrent funding fades into the hazy distance Tunnel vision in stewardship takes the form of an exclusive focus on legislation and the issuing of regulations, decrees, and public orders as means of health policy. Explicit, written rules have an important role to play in the performance of the stewardship function. But formulating regulations is relatively easy and inexpensive. It is also often ineffective, with ministries lacking the capacity to monitor compliance: there are seldom enough public health inspectors to visit all food shops and eating places or enough occupational safety inspectors to visit all factories regularly On the rare occasions when sanctions are invoked they are too mild to discourage illegal practices or to affect widespread disregard of regula tions Good stewardship needs the support of several strategies to influence the behaviour of the different stakeholders in the health system. Among these are a better information bas the ability to build coalitions of support from different groups, and the ability to set incer tives, either directly or in organizational design. As authority becomes devolved, delegated and decentralized to a wide range of stakeholders in the health system, the repertoire of stewardship strategies needs to move away from dependence on"command and control systems towards ensuring a cohesive framework of incentives Health ministries sometimes turn a blind eye to the evasion of regulations which they themselves have created or are supposed to implement in the public interest. A widespread example is the condoning of illicit fee collecting by public employees, euphemistically known as"informal charging". A recent study in Bangladesh found that unofficial fee payments were 12 times greater than official payment (7). Paying bribes for treatment in Poland is cited as a common infringement of patients'rights(8). Though such corruption materially benefits a number of health workers, it deters poor people from using services they need, making health financing more unfair, and it distorts overall health priorities In turming a blind eye, stewardship is subverted; trusteeship is abandoned and institu- tional corruption sets in. A blind eye is often turned when the public interest is threatened in other ways. For instance, doctors can remain silent through misplaced professional loy alty in the face of incompetent and unsafe medical practice by colleagues. A 1999 US study commented"whether care is preventive, acute or chronic, it frequently does not meet pro- Box 6.1 Trends in national health policy: from plans to frameworks National health policy docu- nancial realities and people's pref- economic transition, revised its 1991 nancing and provision ments have a long history, predat- erences Implementation problems policy in 1996 and again in 1998.. identifies policy instruments g but stimulated by international were common A shift is now occurring towards and organizational arrange- concern for promoting primary By no means all countries have more inclusive- but less detailed ments required in both the health care. In many centrally formal national health policies: policy frameworks mapping the di- public and private sectors to planned and developing econo- France, Switzerland, and the United rection but not spelling out the op- meet system objectives: mies, health policies were part of States do not; Tunisia has no formal erational detail, as in Ghana and sets the agenda for capacity a national development plan, with single national policy document; the Kenya building and organizational de- focus on investment needs. UK produced its first formal docu- A national health policy frame- velopment Some health policy documents des guidance for priori programme-specific plans. They whether there are fimo ends on identifies objectives and ad- zing expenditure, thus linking only a collection of project or The lifespan of a policy dep mental dresses major policy issues analysis of problems to deci- ignored the private sector and of- changes to the agenda: India is still defines respective roles of the sions about resource allocation. ten took inadequate account of fi- using its 1983 plan; Mongolia, in public and private sectors in fi- Cassels A. A guide to sector-wide approaches for health development. Geneva, World Health Organization/DANIDA/DFID/European Commission, 1997(unpublished document WHO/ARA/97. 12)
How is the Public Interest Protected? 121 occupy the foreground, while the severe and chronic need to improve the balance between investment and recurrent funding fades into the hazy distance. Tunnel vision in stewardship takes the form of an exclusive focus on legislation and the issuing of regulations, decrees, and public orders as means of health policy. Explicit, written rules have an important role to play in the performance of the stewardship function. But formulating regulations is relatively easy and inexpensive. It is also often ineffective, with ministries lacking the capacity to monitor compliance: there are seldom enough public health inspectors to visit all food shops and eating places or enough occupational safety inspectors to visit all factories regularly. On the rare occasions when sanctions are invoked they are too mild to discourage illegal practices or to affect widespread disregard of regulations. Good stewardship needs the support of several strategies to influence the behaviour of the different stakeholders in the health system. Among these are a better information base, the ability to build coalitions of support from different groups, and the ability to set incentives, either directly or in organizational design. As authority becomes devolved, delegated and decentralized to a wide range of stakeholders in the health system, the repertoire of stewardship strategies needs to move away from dependence on “command and control” systems towards ensuring a cohesive framework of incentives. Health ministries sometimes turn a blind eye to the evasion of regulations which they themselves have created or are supposed to implement in the public interest. A widespread example is the condoning of illicit fee collecting by public employees, euphemistically known as “informal charging”. A recent study in Bangladesh found that unofficial fee payments were 12 times greater than official payment (7). Paying bribes for treatment in Poland is cited as a common infringement of patients’ rights (8). Though such corruption materially benefits a number of health workers, it deters poor people from using services they need, making health financing more unfair, and it distorts overall health priorities. In turning a blind eye, stewardship is subverted; trusteeship is abandoned and institutional corruption sets in. A blind eye is often turned when the public interest is threatened in other ways. For instance, doctors can remain silent through misplaced professional loyalty in the face of incompetent and unsafe medical practice by colleagues. A 1999 US study commented “whether care is preventive, acute or chronic, it frequently does not meet proBox 6.1 Trends in national health policy: from plans to frameworks National health policy documents have a long history, predating but stimulated by international concern for promoting primary health care. In many centrally planned and developing economies, health policies were part of a national development plan, with a focus on investment needs. Some health policy documents were only a collection of project or programme-specific plans. They ignored the private sector and often took inadequate account of financial realities and people’s preferences. Implementation problems were common. By no means all countries have formal national health policies: France, Switzerland, and the United States do not; Tunisia has no formal single national policy document; the UK produced its first formal document in the 1990s, Portugal in 1998. The lifespan of a policy depends on whether there are fundamental changes to the agenda: India is still using its 1983 plan; Mongolia, in economic transition, revised its 1991 policy in 1996 and again in 1998. A shift is now occurring towards more inclusive – but less detailed – policy frameworks mapping the direction but not spelling out the operational detail, as in Ghana and Kenya. A national health policy framework:1 • identifies objectives and addresses major policy issues; • defines respective roles of the public and private sectors in financing and provision; • identifies policy instruments and organizational arrangements required in both the public and private sectors to meet system objectives; • sets the agenda for capacity building and organizational development; • provides guidance for prioritizing expenditure, thus linking analysis of problems to decisions about resource allocation. 