The role of strategic health planning processes in the development of health care reform policies: a comparative study of Eritrea, Mozambique and Zimbabwe

The role of strategic health planningprocesses in the development of healthcare reform policies: a comparative studyof Eritrea, Mozambique and Zimbabwe

Andrew Green1*, Charles Collins1, Angelo Stefanini2, Paulo Ferrinho3,Glyn Chapman4, Besrat Hagos5, Yussuf Adams6 and Mayeh Omar1

1Nuffield Centre for Health and Development, University of Leeds, Leeds, UK2University of Bologna, Via S Giacomo 12, Bologna, Italy3Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal4IMMPACT, Department of Public Health, University of Aberdeen,2nd Floor Foresterhill Lea House, Aberdeen, Scotland, UK5WHO Office for South Sudan, Warwick Centre, UN Avenue, Nairobi, Kenya6Universidade Eduardo Mondlane, Faculdade de Medicina, Av Salvador Allende,Maputo, Mozambique

SUMMARY

This paper reports on comparative analysis of health planning and its relationship withhealth care reform in three countries, Eritrea, Mozambique and Zimbabwe. The researchexamined strategic planning in each country focusing in particular on its role in developinghealth sector reforms. The paper analyses the processes for strategic planning, the valuesthat underpin the planning systems, and issues related to resources for planning processes.The resultant content of strategic plans is assessed and not seen to have driven thedevelopment of reforms; whilst each country had adopted strategic planning systems, inall three countries a more complex interplay of forces, including influences outside both thehealth sector and the country, had been critical forces behind the sectoral changesexperienced over the previous decade. The key roles of different actors in developingthe plans and reforms are also assessed. The paper concludes that a number of differentconceptions of strategic planning exist and will depend on the particular context withinwhich the heatlh system is placed. Whilst similarities were discovered between strategicplanning systems in the three countries, there are also key differences in terms of formality,timeframes, structures and degrees of inclusiveness. No clear leadership role for strategicplanning in terms of health sector reforms was discovered. Planning appears in the threecountries to be more operational than strategic. Copyright# 2006 John Wiley & Sons, Ltd.

key words: strategic planning; health sector reform; policy; Eritrea; Mozambique; Zimbabwe

international journal of health planning and management

Int J Health Plann Mgmt 2007; 22: 113–131.

Published online 18 September 2006 in Wiley InterScience

(www.interscience.wiley.com) DOI: 10.1002/hpm.856

*Correspondence to: A. Green, Nuffield Centre for Health and Development, University of Leeds, 71-75Clarendon Road, Leeds LS2 9PL,UK. E-mail: [email protected]

Copyright # 2006 John Wiley & Sons, Ltd.

BACKGROUND

A key policy focus in health systems in the 1990s, was on reform of health sector

structures caused by a failure of health systems to cope with a worsening health

situation. This focus led to the adoption of a particular reform paradigm (World

Bank, 1993), which included: limits on the public sector role, development of the

private sector, decentralisation and diversification of funding forms. There was also

growing interest in quality of health care, governance and stewardship of health

systems, evidence-based policy-making and priority-setting and the development of

Sector Wide Approaches (SWAps).

The processes for the emergence of such reforms have been the subject of

research. This article complements this by focusing particularly on the role of

strategic planning and its processes in the development of such policies. Traditional

planning approaches have been criticised for a heavy focus on the public sector;

centralised approach to planning using ‘command and control’ mechanisms; and

inflexible 5-year planning cycles (Green, 1995; Cassels, 1997; Bossert et al., 1998;

Mintzberg, 1993). The interface and relationship between health policy and plans is

rarely clearly defined and recent emphasis on strategic planning through initiatives

such as SWAps (Peters and Chao, 1998) which requires the development of strategic

plans has made the understanding of these relationships all the more important.

This research aimed at exploring in three African countries all with reform

agendas, the role of strategic health planning processes in the formulation of health

sector reform policies.

The research reported in here aimed to:

� Describe, analyse and compare the strategic planning processes in country

� Assess the role of strategic health planning in setting the framework for reforms

This article does not attempt to either assess the validity or effectiveness of the

reforms themselves or the effectiveness of planning processes in improving health

per se, but focuses instead on the relevance of strategic planning processes in

developing reform policies.

Six partners were involved in the research1, which involved case studies of Eritrea,

Mozambique and Zimbabwe. The research was funded under the EC INCO-DEV

programme2. In each country between 40–50 in-depth interviews of key informants

from government, NGOs, professional bodies and other stakeholders were conducted

during the period from 1999 to 2001 and documents reviewed with resultant

country–specific analyses (Chapman and Green (2002); Hagos et al. (2002); Adam

and Mariamo (2001)) which formed the basis for this comparative analysis.

