Public Sector and NGO Roles in Changing Health Systems in the LAC Region

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Public Sector and NGO Roles in Changing Health
Systems in the LAC Region

• LAC SOTA, March 13, 2001
• Kathleen Novak, Ph.D

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Overview

• Changing Roles of Public Sector and NGOs
• Lessons Learned from LAC HSR Initiative
• Formalized Public/NGO Partnerships
• Accreditation (Dominican Republic)
• Contracting for Primary Care Services (Guatemala,
  Colombia)
• Contracting for HIV AIDS Prevention and Care
  (Guatemala, Brazil)
• Observations Unresolved Questions

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Definition of Health Sector Reform

• Health Sector Reform is a process that seeks to
  improve access, equity, quality, efficiency, and
  sustainability of health care delivery systems.
  It involves major changes in national policies,
  programs, and practices through the revision of
• health sector priorities
• laws and regulations
• organizational structure
• financing arrangements

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Changing Role of the Public Sector

• Health sector reform typically involves a shift
  in the role of the public sector from the direct
  provision of services to
• planning
• financing
• regulating
• monitoring/evaluating

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Assumptions Regarding Comparative Advantage of
NGOs in Provision of Health Services

• Increased responsiveness to local demand that
  results in improved quality of services
• Increased access/coverage
• geographic
• social/cultural
• financial

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Assumptions Regarding Comparative Advantage of
NGOs in Provision of Health Services

• Able/willing to provide services that public
  sector unable/unwilling to provide (HIV AIDS
  prevention, family planning)
• Increased efficiency
• cost containment
• more cost effective

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LAC HSR Lessons Learned

• Policy Dialogue
• Decentralization
• Quality Assurance
• Formalized Public Sector/NGO Partnerships

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NGO Participation in Health Sector Reform Policy
Dialogue

• NGOs work in isolation and resist state
  interference
• Role of NGOs from public sector perspective
• Consequences of excluding NGOs from policy
  dialogue
• Pro-active NGO responses

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Quality Assurance and the Role of NGOs

• Establishment of standards, norms and protocols
• Training and capacity development
• Research and documentation

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Decentralization Impact on Public/NGO
Partnerships

• Be proactive
• Examine partnership implications for NGO
  capacity
• Consider length of agreement
• Understand obligations and authority
• Weigh risks to other relationships

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Formalized Public/NGO Partnerships

• Accreditation
• Contracting for Primary Care Services
• Contracting for HIV AIDS Prevention

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Accreditation Dominican Republic

• 1998 Contract awarded to start accreditation (178
  NGOs receiving government subsidies)
• Accreditation process Phase I
• developed norms standards/minimum requirements
  for organization
• created an inventory/database of organizations
  receiving subsidies
• developed a participatory evaluation process that
  ensured individual NGOs anonymity

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Accreditation Phase I

• Outcome
• 30 Didnt meet minimum organizational standards,
  had no mission and provided no services
• 30 Didnt meet minimum organizational standards,
  but had some form of a mission, and provided some
  services
• 40 Were structured NGOs, had a defined mission,
  and provided services
• 15 of this group currently have formal
  agreements with the government

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64,000 Question

• Given the outcome of the evaluation process, why
  has the number of NGOs receiving government
  subsidies increased to 220 in 2001, and none of
  the deficient NGOs been dropped from the roster?

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Accreditation Phase IITechnical Evaluation of
NGOs

• human resources to certify personnel in terms of
  level of credentials, training, and skills
• infrastructure i.e., sanitary conditions,
  hot/cold running water, etc.
• equipment meets minimum standards for services
  delivered
• administrative systems, medical records up to
  date, follow-up visits scheduled, etc.
• financial management that is transparent,
  accountable for funds received (government,
  out-of-pocket, donors), and can demonstrate no
  profit

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Why do the Public Sector/NGOs Contract for
Primary Health Care Services?

• Governments
• Expand coverage
• Improve quality of care
• Control costs

• NGOs
• Strengthen financial sustainability
• Extend social mission
• Gain recognition from public sector

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Contracting Guatemala

• Central American Peace Accords NGO strategy to
  increase coverage and quality of care
• Weak legal framework enables agreements, i.e.,
  IDB/UNDP-MOH/SIAS (Sistemas Integradas de
  Atención de Salud)-NGOs
• Per capita budget of Q40/person
• Monitoring Evaluation (SAS HACYA)
• financial
• training
• services
• logistics

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Results

• December 1998
• 116 agreements
• 77 NGOs
• Q57.5 million
• 2,512,362 Guatemalans received care

• February 2001
• Q107 million (may increase to Q125)
• 2,949,000 Guatemalans received care

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Minister of Health Vice-Minister
Human Resources
Administration Management
Regulation
SIAS
IDB PMES Project
Area Level Administration
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Contracting
Districts
330
NGOs contracted under SIAS
Operational planning
Health Posts
1200
COMMUNITY
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Contracting Colombia Profamilia case study

• Legal framework supports public sector
  contracting (1993 Laws 80, 100)
• Government of Colombia strategy to reach
  universal coverage and contain costs
• MOH focus on setting norms and regulations
• Phase-out USAID financing 1995-30, 1999-5
• In 2001, Profamilia is 90 self-sufficient
• Diversified financial base, size, and planning
  has allowed Profamila to accommodate delays in
  government payments

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Contracting for HIV AIDS Prevention Guatemala

• Mid-late 1980s Guatemalan NGOs emerged as primary
  providers of HIV services
• Early 1990s GOG created National Aids Program
  (PNS) to oversee all HIV programs in Guatemala
• 1996 HIV Expanded Theme Group
• formal coordinating body members include 7 UN
  agencies, PNS, NGOs, select intl donors (i.e.,
  USAID, SIDA), and PLWA
• performance-based contracts made between Expanded
  Theme Group members and NGOs
• All HIV/AIDS programs accountable to PNS, but UN
  Expanded Theme Group acts as coordinating body

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Contracting for HIV AIDs Prevention Brazil

• Lessons learned
• Brazilian NGOs instrumental to success of
  National HIV/AIDS Program and a key partner in
  the countrys response to the epidemic
• Involvement of donors (WB, UN agencies and
  others) and NGO Liaison Unit were critical to
  success of NGO contracting
• Donor, government, and NGO partnerships fostered
  through
• face-to-face contact at site visits and
  multi-sector meetings
• wide dissemination of contracting procedures and
  activities
• clarity and transparency in the contracting
  process

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• Contract structure didnt provide NGOs with
  incentives to be cost-efficient
• While there was no evidence of quality problems,
  quality of services and activities provided by
  NGOs is unknown
• Contracting does not appear to have improved
  financial stability of HIV/AIDS NGOs

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Observations Lingering Questions

• Take advantage of opportunities to meet jointly
  with public sector and NGO representatives
• Donors do matter
• Public sector still matters

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• Some evidence supporting the comparative
  advantage of NGOs in the provision of health
  services
• increased coverage
• ability to provide services to stigmatized groups
• NGOs have contributed to quality assurance
  activities
• cost effectiveness (?)
• Opportunities for creative partnerships need to
  be explored taking into account each countrys
  historical, political, economic and cultural
  context

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