1 Cassels A. A guide to sector-wide approaches for health development. Geneva, World Health Organization/DANIDA/DFID/European Commission, 1997 (unpublished document WHO/ARA/97.12)
The World Health Report fessional standards"(9). Ensuring probity in decisions on capital projects and other large purchasing decisions(equipment, pharmaceutical orders), where corruption may be par- Some recent developments create opportunities for better vision and more innovative stewardship. Greater autonomy in decisions relating to purchasing and service provision, example, shifts some responsibility away from central or local government. But it creates new tasks for government in overseeing that both purchasing and provision are carried out in accordance with overall policy. Accumulated experience of practices such as contracting is now available(10) and rapid technological advances enable the fast, inexpensive han- ding of huge amounts of information, thus making it easier in principle for stewards to visualize the whole health system. The notion of stewardship over all health actors and actions deserves renewed empha sis. Much conceptual and practical discussion is needed to improve the definition and meas- urement of how well stewardship is actually implemented in different settings But sev formulating health policy -defining the vision and direction, exerting influence-approaches to regulatic ing and using intelligence These tasks are discussed below HEALTH POLICY VISION FOR THE FUTURE An explicit health policy achieves several things: it defines a vision for the future which in turn helps establish benchmarks for the short and medium term. It outlines priorities and the expected roles of different groups. It builds consensus and informs people, and in doing so fulfils an important role of governance. The tasks of formulating and implement ing health policy clearly fall to the health ministry ome countries appear to have issued no national health policy statement in the last decade; in others, policy exists in the form of documents which gather dust and are never translated into action. Too often, health policy and strategic planning have envisaged unre Box 6.2 Ghana's medium-term health policy framework Forging linkages between private effective use of all available re- process of consultation, the follow- and public providers of health care logistics such as drugs sources from government, g strategies were identified as to ensure consensus and that all her consumables, equip- nongovernmental organiza- providing the means to better per- resources are focused on a com- ment, and vehicles at all levels of tions, and private, mission and formance in health the health system donor sources. Ways of mobilize Re-prioritization of health serv-.Expansion and rehabilitation of Strengthening the monitoring ing additional resources with a res to ensure that primary health infrastructure to increase and regulatory systems withi ealth care services(i.e. services coverage and improve quality the health service to ensure more ore accessible and affordable with maximum benefits in terms Strengthening human resource effective implementation of pro- will also be explor of morbidity and mortality re- Promoting intersectoral action uction) receive more empha ing as a means of providing and for health development, par retaining adequate numbers of communities to take more re- ticularly in the areas of food and The strengthening and decen- good quality and well-motivated sponsibility for their health nutrition, employment, educa- tralization of management health teams to provide the serv- .Improving the financing of health tion, water and sanitation within the context of a national ices care by ensuring the efficient and Source: Medium-term health strategy towards vision 2020 Republic of Ghana Accra, Ministry of Health, 1995
122 The World Health Report 2000 Box 6.2 Ghana’s medium-term health policy framework In Ghana, after an extensive process of consultation, the following strategies were identified as providing the means to better performance in health. • Re-prioritization of health services to ensure that primary health care services (i.e. services with maximum benefits in terms of morbidity and mortality reduction) receive more emphasis in resource allocation. • The strengthening and decentralization of management within the context of a national health service. • Forging linkages between private and public providers of health care to ensure consensus and that all resources are focused on a common strategy. • Expansion and rehabilitation of health infrastructure to increase coverage and improve quality. • Strengthening human resource planning, management and training as a means of providing and retaining adequate numbers of good quality and well-motivated health teams to provide the services. • Provision and management of adequate logistics such as drugs and other consumables, equipment, and vehicles at all levels of the health system. • Strengthening the monitoring and regulatory systems within the health service to ensure more effective implementation of programmes. • Empowering households and communities to take more responsibility for their health. • Improving the financing of health care by ensuring the efficient and effective use of all available resources from government, nongovernmental organizations, and private, mission and donor sources. Ways of mobilizing additional resources with a view to making the services more accessible and affordable will also be explored. • Promoting intersectoral action for health development, particularly in the areas of food and nutrition, employment, education, water and sanitation. Source: Medium-term health strategy: towards vision 2020 Republic of Ghana. Accra, Ministry of Health, 1995. fessional standards” (9). Ensuring probity in decisions on capital projects and other large purchasing decisions (equipment, pharmaceutical orders), where corruption may be particularly lucrative, is another frequent challenge to good stewardship. Some recent developments create opportunities for better vision and more innovative stewardship. Greater autonomy in decisions relating to purchasing and service provision, for example, shifts some responsibility away from central or local government. But it creates new tasks for government in overseeing that both purchasing and provision are carried out in accordance with overall policy. Accumulated experience of practices such as contracting is now available (10) and rapid technological