1. Organizational Reforms Gaston Sorgho, Harvard School of Public Health Reproductive Health and Health Sector Reform

2. Organizational Reforms: Session Objectives  To identify key aspects of organizational reforms;  To discuss impact on reproductive health delivery;  To relate to country settings.

3. Types of Reform  Financial & Resources Allocation  Provider Payments, Incentives & Motivation  Organizational Change  Laws and Regulation  Promoting Healthy Behaviors

4. Reform Types - System Goals Effi- ciency QualityEquity Client response Sustain -ability Financing 444 Providers Payment 444 Organisa- tional Ch. 44444 Regula- tion 44 Promoting H.B. 444

5. Organization  Structure decision making technical expertise  Functional Planning facilities equipment commodities personnel

6. What is the problem ?

7. RH Goals: What was expected ?  Client centered  Integrated services  Efficient  Response to changes  Motivated providers  ……

8. What is the Problem ? Results Poor management of RH services Services not client-oriented Limited range or options Priority to providers convenience Demotivated providers Insufficient responsiveness to client needs ……...

9. Organizational Effects Process Outcomes Organization- al structure

10. Process - Outcomes

12. Challenge Organizational Reform

13. Organizational Vehicle Optimal service delivery Accountability to clients Performance oriented behavior

14. Organizational Reform Challenge - RH Changes needed in providers organization & management  performance oriented behavior  accountability to clients

15. Clients Clients Clients Service Providers District Regional HQ Private Sector 1234512345 Running Health Business

16. MOH / HQ Technical leadership Procurement Provision Information system Financing Regulation Service Provider Staffing Training Policy Budgeting Evaluation Auditing

17. From the Big Elephant to…

18. Reforming MOH Organization 3. Separation of finance from provision 1. District model 2. New public-sector management

19. 1. Health District Model

20.  District hospital & staff  Satellite health clinics handed over responsibilities

21. Ministry of Health Health Centers Health Staff District Administrator District Health Team Ministry of Education District Education Directorate Schools Teachers Administration Staff Ministry of Interior Centralized Structure

22. Ministry of Health Health Centers Health Staff District Administrator District Health Team Ministry of Education District Education Directorate Schools Teachers Administration Staff Ministry of Interior Deconcentrated MOH

23. Devolution Health District Health Team Other Ministry Services Education District Directorate Ministry of Interior Ministry of Education Ministry of Health District Council

24. Discussion : what are the benefits and risks of deconcentration and devolution for reproductive health care?

25. 2. New Public-Sector Management

26. Clients Clients Clients Service Providers District Regional HQ Private Sector 1234512345 From: health system organization

27. To: client-centered organization Regional Districts Service Providers HQ CLIENTS 1234512345

28. What are the characteristics of NGO’s / private organizational structures ?

29. Private Service Provision  Services meet client needs rather than bureaucracy needs rather than cripples providers  Organized structure so it supports

30. Micro - structure  resources/staff management  targets setting  managers accountability l impact from ‘ inside ’  results-oriented policy

31. New Public Sector management u Accountability for performance u Greater autonomy 4 performance monitoring and evaluation 4 annual personnel performance agreements 4 performance-related budgeting

32. 3. Separation of Financing from Provision

33. Macro - structure legal and market conditions monopoly / competition impact from ‘ outside ’

34. Financing - Provision SharePublicPrivate Policy Financing Provision Regulation Information

35. Private For Profit Family Planning Services For-Profit Sources Latin American & Caribbean 46 % Middle East & North Africa 44 % Sub-Saharan Africa 27 % Asia (non-China/India) 26 %

36. Organizational Reforms  Macro structure impact from ‘ outside ’  Micro structure impact fom ‘ inside ’ Performance Acountability

37. Organization’s Authority hire & fire staff AuthorityNo authority Typical Public NGO, Mission, Private Profit build new structures change profile of services decide on user charge policy drug/supply policy

38. Organizational Reforms Decentralization Power Transfer W HO? WHAT ? HOW New W HO?