The paper is structured as follows. The first part sets out a historical and health

system background against which the reforms were developed. This is followed by a

1Nuffield Institute for Health (co-ordinator), University of Leeds, UK; Division of Research and HumanResources Development, Ministry of Health, Eritrea Faculty of Medicine, Eduardo MondlaneUniversity, Mozambique; Department of Community Medicine, University of Zimbabwe, Zimbabwe;Department of Medicine and Public Health, University of Bologna, Italy; Escola Nacional de SaudePublica, Universidade Nova de Lisboa, Portugal.2Contract number: ERBIC18CT980342.

Copyright # 2006 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2007; 22: 113–131.

DOI: 10.1002/hpm

114 A. GREEN ET AL.

description of the planning system. Drawing on the Walt and Gilson (1994) model of

policy development we then turn to an analysis of the contextual factors and the key

actors involved in the development of plans and policies in the countries to try and

explain the divergence between the plans and the reforms. The final section draws

together conclusions.

HISTORICAL AND HEALTH SYSTEM BACKGROUND

We turn firstly to an examination of the historical and health system background to

the study. Figure 1 sets out a timeline for key historical events in the countries.

Eritrea achieved independence from Ethiopia in 1991. The 1990s was

characterised by the development of a constitutional framework, reconstruction

following decades of armed struggle and rapid expansion of education and health

services under the PFDJ Government. Between 1998 and 2000 Eritrea was engaged

in border disputes with Ethiopia. Immediately after independence, the government

adopted a Primary Health Care (PHC) approach. However, this was combined with

the tentative introduction of market style policies such as allowing government

workers to run after-hours private clinics. The existence of a dual health system (one

inherited from the Ethiopian regime and the other that was in operation in liberated

areas controlled by the EPLF) has also had an obvious impact. The post-

independence period was one of harmonising these systems. Combatants’ experience

was important—they gained an understanding and experience of health needs and

developed commitment to PHC. Health care problems at the time of the research

were the shortage of finance and human resources, and a lack of private sector

involvement. An important concern is that of institutionalising the system including a

desire for a comprehensive policy, principles and plans, harmonisation of the dual

system and development of an organisational structure for the MoH.

In Mozambique, independence in 1975 was followed by a revolutionary process, a

one-party system, internal conflict and external interference with problems of

sustainability and de-motivation of health care providers. This period saw the

development of PHC, socialisation of medicine, banning of private medicine and

sidelining of traditional medicine. Attempts were made to introduce alternative

organisational systems involving worker and patient participation, but these were

abandoned in favour of more hierarchical structures. Early concerns also focused on

cadre nationalisation and health care fees were scrapped. After significant

achievements in increasing coverage by PHC programmes in the late 70s, war

led to health status decline and destruction of health facilities. The political and

social instability was compounded by drought and flooding. During the liberation

struggle, responding to the health needs of the population was central to running

liberated areas (Martins, 2001). During the 1990s there was a shift to a multi-party

system and market economy characterised by rapid economic growth. Policy

commitment to PHC was still be apparent, although the overall liberalisation of the

economy has brought a commitment to market-driven reforms (such as promoting

the private sector) and SWAps. The early 1990s saw a shift with the emergence of a

private system in the urban areas albeit dependent on the public sector for many


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STRATEGIC HEALTH PLANNING PROCESSES 115

resources, including personnel (Ferrinho et al., 1998). Current concerns focus on the

low coverage and quality of care, poor recognition of traditional health care,

underdeveloped relations between public and private sectors and between preventive

and curative care, de-motivated and underpaid public sector staff, imprecise role of

the MoH, ineffective collection of fees and a lack of effective priority health

Figure 1. Comparative Time-line


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116 A. GREEN ET AL.

programmes. The health sector budget is overwhelmingly dependent on donor

funding.

In Zimbabwe the end of the Liberation war in 1980 and the post-independence

period saw economic growth along with adoption of a socialist ideology and PHC

approach. The government emphasised development of social services, and

democratised the management of health. The early political, economic and social

optimism however gradually gave way to a new reality with economic decline,

drought, civil unrest and controversies over land redistribution. In 1990 an Economic

Structural Adjustment Programme (ESAP) was introduced leading to important

changes in economic policy within the context of increasing political tension.

Zimbabwe has also been influenced by the international PHC movement. This is

manifest in documents including Equity with Health (Government of Zimbabwe,

1984). However, as with Mozambique, the introduction of reform programmes

resulted in a shift with the introduction of a mixed public–private system. Key issues

at the time of the research were those of finance, human resources and service quality.

