Can donors really build institutions?

Reflections on recent health sector experiences in Sierra LeoneDr Sophie Witter

World Bank Fragility Forum 2016

Research for stronger health systems post conflict

Background on ReBUILD

Post conflict is a neglected

area of health system

research

Opportunity to set health systems in a

pro-poor direction

Focus on HRH and health

financing but also on health system/state building links

Choice of focal

countries enable

distance and close up view

of post conflict

Decisions made early post-conflict can steer the long term development of the health system

Background to talk

• Focus of research in Sierra Leone• Talk based on indirect insights and observations on:• What were the patterns of interaction between donors and MoHS during the

period, across different phases?• Where institutions strengthened?• If not, why not?• Lessons, including how to improve the interaction

Underlying assumptions

• MoHS has core mandate to plan for, manage and regulate the health sector – not the only, but a key institution• Building of MoHS judged by:• Its legitimacy – recognised as playing this core role on behalf of all citizens;

not contested or in competition with other organisations• Its effectiveness – delivering good stewardship and services, which is

underpinned by:• capacity – staffing, resources, flexibility, decision-space to carry out role

• Its resilience – ability to survive and function during and after shocks

Definition of allo

wances

2009 2010 201220112006 2007 2008

FHCI -

Announcement

FHCI -

Launch

National Health

Policy

(2002)

HRH Development P

lan 2004-

2008

HRH Policy

2006

HRH Policy (2

012) &

HRH Strategic

Plan 2012-2016

Payroll c

leaning, fast-

track

recruitm

ent & sa

lary incre

ase

Perform

ance-based Financin

g

Sancti

on Framework

Remote Allowance

Review of th

e Scheme of S

ervice

Attendance Monito

ring

2013 2014 2015 2016

First phase: early development of HRH policies Second phase: launch of FHCI

and related HRH policiesThird phase: post-FHCI policy-

makingEVD and post-EVD policy-making

Risk Allo

wance

Revival o

f TWG

Payroll c

lean & HRH headcount

Review of S

cheme of S

ervice

HRH Strategic

Plan

The four phases of HRH policy-making, Sierra Leone, 2002-16

First phase: 2002-2009• ‘Fire-fighting’ phase: many players (NGOs) and limited control by the MoHS;

broad HRH policies developed but limited ability to implement them; limited data“After the war, it was complete chaos. The NGOs came and went […]. They employed the nurses directly, without even consulting the Ministry. […] But this was a war. We had to bend backwards in the Ministry” (SM – MoHS).

• Official documents highlight challenges and describe potential solutions, while they rarely propose actual implementation plans

Fluid and uncertain policy contextThe HRH Development Plan 2004–2008 states that “a certain flexibility will be allowed in the proposed activities, given the current level of uncertainty regarding the exact nature of the reforms” (p.80 – italics added).

Second phase: 2009 - 2010

• Strengthening and reforming phase: FHCI triggered series of sectoral and HRH changes

• Improved coordination (HRH working group) and specific TA for the design of necessary HRH reforms• Several-fold increase of HWs salaries (2010)• Introduction of a Staff Sanction Framework to reduce absenteeism (2010-11)• Payroll cleaning (2010) – 850 ghost HWs were removed (~12% of total), 1,000 new HWs added• Fast-track recruitment at district level (2010)

• As the implementation of reforms became more coherent and operational, budgeted plans and expenditure frameworks begun to appear.

• Substantial donors’ funding to sustain these reforms (DfID and GF)

Third phase: 2011-2012

Post-FHCI phase• Reforms discussed during FHCI preparation are introduced :

• Implementation of a Performance-Based Financing scheme in PHUs (2011)• Introduction of a rural allowances for health workers in remote posts (2011)• Performance contracts introduced for Ministers, Permanent Secretary and Directors (2011-12)

• New HRH Policy and HRH Strategic Plan (2012) • Official documents which give ex-post shape to the reforms and changes that had already taken

place at operational level

• Pace of change slowing after 2012: less momentum and many implementation challenges

Many commitments not kept, e.g. development of BEmOCs, improved procurement capacity for drugs