advances enable the fast, inexpensive handling of huge amounts of information, thus making it easier in principle for stewards to visualize the whole health system. The notion of stewardship over all health actors and actions deserves renewed emphasis. Much conceptual and practical discussion is needed to improve the definition and measurement of how well stewardship is actually implemented in different settings. But several basic tasks can already be identified: • formulating health policy – defining the vision and direction; • exerting influence – approaches to regulation; • collecting and using intelligence. These tasks are discussed below. HEALTH POLICY – VISION FOR THE FUTURE An explicit health policy achieves several things: it defines a vision for the future which in turn helps establish benchmarks for the short and medium term. It outlines priorities and the expected roles of different groups. It builds consensus and informs people, and in doing so fulfils an important role of governance. The tasks of formulating and implementing health policy clearly fall to the health ministry. Some countries appear to have issued no national health policy statement in the last decade; in others, policy exists in the form of documents which gather dust and are never translated into action. Too often, health policy and strategic planning have envisaged unre-
How is the public Interest protected? alistic expansion of the publicly funded health care system, sometimes well in excess of national economic growth. Eventually, the policy and planning document is seen as infeasible and is ignored. Box 6. 1 sketches how comprehensive health planning has given way to a more flexible framework' approach Ghana,s 1995 medium-term health strategy identified ten ways in which the health system would contribute towards better health(see Box 6.2) Public consultation occurs in some countries at the beginning of the policy formulation rocess.a"rolling framework is sometimes used, and periodically updated and amended In countries where extemal assistance forms an important part of the health systems re sources, an important expansion of this approach to policy-making and implementation is represented by sector-wide approaches(SWAPs). The essence of SWAPs is that, under government leadership, a partnership of funding agencies agrees to work together in sup port of a clear set of policy directions, often sharing many of the implementation proce- dures, such as supervision, monitoring, reporting, accounting and purchasing. Box 6.3 summarizes the development of SWAPs. Health planning thus shows signs of moving beyond investment programming and towards consensus statements on broad lines of policy and system development. A policy framework should recognize all three health system goals and identify strate- gies to improve the attainment of each. Few countries have explicit policies on the overall goodness and faimess of the health system. Yet the need to combine these two values in governance can be traced far back in history(1). Box 6.4 describes the ancient Hisba system of stewardship in Islamic countries, highlighting both its ethical and economic purpo Public statements about the desired balance among health outcomes, system responsive ness and faimess in financing are yet to be made anywhere. Policy should (and in partial Box 6.3 SWAPs: are they good for stewardship Asector-wide approach (SWAP)is the comprehensive attainment of all Zambia. The other duster of coun- operate within a single sector a method of working that brings these different elements from the tries discussing or actively engaging policy and medium-term ex together governments, donors, start. t implies changes to the ways in a SWAP is in Asia: Bangladesh, penditure framework. Joint re- and other stakeholders within any in which both governments and Cambodia, and Viet Nam are exam- view missions have become a sector. It is characterized by a set donor agencies operate, and in their ples. feature in some countries Least of operating principles rather than required staff skills and systems. The evolution of a SWAP takes progress has been made towards specific package of policies or This approach has begun to take time. In Ghana, before the Ministry common financing and procure- activities. The approach involves root primarily in some of the most of Health single sector programme ment arrangements ernment leadership towards: has been driven by both govern- try had already gone through 10 support good stewardship. Walt broadening policy dialogue; devel- ment and donor concerns about the years of institutional development, and colleagues argue that SWAPs oping a single sector policy (that results of historical approaches to 4 years of major policy /strategy are perceived as capable of addresses private and public sec- development assistance, which have work, 3 years of strengthening core strengthening governments'abil- tor issues)and a common, realis- often involved a combination of so- management functions, 2 years of ity to oversee the entire health expenditure programme: cial sector- blind macroeconomic negotiations, planning and design, system, develop policies and en- common monitoring arrange- adjustment policies and sector- and 1 year of slippage and delays. gage with stakeholders beyond ments;and more coordinated fragmenting projects. Many of the Cambodia and Viet Nam are at the the public sector But, most im- procedures for funding and pro- countries are in Africa, for example, earliest stage of discussing sector portantly, SWAPs depend on vi- curement Being engaged in a Burkina Faso, Ethiopia, Ghana, Mali, policy with donors. In other coun- sion and leadership by national SWAP implies commitment to this Mozambique, Senegal, Uganda, the tries, progress has been mostly to- government. direction of change, rather than United Republic of Tanzania, and wards developing and agreeing to n P. Cited in Foster M Lessons of experience from sector-wide approaches in health. Geneva, World Health Organization, Strategies for Cooperation and Partnership, 1999 Walt Get al. Managing extemal resources in the health sector are there lessons for SWAPs? Health Policy and Planning, 1999, 14(3): 273-284
How is the Public Interest Protected? 123 alistic expansion of the publicly funded health care system, sometimes well in excess of national economic growth. Eventually, the policy and planning document is seen as infeasible and is ignored. Box 6.1 sketches how comprehensive health planning has given way to a more flexible ‘framework’ approach. Ghana’s 1995 medium-term health strategy identified ten ways in which the health system would contribute towards better health (see Box 6.2). Public consultation occurs in some countries at the beginning of the policy formulation process. A “rolling” framework is sometimes used, and periodically updated and amended. In countries where external assistance forms an important part of the health system’s resources, an important expansion of this approach to policy-making and implementation is represented by sector-wide approaches (SWAPs). The essence of SWAPs is that, under government leadership, a partnership of funding agencies agrees to work together in support of a clear set of policy directions, often sharing many of the implementation procedures, such as supervision, monitoring, reporting, accounting, and purchasing. Box 6.3 summarizes the development of SWAPs. Health planning thus shows signs of moving beyond investment programming and towards consensus statements on broad lines of policy and system development. A policy framework should recognize all three health system goals and identify