مدیریت عمومی و توابع ضروری بهداشت عمومی

This paper provides an overview of how different approaches to improving public sector management relate to the so-called core or essential public health functions such as disease surveillance, health education, monitoring and evaluation, workforce development, enforcement of public health laws and regulations, public health research, and health policy development. Using the principles of agency theory, the paper summarizes key themes in the public management literature and draws lessons for their application to these core functions, especially in low- and middle-income countries.

This paper provides an overview of how various approaches to improving public sector management relate to the so-called core or essential public health functions (EPHFs)1 such as disease surveillance, health education, monitoring and evaluation, workforce development, enforcement of public health laws and regulations, public health research, and health policy development. The purpose of the paper is to summarize key themes in the public management literature and draw lessons for the EPHFs. To this end, we use agency theory (or the principal–agent problem), which examines how a principal (e.g., the central government) can ensure that the agents’ (e.g., local implementation agents) incentives are consistent with assuring the principal’s objectives.2 Using this approach, we highlight implications for the EPHFs of management reforms which seek to assure effective service delivery by creating incentive structures through mechanisms such as purchaser–provider splits, contracting, provider payment reforms, and decentralization. Section 2 summarizes “new public management” and related approaches. Section 3 reviews traditional approaches to public administration and their relevance to the EPHFs. Section 4 summarizes lessons. Two points are essential to understanding the discussion that follows. The first relates to the nature of the EPHFs. In economic terms, most EPHFs are public goods. This means that they are nonrival (i.e., consumption by one person does not restrict consumption by another) and nonexclusionary (i.e., their benefits accrue to the entire population and cannot be restricted to a discrete group). For example, once erected, a health education billboard benefits everyone who views it, no matter how many people do so (i.e., nonrival); and anyone who wants to view it can, given its public location (i.e., nonexclusionary). This is distinct from private goods—e.g., cancer treatment—which, like most commodities, are both rival and exclusionary. Some disease control services fall into a middle category of “merit goods” because they have both private and public characteristics. Immunization is one example. While immunization has private benefits for the vaccinated individual, it also has public benefits because of its contribution to herd immunity and the protection of others. These distinctions are not purely academic. The market would have few incentives to provide public goods, and would be expected to underprovide merit goods.3 They have major implications on how services should be financed and delivered and are fundamental to our discussion. The second point relates to the difference between public health services and public health functions. Some traditional public health services—immunization, STD clinics, TB control, etc.—are merit goods, while others (such as vector control) are public goods. However, the public health functions—policymaking, disease surveillance, population health assessment, health education, etc.—are almost all pure public goods. The service-function distinction is not always made clear in the literature but is of considerable practical relevance when it comes to questions of management and financing. Public health services are often relatively easy to measure, for example, with indicators such as the number of children immunized or the number of TB cases treated. This makes them easier to manage and provides a wider scope for innovations in service delivery compared to public health functions and those services whose public good nature and complexity of measurement pose special challenges. The public health functions are more akin to other “core government functions” such as revenue collection and maintaining law and order, and draw on similar principles for their management.4

Curative services, preventive services, and essential public health functions have important distinctions that make it impossible for policy prescriptions and organizational forms from one to be applied to the others without adaptation. We summarize the key lessons of the paper below. Provider incentives are complex and difficult to design for the EPHFs and cannot be simply transferred from the experience with curative care. For example, user fees are not an option for the EPHFs because of their public goods characteristics. For incentives to be useful, measurement indicators need to be chosen carefully: complex instruments may be unworkable and costly, while instruments that are too simple may increase the likelihood of opportunistic behavior. Incentives, where used, should be team or network based rather than individualized and should not neglect the role of nonfinancial benefits. Performance improvement can also be achieved in more traditional ways, for example, by having fairly implemented merit-based selection and promotion criteria, clear job descriptions, etc. These should typically be implemented before the adoption of complicated performance incentive schemes and may be sufficient by themselves. Promoting competition among agencies responsible for public health functions does not improve efficiency—on the contrary, it impedes collaboration and technical assistance and can therefore compromise the effectiveness of activities such as surveillance and health promotion. Organizational reforms that rely on provider competition (such as purchaser–provider splits) are therefore not applicable to the EPHFs. Contracting works for some preventive services but not for the EPHFs. For preventive services that are measurable and discrete, such as immunization or campaign-based programs, contracting can be an effective approach—provided there is sufficient government capacity to manage the contracts effectively. But for the EPHFs, where measurement is complex, expensive, and requires strong information systems, contracting imposes transaction and monitoring costs that make efficiency gains unlikely and reduce effectiveness. Decentralizing the EPHFs needs to be approached carefully, since studies from a variety of political and administrative settings indicate that local governments tend to have little incentive to invest in public goods and systematically neglect them. The EPHFs should either remain under central control—with managerial autonomy or other strategies to permit local adaptation and responsiveness—or subjected to alternative forms of central oversight and control such as grants-in-aid, earmarked funds, etc. To ensure this, the central agencies responsible for the EPHFs need to retain their strength, rather than downsizing across the board as decentralization proceeds. This is needed, given the importance of central coordination, oversight, and technical assistance for EPHF functions. The institutional environment—that is, the formal and informal rules and norms at work in government and society at large—are an influential determinant of government effectiveness, and especially for the EPHFs. As a result, efforts to build management capacity through training are helpful but not sufficient to improve managerial effectiveness for the EPHFs. Public sector norms and rules that impede effective administration should be changed where possible. If this is not possible, alternatives—such as insulating programs from these norms and rules or promoting organizational cultures and accountability arrangements that achieve this indirectly—should be pursued instead. Managerial autonomy is important for the EPHFs as a way of promoting adaptation and innovation. It should be introduced cautiously to avoid abuse—though not so cautiously that it fails to materialize at all—but it should also be balanced with instruments to ensure an appropriate degree of policy and program consistency across units and jurisdictions. Strengthening hierarchical accountability within the public health system is essential to strengthening the EPHFs. This requires changes in the capacity, autonomy, and behavior of service managers, but also requires monitoring systems and instruments that are weakly developed at present in many developing countries. Monitoring is critical but instruments need to strike the right balance between simplicity and complexity and should be designed for operational rather than research use. Outcome measures are not useful for month-to-month program management which requires more proximate indicators. Information systems can provide data inputs for this kind of monitoring but are frequently too weak to do so. Standard information and voice-based strategies do not work particularly well for the EPHFs but can be adapted to do so. This might involve constituency building for the EPHFs and the use of civil society and media groups to monitor and have input to decisions concerning them.