Fourth phase (2013-15):pre/during/post EVD

2013: MoHS leadership hit by GAVI funding scandal2014: Ebola – MoHS slow to respond2015: Post-Ebola planning starts but MoHS is not at the centre• Money and TA arrive• Cycle repeats of • Revival of HRH TWG• Renewed cleaning of payroll• Plans for mobile recruitment• Review of all key HRH policy documents

GAVI scandal: tale of unintended (negative) consequences

• Story broke June 2013 – GAVI funds suspended; $1 million not properly accounted for over 2008-11. Money gone to unsecured bank accounts.• Consequences: 15 or so top people (directors) suspended. None have

returned.• Consequences for Ebola period: 9 months later, no-body in place in key

roles

Ebola: further weakening of mandate and capacity• Presidential task force and NERC/DERC took over – command and

control response• Staffed with higher-paid diaspora staff• Still partially in place – complaints also at district level

“MOHS was regarded as part of the problem during Ebola” (national KI, Freetown, January 2016)

Post-Ebola: window of opportunity, but for whom?• Influx of money – $220.5m pledged to Sierra Leone (UNOCHA 2014)• Rival power centres

• Presidential task force• Presidential delivery unit• HSS Hub

• Planning process undertaken by HSS Hub • Paid by Bank at much higher rates • Leading on ‘flagship programmes’, SLAs etc• Reporting to MOHS in theory

• Still weak core institutions • Tiny health financing team, few planners in the MoHS etc.

Patterns• Periods of support, but focus is short term• Capacity building in MoHS is not effective

Internal factors:Chronic under-fundingFailure to reformPoor terms and conditionsSystemic weaknesses, e.g. in financial management Failure to develop strong institutional vision and leadership

External factors:Funding unpredictable and short-termPoor coordination between donorsShort-term objectivesOver-reliance on external TABy-passing of MoHSBrain drain of staffPer diemsCapacity building focused on individuals, not institutions

“Government comes up with strategies but has no money to implement” MoHS KI, January 2016

Implementation of HRH reforms

“They [MoHS at central level] don’t even communicate with us. We are dealing with the staff here, we know the staff movement. [...] But they say that they have the data there. But sometimes they pay staff that are not even in remote areas” (KII – DHMT)

“I mean, [PBF] is good in theory, but when it comes nine months later, I think it defeats the whole purpose” (KII – DHTM).

“I heard many, many health workers, PHU staff, and DMOs talk about performance-based financing. I've never heard anyone mention this remote area allowance”(KII – NGO).

“The real key issue is that with all of these policies and all of these strategies, none of them have been properly operationalised and none of them have stayed around. Like, in 2002, there was a free health care policy announced [...] and then it just didn’t happen. So free health care is announced again in 2010, and it’s like, OK, it’s happening, but is that going to slowly start to fall apart? If PBF is announced, it’s like, oh it comes and then it stops, you know.” (KII – NGO).

Remote allowance: 5%-8% of income of all HWs (Dec. 2012) delayed and then stopped from Jan. 2013Performance Based Financing: 11% of income of HWs (Sept. 2013) payments received more than one year later than services are performed

Conclusion and lessons

Conclusion

Donors are poor at strengthening institutions, especially when they are fragile, weak in capacity and hostage to fragmented support and differing agendas

i.e. in settings where they most need strengthening!

Lessons for donors• Longer term partnerships

• Stability and continuity• Generating better knowledge of institutional history and context • Able to support institution within local political economy networks

• Supporting underlying systems that are contextually sustainable• FM• HMIS, HRIS, M&E• Management• Procurement

• Focus on institutional capacity building, including• Strengthened horizontal (e.g. to MoF & Cabinet) and vertical relationships (with districts)• Developing more depth in core teams• Ability to deliver and build on short term achievements (virtuous cycle)• Gradually becoming a learning organisation• Better internal communication – develop institutional culture

Increased transparency and accountability of partners to MoHS

Only 5% of JPWF (2010-14) fully implemented, according to CMO (Jan 2015)• Bulk of funds are vertical and by-pass MoHS• NGOs report to donors, not MoHS• Consultation with MoHS on core policy issues is not done in coherent and transparent way (current

example of PBF)Donors must find ways to devolve resources and engage MoHS in oversight and policy-setting• E.g. under clear and accountable SWAP types agreements, with transparent audit trails in place

demonstrating good governance and clear devolution of authority• NGO programmes must be tied into agreement contracts, to deliver agreed outputs at district/national

level with DHMTs/MOHS and these should be monitored by a mutually agreed governance mechanism• Support must be focused longer term on sustainable capacity building, rather than direct service

provision: key objectives and values must be jointly agreed and written into contracts • NGOs with consistently poor performance must be reviewed and the issues addressed • Donors must underpin this accountability between NGOs and health services and act as enablers

In order to do that….