strategies to improve the attainment of each. Few countries have explicit policies on the overall goodness and fairness of the health system. Yet the need to combine these two values in governance can be traced far back in history (1). Box 6.4 describes the ancient Hisba system of stewardship in Islamic countries, highlighting both its ethical and economic purposes. Public statements about the desired balance among health outcomes, system responsiveness and fairness in financing are yet to be made anywhere. Policy should (and in partial Box 6.3 SWAPs: are they good for stewardship? A sector-wide approach (SWAP) is a method of working that brings together governments, donors, and other stakeholders within any sector. It is characterized by a set of operating principles rather than a specific package of policies or activities. The approach involves movement over time under government leadership towards: broadening policy dialogue; developing a single sector policy (that addresses private and public sector issues) and a common, realistic expenditure programme; common monitoring arrangements; and more coordinated procedures for funding and procurement. Being engaged in a SWAP implies commitment to this direction of change, rather than the comprehensive attainment of all these different elements from the start. It implies changes to the ways in which both governments and donor agencies operate, and in their required staff skills and systems. This approach has begun to take root primarily in some of the most highly aid-dependent countries. It has been driven by both government and donor concerns about the results of historical approaches to development assistance, which have often involved a combination of ‘social sector-blind’ macroeconomic adjustment policies and ‘sectorfragmenting’ projects. Many of the countries are in Africa, for example, Burkina Faso, Ethiopia, Ghana, Mali, Mozambique, Senegal, Uganda, the United Republic of Tanzania, and Zambia. The other cluster of countries discussing or actively engaging in a SWAP is in Asia: Bangladesh, Cambodia, and Viet Nam are examples. The evolution of a SWAP takes time. In Ghana, before the Ministry of Health single sector programme was endorsed by donors, the country had already gone through 10 years of institutional development, 4 years of major policy/strategy work, 3 years of strengthening core management functions, 2 years of negotiations, planning and design, and 1 year of slippage and delays.1 Cambodia and Viet Nam are at the earliest stage of discussing sector policy with donors. In other countries, progress has been mostly towards developing and agreeing to operate within a single sector policy and medium-term expenditure framework. Joint review missions have become a feature in some countries. Least progress has been made towards common financing and procurement arrangements. SWAPs have the potential to support good stewardship. Walt and colleagues argue that SWAPs are perceived as capable of strengthening governments’ ability to oversee the entire health system, develop policies and engage with stakeholders beyond the public sector.2 But, most importantly, SWAPs depend on vision and leadership by national government. 1 Smithson P. Cited in Foster M. Lessons of experience from sector-wide approaches in health. Geneva, World Health Organization, Strategies for Cooperation and Partnership, 1999 (unpublished paper). 2 Walt G et al. Managing external resources in the health sector: are there lessons for SWAPs? Health Policy and Planning, 1999, 14(3): 273–284
The World Health Report 2000 ways sometimes does) address the way in which the systems key functions are to be im- With respect to the provision of services, all providers should be recognized and their future contribution-greater in some cases, less in others -should be outlined On financ ing, strategies to reduce dependence on out-of-pocket payments and to increase prepay- ment should be identified Roles of the principal financing organizations -private and public, domestic and external -and of households should be recognized and their future directions determined. The machinery of stewardship, designed to regulate and monitor how these functions change in accordance with policy, should also be made explicit. This is ikely to involve opportunities for consumer representatives to balance provider interests Danger exists when particular lines of policy, or whole reform strategies, become asso- ciated with a specific political party or minister of health. Regardless of whether the policy is good or bad, it becomes highly vulnerable. When that minister or party leaves office the olicy dies, usually before it has either succeeded or failed, because the next minister or administration is seldom willing to work under the predecessors banner. Rapid tumover of enior policy officials, and a politically charged environment, are both hazards to good stewardship(11). Establishing good stewardship can reduce exposure to"personality cap- ture"of particular policy directions, by creating an informed constituency of stakeholder pport, and ensuring that the interests, skills and knowledge needed to maintain a par- ticular policy direction are widely distributed All remaining stewardship tasks concern the implementation of policy, as distinct from its formulation and promotion. SETTING THE RULES, ENSURING COMPLIANCE Regulation is a widely recognized responsibility of health ministries and, in some coun- tries, of social security agencies. It covers both the framing of the rules to govern the behav iour of actors in the health system, and ensuring compliance with them. In keeping with Box 6.4 Stewardship: the Hisba system in Islamic countries The institution of Hisba was de- main foundation of Hisba was to the conduct of different crafts, the field of pharmaceutical sery- veloped to carry out the function promote new social norms and de- trades and public services, including ices, technical publications were of stewardship in Islamic countries p the required system to ensure health services. The muhtasib re- prepared, including monographs more than 1400 years ago. The the adherence of various sectors of ceived complaints from the public describing standards and specifi Hisba system is a moral as well as society to these norms. but could also order an investigation cations for various drugs as well on. The first muhtasib in Islam was methods of quality assurance whose raison d'etre is to ordain woman called Al Shifa, appointed in Medical services were also regu- The system also included inspe good and forbid evil. The functions Medina, the capital of the Islamic lated by the Hisba system. Physi- tions and enforcement mech of the muhtasib(the head of Hisba state, by the second calif, Omar ibn cians and other health specialists nisms ategories: those relating to( the and given authority to control the tions and possess the necessary Hisba system underwent drastic hts of)God; those relating to markets. Another woman called equipment before being licensed. modification with the advent of (the rights of) people; and those Samra bint Nuhayk was given a The muhtasib had to ensure compli- westem colonization its functions milar authority in Mecca, the sec- ance of practising physicians to were transformed into a number The second and third categories ond city, by the same calif. moral and ethical norms, induding of secular departments and its are related to community affa The muhtasib could appoint tech- equitable provision of services and moral content reduced. and municipal administration. The nically qualified staff to investigate protection of the public interest. In ontributed by the World Health Organization Regional Office for the Eastern Mediterranean Source: Al-Shaykh al-Imam Ibn Taymiya Public duties in Islam: the institution of the Hisba Markfield, UK, The islamic Foundation, 1985