It can be seen that each country experienced a post-Independence period in which

a PHC approach was promoted. The timing of this however led to country

differences. In Zimbabwe the independence and government adoption of PHC

policies coincided with international acceptance of PHC in the 1980s. In Eritrea, the

development of PHC coincided with a significant shift in the international agenda to

health sector reform. In Mozambique, the policy adoption of PHC has been

continued in the 1990s but, once again, the international climate of reform has shifted

to a neo-liberal approach. In all countries, however, the initial PHC has since been

combined, albeit to different degrees, with elements of a market-driven approach.

At the time of the research, each country was either entering into or experiencing

reforms involving more market-driven approaches including decentralisation and

private sector development. Country-specific issues included: in Mozambique, the

introduction of fees into the special hospital clinics; in Zimbabwe public sector

downsizing, contracting and the development of the Health Service Fund and in

Eritrea, health care financing. Whilst Eritrea has followed similar policy trends to

Mozambique and Zimbabwe there has been a reluctance to refer to it as a ‘reform’

process on the basis that government was ‘forming’ rather than ‘reforming’ a system,

reflecting the youth of the State.

It is these reforms, which form the focus of this study, and in particular, their

relationship with strategic health planning.

HEALTH PLANNING SYSTEM

We turn now to an analysis of the planning system starting with a description and

comparison of the processes for health planning in each country, followed by a

review of the values underpinning the planning system as perceived by respondents

and a discussion of some of the resource constraints facing the planning systems. The

section ends with an overview of the products of the planning system and their

relationship to the reform policies.


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Strategic planning processes

We examine now the processes for strategic planning in each country. For ease of

analysis the strategic planning process is divided conceptually into six phases, each

of which is examined separately. In practice of course such conceptual distinctions

are less obvious.

Analysis and formulation of the plan. In both Zimbabwe and Mozambique the

process for developing the strategic plan was one-off and not institutionalised. In

Zimbabwe the ‘Group of 10’ was set up to analyse and formulate the plan. Within

Mozambique a similar ad hoc arrangement was made, though the MoH Department

of Planning and Co-operation led the process. Initially the strategic planning

development process used a consultant. However this was replaced by a process of

six working groups with membership from not only the health ministry, but also the

donors with technical expertise. It was seen by many as following a ‘text-book

process’ with key elements of a study of the situation, identification of problems,

definition of strategy, elaboration of a policy plan and procurement of funds.

Within the Mozambique and Zimbabwe central ministries, the non-institutiona-

lised nature of the process may explain the apparent lack of ownership of the

resultant plan within the MoH. This was particularly so in Mozambique, though less

strong in Zimbabwe where there was involvement from department heads. This lack

of ownership may also be a function of cynicism on the part of key actors that the

strategic plan in both countries was a response to external requirements.

In contrast, in Eritrea, the development of plans is a routine (rather than one-off)

part of the operation of the MoH, through committee processes with no specific

planning department.

Consultation. Consultation of stakeholders can take many forms including seeking

views as to priorities and strategies at the beginning of the planning process, on

alternative options and on a formulated plan. Each has pros and cons, in terms of

ownership of resultant plans and resources required for the process and timing. In

both Zimbabwe and Mozambique the consultation with stakeholders was primarily

of the latter form and seen as one-off rather than a more ongoing management

process for dialogue. Both systems were criticised for failing to consult key

stakeholders adequately. In Zimbabwe, the National Health Strategy states that ‘it is

a result of extensive consultation with stakeholders in health’ but a number of

interviewees saw the process as being less consultative. For example, despite the

existence of community-based structures of Village and Ward Development

Committees, these were not widely consulted. Indeed some respondents perceived

that this failure to consult had led to the creation of the Presidential Commission into

Health (ongoing at the time of the research)—effectively a parallel consultation

process since the objective of the Commission was to ask questions as to what is

wrong with the health sector, to identify solutions and to determine ways of funding

necessary changes.

Approval. The approval processes for the plans differed between countries though

there was a general requirement for central government approval. In Eritrea any


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118 A. GREEN ET AL.

agreement with donors requires approval by the central Macro Policy Unit but

individual Ministries have sufficient autonomy to make their own plans. In

Zimbabwe the Ministry of Finance and Planning and the Cabinet approved the plan

and in Mozambique the strategic plan was approved by the Council of Ministers

(interestingly, due to the need to meet a World Bank deadline for funding, this took

place before approval by the National Health Council).

