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 frequently120 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￾tries 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 organiza￾tions providing health 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: nongovernmental 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 regulation. Some large health insurance schemes in India currently have no legal status (6). In Eu￾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 obvi￾ously 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