124 The World Health Report 2000 ways sometimes does) address the way in which the system’s key functions are to be improved. With respect to the provision of services, all providers should be recognized and their future contribution – greater in some cases, less in others – should be outlined. On financing, strategies to reduce dependence on out-of-pocket payments and to increase prepayment should be identified. Roles of the principal financing organizations – private and public, domestic and external – and of households should be recognized and their future directions determined. The machinery of stewardship, designed to regulate and monitor how these functions change in accordance with policy, should also be made explicit. This is likely to involve opportunities for consumer representatives to balance provider interests. Danger exists when particular lines of policy, or whole reform strategies, become associated with a specific political party or minister of health. Regardless of whether the policy is good or bad, it becomes highly vulnerable. When that minister or party leaves office the policy dies, usually before it has either succeeded or failed, because the next minister or administration is seldom willing to work under the predecessor’s banner. Rapid turnover of senior policy officials, and a politically charged environment, are both hazards to good stewardship (11). Establishing good stewardship can reduce exposure to “personality capture” of particular policy directions, by creating an informed constituency of stakeholder support, and ensuring that the interests, skills and knowledge needed to maintain a particular policy direction are widely distributed. All remaining stewardship tasks concern the implementation of policy, as distinct from its formulation and promotion. SETTING THE RULES, ENSURING COMPLIANCE Regulation is a widely recognized responsibility of health ministries and, in some countries, of social security agencies. It covers both the framing of the rules to govern the behaviour of actors in the health system, and ensuring compliance with them. In keeping with Box 6.4 Stewardship: the Hisba system in Islamic countries The institution of Hisba was developed to carry out the function of stewardship in Islamic countries more than 1400 years ago. The Hisba system is a moral as well as a socioeconomic institution, whose raison d’être is to ordain good and forbid evil. The functions of the muhtasib (the head of Hisba system) can be classified into three categories: those relating to (the rights of ) God; those relating to (the rights of) people; and those relating to both. The second and third categories are related to community affairs and municipal administration. The main foundation of Hisba was to promote new social norms and develop the required system to ensure the adherence of various sectors of society to these norms. The first muhtasib in Islam was a woman called Al Shifa, appointed in Medina, the capital of the Islamic state, by the second calif, Omar ibn Al Khattab, almost 1450 years ago, and given authority to control the markets. Another woman called Samra bint Nuhayk was given a similar authority in Mecca, the second city, by the same calif. The muhtasib could appoint technically qualified staff to investigate the conduct of different crafts, trades and public services, including health services. The muhtasib received complaints from the public but could also order an investigation on his or her own initiative. Medical services were also regulated by the Hisba system. Physicians and other health specialists had to pass professional examinations and possess the necessary equipment before being licensed. The muhtasib had to ensure compliance of practising physicians to moral and ethical norms, including equitable provision of services and protection of the public interest. In the field of pharmaceutical services, technical publications were prepared, including monographs describing standards and specifications for various drugs as well as methods of quality assurance. The system also included inspections and enforcement mechanisms. Like many other institutions, the Hisba system underwent drastic modification with the advent of western colonization: its functions were transformed into a number of secular departments and its moral content reduced. Contributed by the World Health Organization Regional Office for the Eastern Mediterranean. Source: Al-Shaykh al-Imam Ibn Taymiya. Public duties in Islam: the institution of the Hisba. Markfield, UK, The Islamic Foundation, 1985
How is the public Interest protected? the policy-making and intelligence tasks, regulation has to encompass all health actions and actors, and not just those of the health ministry or the public sector. While the public health care system is often replete with regulations, few countries(with either high or low income) have developed adequate strategies to regulate the private financing and provi sion of health services. The rethinking of a consistent set of regulatory approaches to pri- vate providers and sources of finance, in line with national goals and priorities, is a to priority task in most countries. gulation can either promote or restrict. Since the private sector comprises many differ- ent players, national policy needs to distinguish carefully where to promote and where to restrict. A single position on the private sector is unlikely to be appropriate In promotive terms, explicit incentives may be provided for private practice such as the sale of public assets, preferential loans, or donations of land. Tax incentives may be offered to promote private provision, with no or very little government regulation of providers market behav iour. China re-legalized private practice in the 1980s and promoted joint public/private ventures in hospital ownership. Thailand,'s finance ministry offers tax incentives to private hospital investors At the other extreme, significant barriers to market entry have sometimes such as a legal ban on private practice. This is still the case in Cuba and was previously in Ethiopia, Greece(for hospitals), Mozambique, the United Republic of Tanzania and several other countries. Between these extremes are policies that allow relatively free market entry, provide modest incentives, or have limited prerequisites for those wishing to enter the private market, including some standards for market behaviour and some level of oversight Incentives for greater private sector opportunities in health are often sought by govern- ment agencies other than the health ministry, and by private investors themselves. Finance, rade, and development ministries often advocate greater private investment in health in line with overall economic liberalization strategies Promotive policies seem to work, contributing to growth in private finance and provi sion(12, 13). But they have also had serious side-effects: rising inequities, uneven quality of care, and inefficiency. The health ministry needs to know in advance what conditions it will require for such investments to contribute to the efficiency, quality, or equity goals of th health system, and how to defend the view that health is not just like all other sectors The harm caused by market abuses is difficult to remedy after the fact. The United States is probably the best-documented case of regulators trying to catch up with private health insurers(14). State governments have extensive laws, regulations and enforcement author ity over private insurers in the USa to ensure fair competition, assure quality and generally protect consumers from fraudulent marketing. This regulatory framework took many years to develop and is still far from perfect: it does not guarantee insurance for everyone. Recent ea access but not the affordability of, private by small employers and individuals. Private employers have devised various ways of avoid he rules, so as to come under the looser federal regulations. But the system prevents many of the worst abuses- financially unsound or unscrupulous insurers-and hell ameliorate many market failures. Chile and South Africa have similar experiences in regu lating private health insurance practice. South Africa has recently changed earlier regula- tions governing medical schemes to reduce risk selection and increase risk pooling(see Box Chile has been unable to establish explicit contractual obligations for private insurers or prohibit risk selection by these private companies, due to the political influence of insurers