Dissemination. In Mozambique the strategic plan and its drafts were widely

circulated. The process took place in five phases: the first in 1999, when the MoH and

donors defined together the framework of the Strategic Plan; the second phase

included consultation to the provinces and civil society; the third, in early 2000,

included the work of six task forces, nominated by the MoH and comprised mostly of

MOH personnel and donors; the next phase in early 2001 included a visit by a British

dissemination consultant; the final phase later in 2001 consisted of the writing up and

approval of the plan (Craveiro, 2001). In Zimbabwe it was clear from a number of

respondents outside the central MoH that they were unfamiliar with plan detail,

suggesting that dissemination had been less effective than might be desirable. In

Eritrea, the dissemination process was also limited.

Implementation. Strategic plans need to be implemented through a process of short-

term operational plans and budgets. There are established decentralised processes for

this in each country. However the relationship between different planning processes

in all three countries was not always clear. For example in Zimbabwe, there was no

formal connection between the city health department plans and the national

strategic plan. This suggests that if further devolution occurs, then the power of the

strategic plan as a national cohesive policy may be diminished.

In Mozambique it was too early to assess the relationship between the national

strategic plan and the operational level plans. However there was concern expressed

by some respondents that the plan may not have integrated the vertical programme

plans (effectively operational plans) sufficiently into the national strategy to provide

the necessary cohesion.

Monitoring, evaluation and updating. Each plan had objectives by which they could

be monitored and evaluated, but no process was set out for doing this. Neither the

Zimbabwe nor the Eritrean plans had any set process for updating the plans. The

Mozambican plan was deliberately written to allow for regular updates and indeed,

was not considered to be a ‘finished product’. This partly reflects the production of a

plan within a very tight time frame. It has the potential advantage of flexibility but

also the danger of providing insufficient forceful direction to the sector.

Purpose and values of strategic planning

The research investigated how key informants viewed and interpreted the purposes of

strategic planning. The range of interpretations is summarised in Figure 2.

A common response from respondents was that the purpose of strategic planning

was to provide direction to development of the health sector, implying some role in


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the development of reform policies. However two broader interpretations came

through in a number of responses: planning’s political function and as a mechanism

for dealing with donors.

One challenge facing planners is to link the purpose with the different values that

strategic plans claim to reflect. Values in planning can change over time and are

expressed by stakeholders who attach different meanings or importance to values

such as participation. Awide range of potentially contradictory values were revealed

ranging from equity-focused ones, to more economic ones (such as efficiency and

effectiveness) through to those reflecting governance issues (such as transparency,

accountability, partnership working and personal responsibility) and rights-based

concerns (gender and cultural sensitivity). Furthermore, there is a difference between

expression of a value and its recognition in practice. In Zimbabwe, for example

respondents cast doubt as to whether the declared values of transparency,

accountability, community participation and equity really existed. Similarly in

Eritrea respondents from the private sector raised doubts as to transparency and

participation in planning. Changes in values over time, for example in Zimbabwe a

shift away from equity, were also referred to.

Paying lip service to values while ignoring them in practice can reflect either

conflicting influences on the planners or political expediency. Planners need to find

ways to manage the various and potentially contradictory purposes of planning.

Resources to conduct planning

Two key resources for conducting strategic planning processes were examined in the

research—staffing and information.

Figure 2. Interpretations of strategic planning purpose


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120 A. GREEN ET AL.

The staff resources required for strategic planning should not be underestimated,

particularly when those staff that are not specialist planners are included. In each

country a significant amount of time was devoted to planning. However, there would

still appear to be insufficient planning resources. Furthermore, improvements in the

strategic planning process would require even more inputs particularly from

stakeholders outside the central ministry. In Eritrea there was a constraint in terms of

numbers of qualified health planning staff. This may also reflect the fact that Eritrea

had chosen to use a planning structure which does not include a specialised planning

unit. In contrast, the presence of a Planning Unit, as existed in both Mozambique and

Zimbabwe, provided a focus of recognition of the need for specialist training. The

lack of an Eritrean planning unit also meant that there was no specific budget for

planning activities.

Though both the Mozambican and Zimbabwean ministries and planning units had

accompanying budgets and staff, the strategic planning processes relied heavily on

donor support both in terms of funds for the process and for the recruitment of

consultants. In Eritrea donors and consultants were also used in the planning process.

The use of outside consultants reflected a shortage of appropriate available skills.

Whilst it may be argued that it is appropriate to use consultants for short-term

periodic specialist tasks, there are potential problems with their linkages to specific

donors and their external agendas.

The weaknesses in approach in strategic planning identified above, also suggest

the need for staff development to meet the changing needs of strategic planning.

