Key Issues and Structural Obstacles

Low wages:

All these positive developments, which show the willingness of the Ministry of Health to develop the public health sector, are however jeopardised by a number of structural obstacles, which are beyond the Ministry of Health's authority but need to be addressed at a higher level. Thus, the problem of low salaries, which discourages public health workers, jeopardises the quality and availability of public health services. Senior consultants who are supporting the Ministry of Health in building the national Health Sector Strategic Plan noted that the issue was not selected during the national workshop organised to establish the health sector priorities for 2003-2007. When participants were questioned informally about this, the response usually was that this issue " has come up time and time again and no one seems to be able to address it so we have given up…"[1] Medicam joins other partners who strongly recommend an increase in salaries to the level of a living wage. The recently established "Position allowance" and the "Priority Mission Group" strategy adopted by the Council for Administrative Reform are two positive steps forward, but the salary increase they generate is so meagre for field health workers that they still do not address the low wage problem. Still, access to affordable quality health services in the public sector is a crucial factor of poverty reduction, and this can only happen if health workers are able to perform without the recurrent worry about insufficient income.

Salary reform is not included in the health section of the text or of the Action Plan matrix, though it is included in the education section and the Finance Reform matrix. There is reference, though, to “Incentives to staff working in remote areas will be effectuated through performance based measures.”

So far, the government has argued that it does not have the financial capacity to increase salaries. Medicam joins other partners who recommend that the government assess strategies that will better balance its budget between running costs and public staff compensations. A much higher budget should be provided to the Ministry of Health to allow the latter to provide public health workers with specific significant allowances, in particular 1) to encourage health workers who are ready to work in remote areas, and 2) to motivate health workers to provide quality services. It has to be noted here that only experiences of bonus provision that have linked bonus payment to performance have been successful. As such, local independent monitoring and evaluation bodies need to be established to monitor performance and encourage public health workers to perform well.

As noted above, there is reference to “incentives to staff working in remote areas will be effectuated through performance based measures.” Public support for health care is projected to increase during the next coming years and in addition, human resource development is one working principles in The Health policy Statement 2002-2007. However, the need for raising salaries for health workers is not mentioned.  By contrast, the Action Plan matrix includes specific indicators for increasing salaries in the education sector.

Budget Release and Access to Budget:

Current cash flow procedures are another structural obstacle that prevents the public health system developing as they dramatically delay budget release and access to budget. As a result, only 3% of the health section of the PAP budget (against 25% after three months in 2001) and close to 0% of the health section of Chapter 11 were released during the first four months of 2002. This deep structural macro-economic problem worsens year after year and paralyses the whole public health sector. The NGO community would appreciate being briefed on plans and progress being made at that level to address this crucial issue.

Not included.  The need for timely disbursements is mentioned in Chapter 5, but no specific data, indicators and consultative measures are mentioned, neither in the text nor in the Action Plan matrix. There is, though, reference to the “National Commission on Macroeconomics and Health, a joint initiative between the MoH and the MEF, to be formed in 2003 to focus on investments in the health sector.”

Equity Funds

In this difficult structural context, some intermediary priority measures can be taken to improve the health status of the population and contribute to poverty alleviation. Exemption status for the poor has already been established, which is a positive step towards improving access to public health care for the poor. It is recommended that the financial burden of the exemption for the poor be not borne completely by the health facilities and the health workers. Thus, equity funds could be established in all Operational Districts where quality of care and management are present to support them. To avoid conflict of interest, it is highly recommended that a third party, with a good understanding of the local communities, manages these equity funds.

Partly included in the text. The equity funds are included in the text, but there is no mention of a third party to manage these funds. No budget is available in the Action Plan matrix.

Nutrition, Outreach Activities and Behaviour Change

Improvement of the nutrition status and prevention of disease, particularly for poor people, would help them cut their expenditures for curative health services. Thus, outreach activities could be promoted and monitored. Also, promotion of behavioural change at consumer level, as well as at practitioner level, could be undertaken on a large scale. Firstly, at consumer level, this would require studies in health behaviours, particularly health behaviours relating to the poor. Medicam congratulates the Ministry of Health for considering the inclusion of behaviour change in the coming five-year Health Sector Strategic Plan, and would stress that the ministry give this a high priority in its annual plans.

Included in the text, budget references provided in the Action Plan Matrix under Section 3.2. (Nutrition).

conclusion

Improving the population’s health status is a necessary pre-requisite to other poverty reduction and human development objectives. The booming private sector presents itself as an alternative to the public health sector affected by the structural weaknesses and financial difficulties. However, in an environment notorious for its reluctance to accept regulation, commercial health care provision with its high prices, will not lead to improved access to the poor. Moreover, a recent study revealed that 49% of private practitioner's prescriptions are hazardous.[2]

Not included.

Strengthening the public health sector and regulating the private sector will remove threats to the health status of the people and obstacles to economic development.

Reference to “strategies aimed at reducing financial barriers among the poor and improving management capacity within the public sector, but there is no specific reference to quality control.