How is the Public Interest Protected? 125 the policy-making and intelligence tasks, regulation has to encompass all health actions and actors, and not just those of the health ministry or the public sector. While the public health care system is often replete with regulations, few countries (with either high or low income) have developed adequate strategies to regulate the private financing and provision of health services. The rethinking of a consistent set of regulatory approaches to private providers and sources of finance, in line with national goals and priorities, is a top priority task in most countries. Regulation can either promote or restrict. Since the private sector comprises many different players, national policy needs to distinguish carefully where to promote and where to restrict. A single position on the private sector is unlikely to be appropriate. In promotive terms, explicit incentives may be provided for private practice such as the sale of public assets, preferential loans, or donations of land. Tax incentives may be offered to promote private provision, with no or very little government regulation of providers’ market behaviour. China re-legalized private practice in the 1980s and promoted joint public/private ventures in hospital ownership. Thailand’s finance ministry offers tax incentives to private hospital investors. At the other extreme, significant barriers to market entry have sometimes been created, such as a legal ban on private practice. This is still the case in Cuba and was previously in Ethiopia, Greece (for hospitals), Mozambique, the United Republic of Tanzania and several other countries. Between these extremes are policies that allow relatively free market entry, provide modest incentives, or have limited prerequisites for those wishing to enter the private market, including some standards for market behaviour and some level of oversight and enforcement. Incentives for greater private sector opportunities in health are often sought by government agencies other than the health ministry, and by private investors themselves. Finance, trade, and development ministries often advocate greater private investment in health in line with overall economic liberalization strategies. Promotive policies seem to work, contributing to growth in private finance and provision (12, 13). But they have also had serious side-effects: rising inequities, uneven quality of care, and inefficiency. The health ministry needs to know in advance what conditions it will require for such investments to contribute to the efficiency, quality, or equity goals of the health system, and how to defend the view that health is not just like all other sectors. The harm caused by market abuses is difficult to remedy after the fact. The United States is probably the best-documented case of regulators trying to catch up with private health insurers (14). State governments have extensive laws, regulations and enforcement authority over private insurers in the USA to ensure fair competition, assure quality and generally protect consumers from fraudulent marketing. This regulatory framework took many years to develop and is still far from perfect: it does not guarantee insurance for everyone. Recent regulatory changes have improved access to, but not the affordability of, private insurance by small employers and individuals. Private employers have devised various ways of avoiding the rules, so as to come under the looser federal regulations. But the system prevents many of the worst abuses – financially unsound or unscrupulous insurers – and helps to ameliorate many market failures. Chile and South Africa have similar experiences in regulating private health insurance practice. South Africa has recently changed earlier regulations governing medical schemes to reduce risk selection and increase risk pooling (see Box 6.5). Chile has been unable to establish explicit contractual obligations for private insurers or prohibit risk selection by these private companies, due to the political influence of insurers
126 and their clients. If there is a long delay between market entry and the enforcement of rules regarding market behaviour, experience suggests that the task of instituting those rules will politically very difficult(15, 16 A more moderate form of incentives for private sector involvement are represented by contracts between public purchasers and private providers In Lebanon, for example, 90% of hospital beds are in the private sector and nongovernmental organizations provide am bulatory care to about 10-15% of the population, particularly to the poor. Out of necessity, e Ministry of Health contracts with almost all private hospitals for a predetermined number of beds to serve public patients(17). But the government does not use this regulatory tool to its advantage. Reimbursement policies allow unnecessary hospitalizations and overuse of services, which result in cost escalation; and private hospitals operate in a largely unreg lated environment, which leads to uncontrolled investment. This in turn can lead to pres financial support, which will appear to justify further investment. Stewardship needs to ensure consistency in the incentive messages sent out by different levels of public policy. Regulation requires resources. Regulatory oversight and contractual strategies entail high transaction costs for both government and providers or insurers, which may reduce the potential cost savings of these strategies. High levels of awareness of these costs accompa nied the moves to separate the roles of purchasers and providers in the United Kingdom and New Zealand(18). Often, lack of commitment and funds hamper government capac- ity to carry out regulatory responsibilities, old as well as new. This suggests that capacity building in contracting skills and regulatory oversight is critically needed both via recruit ment of skilled staff and through training and technical aid to existing staff Box 6.5 South Africa: regulating the private insurance market to increase risk pooling The government which came to heightening the problem of in- sure that a greater proportion of team to prepare new regulations power in 1994 after South Africas equality contributions flows into the com for medical schemes the team first democratic elections found The new government's response mon risk po produced its first discussion docu- itself with a health sector which to these challenges was to enact Promoting lifetime coverage. Com- ment in 1996, and consulted mirrored the inequalities existing new legislation for