Firstly, the reforms that the countries were engaged in suggest that the legacy of the

previous ‘command and control’ approach to planning will become less appropriate

in the future. The focus of strategic planning was at the central level with

decentralised levels mainly developing operational plans. With greater decentralisa-

tion it is inevitable that more decentralised strategic planning will be required with

staffing implications both at the lower levels and the need for new skills and attitudes

at the centre. The reforms were also leading to a more significant role for the private

sector, and planners need to adapt their approaches and related skills to this.

Secondly in both Zimbabwe and Mozambique, and to a lesser extent, Eritrea,

the strategic planning processes were weak in terms of the ability to consult with

stakeholders, and in particular, communities again suggesting the need for new staff

skills. Lastly, the need to understand the context within which strategic planning

occurs suggests the need for the incorporation of appropriate analytical skills in this

area.

The second key resource is information. Various sources were seen as being

potentially relevant for planning. These include routine HMIS information, and

research and consultancy reports.

The gaps in information identified are not unusual—indeed it would be strange

and potentially worrying if planners were to suggest otherwise. Of more concern was

the suggestion that information was available but not being adequately used. In

Zimbabwe, for example concern was expressed that the strategic plan failed to take

sufficient account of the HIV/AIDS situation despite the evidence on the severity of

the epidemic that was emerging during the development of the plan. This was

characterised as a reluctance to use information that is not fully verified or formally


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available. This may be understandable, particularly given the current global push to

‘evidence-based’ policy-making. However there is a danger that appropriate plans

are not made because of concern that information is not yet scientifically robust. In

Zimbabwe this seems to have been exacerbated by the political environment

prevalent at the time of developing the strategic plan in what may be described as a

denial phase towards AIDS.

Zimbabwe and Mozambique have well developed research capabilities, both in

terms of the universities and the Zimbabwean Blair Research and the Mozambique

National Health Institutes. However the research identified weaknesses in terms of

the links between research and strategic planning. In Zimbabwe, criticisms suggested

that research focused on the public sector largely ignoring the private sector. Eritrea

has a well-developed HMIS but less developed research capacity, reflecting its more

recent independence and conscious decision to devote resources to training rather

than research. Indeed it would appear that research is conducted internally within the

MoH rather than independently at research institutes or the university. Whilst this

may strengthen the links between research and policy, it may also lead to a lack of

independent research.

Content and scope of strategic health plans

This section gives a brief overview of the strategic health plans in each country and

their relationship with the reform policies.

In Eritrea there are various strategic planning documents including one from 1996

called the Strategic Plan. This, in addition to setting out programme objectives, has a

focus on human resources, reflecting the particular issues facing the country in the

post-independence period. A later 5-year plan includes priority areas of expansion

and restoration of facilities, training, surveillance, control of communicable diseases

including HIV/AIDS and provision of services to returning refugees. The main

criticism of the plan expressed by respondents was a failure to incorporate private

sector issues.

In Zimbabwe, the strategic plan covers the 1997–2007 period. Some respondents

saw it as insufficiently focused—a strategy rather than a strategic plan. Part of this

concern related to a perceived failure to match the strategy to resources. In contrast to

Eritrea the plan was criticised for giving insufficient attention to human resources.

Other sectors, and in particular the private health sector, were also seen to be

inadequately reflected, and concern was expressed that it did not have sufficient focus

on PHC, or attention paid to the wider context.

The Mozambique plan covers the 2001 to 2005/2010 period. It was approved in

April 2001 and is a working document designed to cover a 10-year period but to be

revised after 5 years. As such it sets an agenda but recognises that certain issues have

not yet been fully analysed. Instead a broad direction is set (e.g. development of

greater decentralisation) without details. It concentrates on structural issues and

includes an Institutional Development Plan. Interestingly it includes, in addition to

reference to policies on health care provision, a focus on advocacy for action by other

sectors.


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122 A. GREEN ET AL.

In each country there are also shorter-term (1–3 year) operational plans, which are

formally seen as the mechanism for implementing the strategic plan, but which are

not always closely aligned to the strategic plans.

Whilst all three plans contained important elements related to the reform process,

it is also clear that in all of the countries they were not seen as the driving force for the

reforms, and to the degree they related to the reforms, were an incomplete reflection

of them, rather than a comprehensive statement providing a leading role in the

development of the detailed reform policies.

ROLE OF CONTEXT IN THE PLANNING AND POLICY PROCESSES

Three key factors in the context emerged in the research—ideology, economic

factors and wider international factors.

Ideology

Ideology has played an important part in the development of health policies. In

Eritrea the EPLF experience led to clear priority to health, the adoption of the basic

principles associated with PHC, and self-reliance policies. In Mozambique the

ideology developed during the armed struggle emphasised health as a human right.

