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 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 base, the ability to build coalitions of support from different groups, and the ability to set incen￾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 turning 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￾ments have a long history, predat￾ing but stimulated by international concern for promoting primary health care. In many centrally planned and developing econo￾mies, 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 of￾ten took inadequate account of fi￾nancial realities and people’s pref￾erences. 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 docu￾ment 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 di￾rection but not spelling out the op￾erational detail, as in Ghana and Kenya. A national health policy frame￾work:1 • identifies objectives and ad￾dresses major policy issues; • defines respective roles of the public and private sectors in fi￾nancing and provision; • identifies policy instruments and organizational arrange￾ments required in both the public and private sectors to meet system objectives; • sets the agenda for capacity building and organizational de￾velopment; • provides guidance for prioriti￾zing expenditure, thus linking analysis of problems to deci￾sions 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)