medical schemes munity rating and guaranteed ac- widely with key stakeholders on in the wider society. A long-estab- to offer a minimum benefits pack- cess will be combined with its proposals. Discussion and de- lished and well-developed private age and increased risk pooling. The premium penalties for those who bate continued until mid-1997 health care industry accounted for fundamentalprinciples and objectives choose only to take out cover later when a formal policy paper re- 61 of health care financial re- the core of the Act are as follows. in life, to provide powerful incen- sulted. After a period of intense, ources, whi nly the affluent 20% of product or option, the only ive process, the new Medical the population. The vast majority grounds on which premiums may Prescribed minimum benefits. Schemes Act and its of the population had to rely upon be varied are family size and in- Every medical scheme must guar- Regulations came into force on 1 orly distributed, underfunded come Risk or age rating are pro- antee to cover in full the cost of January 2000, three anda halfyears and fragmented public services. hibited treating a specified list of condi- after the committee was formed st escalation in the private sec- Guaranteed access. No-one who tions and procedures in public fa- One important group will benefit tor typically exceeded inflation can afford the community rated cilities, thus greatly decreasing the immediately. HIV-positivemembers during most of the late 1980s and premium 1990s. The private sector re- sponded to this by limiting ben- c ns 8 o may be excluded on impact of dumping" patients of medical schemes now have ac- or health status. onto the state cess to subsidized care, induding risk pooling. Caps on the drugs for opportunistic infections, efits, increasing co-payments and sible contributions and ac- A committee of inquiry was ap. whereas previously they were ex- accelerating the exclusion of high- mulations through individual pointed by the health minister dur- duded or theirentitlementwas lim- risk members from cover, thereby medical savings accounts will en- ing 1995. It set up a small technical ited to very low benefit levels I Reforming private health financing in South Africa: the quest for greater equity and efficiency. Pretoria, Department of Health, 1997
126 The World Health Report 2000 and their clients. If there is a long delay between market entry and the enforcement of rules regarding market behaviour, experience suggests that the task of instituting those rules will become politically very difficult (15, 16). A more moderate form of incentives for private sector involvement are represented by contracts between public purchasers and private providers. In Lebanon, for example, 90% of hospital beds are in the private sector and nongovernmental organizations provide ambulatory care to about 10–15% of the population, particularly to the poor. Out of necessity, the Ministry of Health contracts with almost all private hospitals for a predetermined number of beds to serve public patients (17). But the government does not use this regulatory tool to its advantage. Reimbursement policies allow unnecessary hospitalizations and overuse of services, which result in cost escalation; and private hospitals operate in a largely unregulated environment, which leads to uncontrolled investment. This in turn can lead to pressure for sustained public financial support, which will appear to justify further investment. Stewardship needs to ensure consistency in the incentive messages sent out by different levels of public policy. Regulation requires resources.Regulatory oversight and contractual strategies entail high transaction costs for both government and providers or insurers, which may reduce the potential cost savings of these strategies. High levels of awareness of these costs accompanied the moves to separate the roles of purchasers and providers in the United Kingdom and New Zealand (18). Often, lack of commitment and funds hamper government capacity to carry out regulatory responsibilities, old as well as new. This suggests that capacity building in contracting skills and regulatory oversight is critically needed both via recruitment of skilled staff and through training and technical aid to existing staff. Box 6.5 South Africa: regulating the private insurance market to increase risk pooling The government which came to power in 1994 after South Africa’s first democratic elections found itself with a health sector which mirrored the inequalities existing in the wider society. A long-established and well-developed private health care industry accounted for 61% of health care financial resources, while providing for the needs of only the affluent 20% of the population. The vast majority of the population had to rely upon poorly distributed, underfunded and fragmented public services. Cost escalation in the private sector typically exceeded inflation during most of the late 1980s and 1990s. The private sector responded to this by limiting benefits, increasing co-payments and accelerating the exclusion of highrisk members from cover, thereby heightening the problem of inequality. The new government’s response to these challenges was to enact new legislation for medical schemes to offer a minimum benefits package and increased risk pooling. The fundamental principles and objectives at the core of the Act are as follows. • Community rating. For a given product or option, the only grounds on which premiums may be varied are family size and income. Risk or age rating are prohibited. • Guaranteed access. No-one who can afford the community rated premium may be excluded on grounds of age or health status. • Increased risk pooling. Caps on the permissible contributions and accumulations through individual medical savings accounts will ensure that a greater proportion of contributions flows into the common risk pool. • Promoting lifetime coverage. Community rating and guaranteed access will be combined with premium penalties for those who choose only to take out cover later in life, to provide powerful incentives for affordable lifetime membership. • Prescribed minimum benefits. Every medical scheme must guarantee to cover in full the cost of treating a specified list of conditions and procedures in public facilities, thus greatly decreasing the impact of “dumping” patients onto the state. A committee of inquiry was appointed by the health minister during 1995. It set up a small technical team to prepare new regulations for medical schemes. The team produced its first discussion document in 1996, and consulted widely with key stakeholders on its proposals. Discussion and debate continued until mid-1997, when a formal policy paper resulted.1 After a period of intense, open debate during the legislative process, the new Medical Schemes Act and its accompanying Regulations came into force on 1 January 2000, three and a half years after the committee was formed. One important group will benefit immediately: HIV-positive members of medical schemes now have access to subsidized care, including drugs for opportunistic infections, whereas previously they were excluded or their entitlement was limited to very low benefit levels. Contributed by T. Patrick Masobe, Department of Health, South Africa. 1 Reforming private health financing in South Africa: the quest for greater equity and efficiency. Pretoria, Department of Health, 1997