Socialist ideology also played an important role in Zimbabwe in the 1980s and

resulted in the rapid growth of social services as well as expansion of the civil

service. Subsequently however there were shifts away from these ideologies despite

lip service to the values that underpinned them.

Economic factors

Changes in economic policy and the introduction of neo-liberal reforms have also

affected health policies. In Zimbabwe expansion of the government’s health budget

ended with the 1990s economic downturn and implementation of structural

adjustment. These problems were compounded by droughts, and the fall in donor

assistance (due to involvement in DRC and governance issues). In Mozambique,

economic problems associated with civil war together with both drought and floods

have already been alluded to. The 1990s liberalisation process and shift to a market

economy and economic growth also provide an important contextual backdrop to

health sector reform. Eritrea has had similar problems including war, drought and

displacement of its workforce, which had a major economic impact on health

policies and change of government focus from health to defence and rehabilitation.

International factors

International influences were both a major inspiration for ideological shifts and a

significant source of resources. A distinction is needed between international

influences through the private and government sectors. The former is important in


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areas such as the cost of pharmaceuticals. The latter mostly comes through donors

and is discussed in the next section.

Regional issues, including cross-border use of health services, are also important.

In Zimbabwe the effect of the conflict in the DRC on external relationships; concern

that Zimbabwe would follow the donor-led route of Zambia; emigration of staff and

capacity of communicable diseases, and particularly HIV/AIDS, to cross national

boundaries were critical. In Eritrea war with Ethiopia led to internal displacement of

citizens, distortion of regional trade, reduction in exports and investment in the

international market, and reduced foreign currency reserves with implications,

especially on purchase of drugs and technologies.

ROLES OF DIFFERENT ACTORS IN THE DEVELOPMENT OF

STRATEGIC PLANS AND POLICIES

We look now at the roles of the different actors (Walt and Gilson (1994)) in the health

sector in the development of both strategic plans and policies such as the reforms.

Actors at central government level

Between the central governments there was variation as to where the locus of policy-

making and planning lay. In each country there is a tradition of public sector planning

with a central controlling mechanism. In Mozambique, the National Planning

Commission is traditionally strong, but at the time of the research was becoming

weaker due to the technical nature of the health sector and the flow of funds from

donors directly to the MoH. In both Eritrea and Zimbabwe, a clear central influence

was perceived. In Eritrea this is manifested through the Macro Policy Unit under the

Office of the President, which is responsible for overall government policy direction.

A similar, though less formal influence, is to be found in Zimbabwe where the

Planning Department of the President’s Office was seen as exerting political control

and vetoing MoH decisions.

An important issue concerns the locus of leadership for health sector reform,

which can suffer from fragmentation. The case of Zimbabwe exemplifies this. The

Public Service Commission took an important lead in relation to downsizing, the

Ministry of Local Government was promoting cross-governmental decentralisation,

and the promotion of the private sector came within the overall liberalisation policies

of the government.

Intersectoral actors

An issue for health planning concerns mechanisms whereby the wider health (as

opposed to health care) agenda can be addressed. In Zimbabwe, ministries such as

Construction, Local Government, Public Service Commission and Finance have

inputs into health planning decisions. Nevertheless, there are few opportunities or

mechanisms for genuine intersectoral strategic development. In Eritrea, a National

Health Advisory Council was proposed in 1996 to bring together different


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124 A. GREEN ET AL.

stakeholders but had not been set up. Despite the Macro Policy Unit, which operates

at the Central government level, there are few opportunities at the national level for

intersectoralism, although possibly more at the decentralised zonal level. Here yearly

operational plans are developed by Zonal Health Management Teams (ZHMT), with

participation of different stakeholders. However, it is unclear who leads the process

at this level as the ZHMTs are answerable both to the local government at zonal level

and the (MoH) at central level. In Mozambique, there is an established process of

bringing national level partners together in regular meetings, though in practice this

means donors.

Role of the Ministry of Health

The level of autonomy and the specific role of the MoH in the planning process is

important. In both Eritrea andMozambique, MoH respondents emphasised their lead

role in health planning. Following independence, the high priority in Mozambique

given to health issues accorded the MoH a degree of autonomy and some ability to

bypass central government machinery such as the Ministry of Planning. In

Zimbabwe there was a perception that the MoH had limited autonomy. Firstly,

national institutions, such as the Ministry of Finance and the Public Service

Commission, were adopting national leadership on public sector reform. However, as

with Mozambique, donors were also viewed as having an important influence over

the MoH.