• Better coordination and learning• Need to learn better as a group – often internally incoherent in policies• More reflection and understanding of the drivers of change in institutions

• Reduce staff turn over• Build capacity in-country• Built better institutional memory

Do no harm….Fundamentally, institutions have to be internally constructed BUT donors have a duty to not disrupt:• Not creating parallel structures and power bases• Not offering salaries that attract all of talent out of core institutions• Not circumventing mandated decision-makers in MoHS (donors

commonly play off different stakeholders in MoHS)• Providing funds in a way that does not undermine role of MOHS

(direct to NGOs, with no MoHS oversight etc.)

“The disparities created by salary top-ups and parallelimplementation units (PIU), also donor-created, complicate civil service reform and may leave a new legacy of publicservants who believe themselves to be specially entitled” (OECD report on Sierra Leone, 2010)

Some references from the groupWurie, H., Samai, M., Witter, S. (2016) Retention of health workers in rural and urban Sierra Leone: findings from life histories. Human Resources for Health, 14 (3). http://www.human-resources-health.com/content/pdf/s12960-016-0099-6.pdf

McPake, B., Witter, S., Ssali, S., Wurie, H., Namakula, J. and Ssengooba, F. (2015) Ebola in the context of conflict affected states and health systems: case studies of Northern Uganda and Sierra Leone. Conflict and Health; 9; 23. http://www.conflictandhealth.com/content/9/1/23

Bertone, M. and Witter, S. (2015) An exploration of the political economy dynamics shaping health worker incentives in three districts in Sierra Leone. Social Science and Medicine, volume 141, pp56-63. http://www.sciencedirect.com/science/article/pii/S0277953615300447

Witter, S., Benoit, J-B, Bertone, M, Alonso-Garbayo, A., Martins, J., Salehi, A., Pavignani, E., Martineau, T. (2015) State-building and human resources for health in fragile and conflict-affected states: exploring the linkages. Human Resources for Health special edition on investing in HRH. http://www.human-resources-health.com/content/13/1/33

Witter, S., Wurie, H. And Bertone, M. (2015) The Free Health Care Initiative: how has it affected health workers in Sierra Leone? Health Policy and Planning journal, 1-9. http://heapol.oxfordjournals.org/content/early/2015/03/21/heapol.czv006.full.pdf?keytype=ref&ijkey=VPzC5PJtxdrYeKa

Bertone, M., Samai, M., Edem-Hotah, J. and Witter, S. (2014) A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002-2012. Conflict and Health, 8:11. http://www.conflictandhealth.com/content/pdf/1752-1505-8-11.pdf

Evidence for supporting a skilled health workforce for all in Sierra Leone. https://rebuildconsortium.com/media/1243/sl-project-2-briefing-nh-edit-2b.pdf

Universal health coverage amid conflict and fragility: ten lessons from research.

http://globalhealth.thelancet.com/2015/12/14/universal-health-coverage-amid-conflict-and-fragility-ten-lessons-research

Thank you

On behalf of ReBUILD consortium• Institute for International Health and Development (IIHD), Queen Margaret University, UK• Liverpool school of Tropical Medicine (UK)• College of Medicine and Allied Health Sciences (CoMAHS), Sierra Leone• Biomedical Training and Research Institute (BRTI), Zimbabwe• Makerere University School of Public Health (MaKSPH), Uganda• Cambodia Development Research Institute (CDRI)

Also to colleagues who contributed ideas and examples, including Maria Bertone, Haja Wurie, Carole Green, and Sas Kargbo

www.rebuildconsortium.com

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