Author: Enrico Pavignani
Analysing disrupted health sectors: a toolkit
Module 12: Formulating strategies for the recovery of a disrupted health sector
The module discusses practical ways to approach the recovery of a disrupted health sector, suggesting step-by-step iterations aimed at appraising and costing merits and drawbacks of different broad options available to policy makers. Ways to project the effects of conservative recovery strategies, alongside those induced by the adoption of alternative service delivery models, are described. Flaws commonly found in troubled health sectors and possible policy responses are sketched. The methods described are supposed to be applied to a transitional context, such as during the last years of a conflict, when peace negotiations are under way and a final settlement is anticipated. This module assumes familiarity by the reader with most of the issues covered by Modules 2 to 11. For the sake of brevity, issues and methods discussed in detail in other parts of the toolkit are only briefly mentioned.
Annex 12 presents summaries of some already completed reconstruction processes, proposed as empirical reference frames to decision-makers involved in transitional health sectors.
Recovery after extensive destruction may offer a unique chance to reconsider the whole health sector and plan it on a comprehensive, rational basis. In many instances, large amounts of capital become frequently available to address major allocative distortions; the atmosphere of change may reduce resistance aimed at preserving the status quo; massive destruction and dilapidation make the abandonment of unwanted facilities easier. Thus, building an equitable and sustainable (in the long-term) health system may become a realistic target. A country emerging from a prolonged crisis cannot afford to miss that chance.
Furthermore, in the optimistic mood that usually characterises reconstruction, investment decisions should not be taken light-heartedly. They will shape the health sector far into the future. In the same way present allocative decisions are heavily influenced by investment choices made decades ago, the future allocation of recurrent resources will follow to a large extent the distribution of the physical infrastructure resulting from the recovery.
The rethinking of the health sector should go beyond the hardware that usually absorbs the attention of decision-makers. To take advantage of the opportunity and to complete the reassessment of the sector, legal, regulatory and management systems, as well as health care delivery models, need equivalent revisiting. If the rethinking of the sector is based on a robust understanding of the situation, success can follow. Conversely, policy changes inspired by imported and often untested recipes imposed by outsiders, whose only merit is the power they hold, are frequently unsuccessful. A sensible and effective recovery strategy is likely to emerge from the balanced encounter of insiders knowledgeable of the country and outsiders familiar with potentials and pitfalls of transitional processes.
Many health sectors grow organically over the years, being shaped by countless political and economic decisions unrelated to each other. Even in countries where PHC has dominated the policy discourse over a long time, certain distortions, such as the hospital bias, may persist unabated, because of strong interests. Additionally, protracted crises tend to hide existing distortions, which when left unrecognized can only get worse.
In most instances, the recovery of a disrupted health sector calls for:
- the expansion of service provision to cover underserved areas and populations; in some cases, the merging of formerly partitioned health services is part of the process.
- the improvement of the technical contents of the offered health care; surgical basic care, laboratory and other diagnostic aids, inpatient care must be made again accessible to users.
- the adoption of new service delivery models, if the dominant ones are recognized as outdated, in light of new health needs or a changed environment.
- increased returns from the inputs absorbed by the delivery process, so as to free resources to support the actions mentioned above.
Thus, to revamp a crippled sector means to increase its equity, effectiveness, appropriateness and efficiency. These dimensions can receive different degrees of attention, according to the perceptions and priorities of decision-makers and the constraints conditioning their actions. For instance, to expand service provision to cover previously destitute populations may appear more attractive to politicians than to health professionals, who are often more worried with the quality of the offered care. Local grievances may be appeased with health infrastructures, financed by aid agencies, as a peace-building measure. Ruling elites, mainly concerned with their own welfare and their own constituency, are prone to give precedence to tertiary care in the capital town. MoH officials may perceive the recovery process as an opportunity to claw power back from aid agencies. Other stakeholders, such as external financiers, may emphasize efficiency considerations, or, when under pressure to demonstrate progress, just give precedence to actions that are visible, easy and fast to implement. Frequently, most parties support physical rehabilitation, while other aspects of health care delivery are neglected.
Analysing disrupted health sectors: a toolkit:
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