Within theMoH itself differences were evident. In Zimbabwe different groups and

units who had overlapping planning roles were identified including the ‘Group of 10’

(a combination of department heads in the MoH and external members), the

Planning, Monitoring and Evaluation Unit, the Policy Unit, the Strategy

Development Unit, the Planning Pool and the different programmes. In Mozambique

there is a strong tradition of, and attachment to, programme-based operational

planning, which has caused difficulties for the strategic planning process,

particularly in association with the resistance of some donors who considered the

investment in a broader planning process wasteful when the existing programme

goals remained unfulfilled. The status of the Planning Directorate gave it little power

to mediate between different views within the ministry. In Eritrea there was no

formal Health Planning Unit as such with Planning Committees being constituted on

an ad hoc basis when felt necessary. Planning was done by the Directorates, often

with the help of international consultants. The Directorates were represented in

planning committees, which then incorporate their plans into the overall plan.

Technical versus political actors

One key area is the relative inputs in planning from technical versus political groups.

In Zimbabwe technical groups were seen as having significant influence over

strategy. However, the political roles were emphasised in both Mozambique and

Eritrea, with access to the Minister seen as an important means of influencing policy.


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Decentralised actors

The planning role of decentralised levels varied. In each country strategic plans are

developed at the national level with little involvement at the local level other than in

the development of operational plans. Zimbabwe has a more decentralised system

within its urban authorities than either of the other countries. However there is little

connection between the central strategic decisions and those of local authorities.

Donors

Donors have played an influential role in terms of both the wider context (e.g.

structural adjustment), and the strategic planning processes. Different views

highlighted particular facets of donor operation and relationship with the

government. In Zimbabwe, for example it was seen positively by some as

‘tempering the excesses of politicians’ whilst others suggested that donors promoted

policies that they would not consider for their own country. Specific donors, and in

particular the World Bank and the IMF (often indirectly through the Ministry of

Finance), were perceived as having greatest influence. DANIDA was also often

mentioned largely due to its influence on reforms in neighbouring Zambia. The links

between the funding leverage of donors and policy setting was also often referred to.

In Mozambique, the opening up of the system to market forces in the 1990s

coincided with a changed international presence in the health sector. The brokering

of peace was supported by international agencies and associated with promises of

resources. Donor agencies took on a greater presence in the country. The concerns of

donors over issues such as user and beneficiary participation, poverty orientation and

rational resource use were expressed in a series of studies produced prior to writing

the Strategic Plan. Indeed the strategic planning process itself was seen by some to

have resulted from donor pressure partly as a mechanism for international co-

operation activities and financing. Donors were seen to be jointly occupying the

driving seat with government with the relationship defined by formal agreement. In

Eritrea, the role of donors was less apparent partly due to the deliberate self-reliance

policy arising from the liberation history. The resultant policy of reliance on internal

resources may also explain the less positive attitude to NGOs reported by some

respondents. Despite this there was a significant use of donor agencies’ consultants in

developing plans.

Private sector

With the increasing public/private mix one might have expected greater planning

involvement from the private sector. However, the degree towhich this happened was

unclear with differing perceptions between government and private sector officials.

In Eritrea, NGOs and other stakeholders felt that they had little influence over the

development of strategy and that there was no participatory forum in which they

could engage. In Zimbabwe, a number of potential stakeholders were identified

including NGOs and the church sector, professional associations, trade unions and

the private sector. While MoH officials felt that there was involvement in the central


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126 A. GREEN ET AL.

planning process by such groups, some respondents, particularly from NGOs and the

private-for-profit sector, saw little opportunity for participation. Some controversy

surrounded the role of NGOs, since they were seen by some in government, as having

undue influence. However, despite their significant role in the health sector, church

health services were paradoxically seen as having little influence. In Mozambique,

although some international NGOs were consulted in the development of the plan,

churches, religious groups, professional associations, trade unions, local NGOs were

apparently not consulted.

Communities

In none of the countries were communities seen to have any influence over planning

decisions. In Eritrea a legacy of the liberation struggle was a sense of government

identification with community needs. However though health professionals working

at the zonal level were perceived to have good understanding of community needs,

there was criticism that their role was not significant in planning at the central level.

In Mozambique, there was limited community participation and a feeling that it had

been promoted to satisfy donors. In Zimbabwe there was also limited community

participation.

The above suggests that decision-making influences in health planning and policy

is diversified and non-monolithic, but within a restricted number of stakeholders,

particularly politicians, senior public servants and donors and with different levels of

relative power. The relative position of stakeholders also changes over time.

CONCLUSION

In this final section we pull together key conclusions regarding the underlying

research questions.