How is the public Interest protected? Shortcomings in staff skills or resources are often cited as the cause of outdated regula tory frameworks, or those which are not adequately enforced ( 4). Lack of legislative author- ity, too, is sometimes at fault. For example, in the late 1970s, Sri Lanka deregulated private practice by government doctors and liberalized the economy in general, which increased availability of capital (19). However, the health ministry failed to register effectively the wing number of private providers. It had no regulatory strategy, no staff responsible for private sector relations, and it lacked adequate legislative authority to take on many tasks. The only law on the books required registration of nursing homes, but not private clinics or doctors. A law has been pending since 1997 but has not yet been implemented. However, a new Ministry of Health unit for development and regulation of the private sector was set up in 1998 In Egypt, most physicians work simultaneously for the government and in private prac. e. As a result, much of their work escapes oversight and regulation. Similar practice is widespread in Latin America. In India, mechanisms for monitoring, let alone regulating, the private sector have not kept pace with its expansion, despite concems about quality of care Health professionals are aware of practice-related laws but know that enforcement is weak or non-existent and that professional associations, which are nominally responsible tion,are also ineffective. When public providers illegally use public facilities to provide special care to private patients, the public sector ends up subsidizing unofficial private practice. It is nearly impos sible to completely prohibit private practice by health workers on the public payroll,but several steps can be taken to ensure that private practitioners compete on a fair basis and lo not flourish by"moonlighting " at public expense(20, 21). Ensuring that patients, the public, and the media, as well as providers, know the rules is an important factor in regulat ng the public-private mix. Effective public services themselves can be a regulatory tool Developing effective public provision and financing systems becomes even more important if government policy seeks to restrict the development of a private health market, or when it lacks the resources to prevent undesirable market failures. The public sector must then respond to the changing needs of consumers, to the introduction of new medical technologies, and to reasonable expectations of health professionals. A strong public sector may even be a very good strat gy for regulating private provision and for consumer protection, if it helps to keep the private sector more competitive in price and quality of service or which is seen as I quality and responsiveness, in spite of its free or subsidized services. If the public system deteriorates or does not continually improve, an unhealthy amount of resources and atten tion will be siphoned off trying to catch offenders in the "black market, and growing un der-the-table payments Rules rarely enforced are invitations for abuse. Stricter oversight and regulation of pri- vate sector providers and insurers is now on the policy agenda of many countries. But progress is slow if not impossible. This suggests that countries must not only consider the impact of the private sector on the public sector and develop the regulatory framework to limit deleterious effects, but must make a continuing commitment to enforce the rules by investing in the knowledge and skills of regulatory staff. a study in Sri Lanka conclude the slow response in the 1980s makes the regulatory task in the 1990s more difficult: uncoordinated and unmonitored private sector growth has created a market context which is bigger, more complex, and with more established provider and user interests"(19)
How is the Public Interest Protected? 127 Shortcomings in staff skills or resources are often cited as the cause of outdated regulatory frameworks, or those which are not adequately enforced (4). Lack of legislative authority, too, is sometimes at fault. For example, in the late 1970s, Sri Lanka deregulated private practice by government doctors and liberalized the economy in general, which increased availability of capital (19). However, the health ministry failed to register effectively the growing number of private providers. It had no regulatory strategy, no staff responsible for private sector relations, and it lacked adequate legislative authority to take on many tasks. The only law on the books required registration of nursing homes, but not private clinics or doctors. A law has been pending since 1997 but has not yet been implemented. However, a new Ministry of Health unit for development and regulation of the private sector was set up in 1998. In Egypt, most physicians work simultaneously for the government and in private practice. As a result, much of their work escapes oversight and regulation. Similar practice is widespread in Latin America. In India, mechanisms for monitoring, let alone regulating, the private sector have not kept pace with its expansion, despite concerns about quality of care. Health professionals are aware of practice-related laws but know that enforcement is weak or non-existent and that professional associations, which are nominally responsible for self-regulation, are also ineffective. When public providers illegally use public facilities to provide special care to private patients, the public sector ends up subsidizing unofficial private practice. It is nearly impossible to completely prohibit private practice by health workers on the public payroll, but several steps can be taken to ensure that private practitioners compete on a fair basis and do not flourish by “moonlighting” at public expense (20, 21). Ensuring that patients, the public, and the media, as well as providers, know the rules is an important factor in regulating the public–private mix. Effective public services themselves can be a regulatory tool. Developing effective public provision and financing systems becomes even more important if government policy seeks to restrict the development of a private health market, or when it lacks the resources to prevent undesirable market failures. The public sector must then respond to the changing needs of consumers, to the introduction of new medical technologies, and to reasonable expectations of health professionals. A strong public sector may even be a very good strategy for regulating private provision and for consumer protection, if it helps to keep the private sector more competitive in price and quality of service. Too often, however, it is the public sector which is seen as uncompetitive in terms of quality and responsiveness, in spite of its free or subsidized services. If the public system deteriorates or does not continually improve, an unhealthy amount of resources and attention will be siphoned off trying to catch offenders in the “black market”, and growing under-the-table payments will undermine equity goals. Rules rarely enforced are invitations for abuse. Stricter oversight and regulation of private sector providers and insurers is now on the policy agenda of many countries. But progress is slow if not impossible. This suggests that countries must not only consider the impact of the private sector on the public sector and develop the regulatory framework to limit deleterious effects, but must make a continuing commitment to enforce the rules by investing in the knowledge and skills of regulatory staff. A study in Sri Lanka concluded, “the slow response in the 1980s makes the regulatory task in the 1990s more difficult: uncoordinated and unmonitored private sector growth has created a market context which is bigger, more complex, and with more established provider and user interests” (19)