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World Health Report 2008

World Health Report 2008

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UN World Health Report for 2008
UN World Health Report for 2008

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The stimulation of open, collaborative structures
that supply reforms with strategic intelligence
and harness innovation throughout the health
system requires a critical mass of committed and
experienced people and institutions. They must
not only carry out technical and organizational
tasks, but they must also be able to balance fex-
ibility and coherence, adapt to new ways of work-
ing, and build credibility and legitimacy54
.
However, that critical mass of people and
institutions is often not available31

. Institutions
in low-income countries that have suffered
from decades of neglect and disinvestment are
of particular concern. They are often short on
credibility and starved of resources, while key
staff may have found more rewarding working
environments with partner agencies. Poor gover-
nance complicates matters, and is compounded
by international pressure for state minimalism
and the disproportionate infuence of the donor

community. The conventional responses to lead-
ership capacity shortfalls in such settings, which
are characterized by a heavy reliance on external
technical assistance, toolkits and training, have
been disappointing (Box 5.4). They need to be
replaced by more systematic and sustainable
approaches in order to institutionalize competen-
cies that learn from and share experience55
.

Documented evidence of how individual and
institutional policy dialogue and leadership
capacities build up over time is hard to fnd, but
a set of extensive interviews of health sector lead-
ers in six countries shows that personal career
trajectories are shaped by a combination of three
decisive experiences56
.
At some point in their careers, all had been

part of a major sectoral programme or project,
particularly in the area of basic health serv-
ices. Many of them refer to this as a formative
experience: it is where they learned about
PHC, but also where they forged a commit-
ment and started building critical alliances
and partnerships.
Many became involved in national planning

exercises, which strengthened their capacity to
generate and use information and, again, their
capacity to build alliances and partnerships.
Few had participated personally in major stud-
ies or surveys, but those who had, found it an
opportunity to hone their skills in generating
and analyzing information.
All indicated the importance of cooptation and

coaching by their elders: “You have to start out
as a public health doctor and be noticed in one
of the networks that infuence decision making
in MOH. After that your personal qualities and
learning by doing [determine whether you’ll get
to be in a position of leadership].”56

These personal histories of individual capacity
strengthening are corroborated by more in-depth
analysis of the factors that contributed to the
institutional capacities for steering the health
sector in these same countries. Table 5.2 shows
that opportunities to learn from large-scale
health-systems development programmes have
contributed most, confrming the importance of
hands-on engagement with the problems of the
health sector in a collaborative environment.

91

Chapter 5. Leadership and effective government

Box 5.4 Limitations of conventional capacity building in low- and middle-income countries55

The development community has always tended to respond to the
consequences of institutional disinvestment in low- and middle-
income countries through its traditional arsenal of technical assist-
ance and expert support, toolkits and training (Figure 5.5). From
the 1980s onwards, however, it became clear that such “technical
assistance” was no longer relevant
58

and the response re-invented
itself as “project management units” concentrating on planning,
financial management and monitoring.

The stronger health systems were able to benefit from the
resources and innovation that came with projects but, in others,
the picture was much more mixed. As a recurrent irritant to national
authorities, accountability to funding agencies often proved
stronger than commitment to national development: demonstrat-
ing project results took precedence over capacity building and
long-term development
59

, giving disproportionate weight to project
managers at the expense of policy coherence and country leader-
ship. In more recent years, the wish to reinforce country ownership
– and changes in the way donors purchase technical assistance
services – paved the way for a shift from project management to
the supply of short-term expertise through external consultants.
In the 1980s and early 1990s, the expertise was essentially pro-
vided by academic institutions and the in-house experts of bilateral
cooperation and United Nations agencies. The increased volume of
funding for technical sup-
port contributed to shift-
ing the expertise market
to freelance consultants
and consultancy firms, so
that expertise has become
increasingly provided on a
one-time basis, by techni-
cal experts whose under-
standing of the systemic
and local political context
is necessarily limited
60
.

In 2006, technical coop-
eration constituted 41%
of total overseas devel-
opment aid for health.
Adjusted for inflation, its
volume tripled between
1999 and 2006, particu-
larly through expansion of
technical cooperation on
HIV/AIDS. Adapting to the complexities of the aid architecture,
experts and consultants now also increasingly act as intermediar-
ies between countries and the donor community: harmonization
has become a growth business, lack of country capacity fuelling
further disempowerment.

12 000

10 000

Millions I$ 2005

0

2002

Figure 5.5 A growing market: technical cooperation as part of Official
Development Aid for Health. Yearly aid flows in 2005,
deflator adjusted
61

2000

8000

4000

6000

14 000

Other health aid
Technical cooperation HIV/AIDS

Technical cooperation health

11%
36%

2003

2004

2005

2006

20%

21%

The second mainstay response to the capacity problem has been the
multiplication of planning, management and programme toolkits.
These toolkits promise to solve technical problems encountered
by countries while aiming for self-reliance. For all their potential,
rigour and evidence base, the usefulness of toolkits in the field has
often not lived up to expectations for four main reasons.
They often underestimate the complexity of the problems they

are supposed to deal with62
.
They often rely on international expertise for their implementa-

tion, thereby defeating one of their main purposes, which is
to equip countries with the ways and means to deal with their
problems themselves.
Some have not delivered the promised technical results

63

or

led to unexpected untoward side-effects64
.
The introduction of toolkits is largely supply driven and linked to

institutional interests, which makes it difficult for countries to
choose among the multitude of competing tools that are proposed.

The capacity-building prescription that completes the spectrum is
training. Sometimes, this is part of a coherent strategy: Morocco’s
Ministry of Health, for example, has applied a saturation training
approach similar to that of Indonesia’s Ministry of Finance
65

, send-
ing out large numbers of young professionals for training in order
to build up a recruitment
base of qualified staff and,
eventually, a critical mass
of leaders. Such deliberate
approaches, however, are
rare. Much more common are
short “hotel” training courses
that mix technical objectives
and exchange with implicit
aims to top-up salaries and
buy political goodwill. The
prevailing scepticism about
the usefulness of such pro-
grammes (systematic evalu-
ation is uncommon) contrasts
sharply with the resources
they mobilize, at a consider-
able opportunity cost.

In the meantime, new mar-
kets in education, training
and virtual learning are
developing, while actors in
low- and middle-income countries can access Internet sites on
most health systems issues and establish electronic communi-
ties of practice. With contemporary information technology and
globalization, traditional recipes for capacity development in poor
countries are quickly becoming obsolete
54
.

The World Health Report 2008

Primary Health Care – Now More Than Ever

92

Especially noteworthy is the fact that the intro-
duction of tools was rarely identifed as a critical
input, and respondents did not highlight inputs
from experts and training.
The implication is that the key investment
for capacity building for PHC reforms should be
to create opportunities for learning by linking
individuals and institutions to ongoing reform
processes. A further consideration is the impor-
tance of doing so in an environment where
exchange, within and between countries, is
facilitated. Unlike the conventional approaches
to capacity building, exchange and exposure to
the experience of others enhances self-reliance.
This is not just a recipe for under-resourced
and poorly performing countries. Portugal, for
example, has organized a broad societal debate
on its 2004−2010 National Health Plan involving
a pyramid of participation platforms from local
and regional to national level, and 108 substantial
contributions to the plan from sources ranging
from civil society and professional organizations
to local governments and academia. At three crit-
ical moments in the process, international panels
of experts were also invited from other countries
to act as sounding boards for their policy debate:
a collaboration that was a learning exercise for
all parties57
.

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