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