The research suggests that the strategic planning process had not been a key

instrument in designing the reforms, and though resultant plans mirrored a number of

the reforms, they were not always consistent with them. Whilst each country had

adopted strategic planning systems, in all three countries a more complex interplay

of forces, including influences outside both the health sector and the country, had

been critical forces behind the sectoral changes experienced over the previous

decade. For analysts of policy processes this will not come as a surprise. Walt and

Gilson (1994) for example point out the importance of the interplay between

processes, actors and context in developing policy content. However, if one of the

roles of strategic planning is to provide a framework for managing this interplay; the

strategic planning processes in the systems failed to do this, and hence to live up to

the name of ‘strategic’.

Planning processes were seen to be carried out either through dedicated structures

such as in Zimbabwe (which may be permanent or ad hoc) or through integrated

general government structures such as in Eritrea. Both approaches were seen to have

positive and negative implications. The former allowed specific resources to be

allocated to the planning process; however, it carried the danger of being isolated


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from broader decision processes. The more integrated approach had greater potential

not only for broad ownership of plans, but also for a failure to provide a focus for

planning. The planning process suggests the need for planners to look in a wide range

of potential organisational directions including other ministries, lower organisational

levels and other providers. It also needs to consider the relationships between

strategic planning, operational planning and management. In the formulation and

implementation of a strategic health plan, a number of trade-offs have to be made

(such as the pressures of tight deadlines vs. the need for consultation and

development of stakeholder ownership)

The research highlighted the complexity of forces that influence the ability of

government to impact on health. Planning systems need to recognise these forces and

be shaped accordingly. Each planning system displayed similarities and differences

and strengths and weaknesses. Differences existed in terms of the formality of the

process, timeframes, forms of structures for decision-making, degree of inclusive-

ness in decision-making and the value base on which they rest. One common feature,

though different in presentation, related to the existence within each country of other

decision-making processes which may run in parallel with strategic planning and

either re-enforce this, conflict with it or sideline it.

The strengths and weaknesses are not inherent in the structures and processes

themselves but are related to the environment within which they operate and the

purpose of the planning system.Whilst planning systems may superficially be seen to

share a single purpose—the promotion of health—the research has shown a number

of related, different and occasionally conflicting purposes. In order for planning to be

effective, the purpose and values on which it is based need to be explicit and the

structures and tools closely linked to these.

The research raises questions as to what is actually meant by strategic planning.

Conventionally a strategic plan is seen as choosing priorities, defining a future

direction within specified time-boundaries, clarifying roles, rationalising resources,

documenting process and identifying agendas for further attention. Important issues

were raised in the research about the nature of a plan. These included the extent to

which a strategic health plan has to be expressed in a written document, formally

recognised as ‘the plan’, and the degree to which plans may be seen as either organic

or evolving documents allowing for updating over time or finished and unchanging

documents. Strategic planning may be seen as a process, which formally leads to a

strategic plan; or it may be seen as a process and institutions that make strategic

decisions. The exact combination of forms it takes will reflect decisions taken by

policy-makers and planners as to how the planning system should be constituted and

its exact nature.

The extent to which a strategic plan relates specific resources to strategic direction

is also clearly important. Plan content may however take on forms, which do not

make a strong connection between these. Plans may, for example be anodyne, saying

little concrete; or trajectory, maintaining the status quo into the future. Theymay also

embed contradictions or set agendas without showing a clear sense of direction.

These options may be appropriate in different contexts.

For example, does a strategic plan have to include an explicit description of how

resources are to be linked to action and objectives? Does it have to confront the key


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128 A. GREEN ET AL.

problems, contradictions and challenges in that country and does it have to cover all

key areas of the health system including inter-sectoral issues? An understanding of

the meaning of strategic planning within any context is a critical precursor to any

strengthening of the system.

The research has also suggested that in all of the countries there had been

insufficient investment in appropriate planning resources particularly in terms of

staff with appropriate skills for the changing environment and information.

The research also examined, though is not reported on in any detail here, the likely

impact of the reforms, many of which were still being implemented, on the

effectiveness of health planning. There was little evidence that the planning

processes are adjusting to the new post-reform context. Thus the expectation that

different approaches to planning would emerge as a result of, in particular,

decentralisation and the growth of the private sector was not met.

Given all this, it is suggested that more attention is needed in health systems as to

the design and resourcing of strategic planning. As an output from the research a 15-

point checklist for assessing a strategic health planning based on the issues identified

in the research (Green et al, 2002) was developed (see Figure 3).

Underlying all of the above is the recognition that in each country two processes of

strategic planning were taking place in parallel—the formal health planning

processes and the health care reform processes. The former is a type of strategic

planning that is the formal, technically driven process, with explicit health objectives

and with usually a written plan. However the latter is, in contrast, a more political

process involving the key stakeholders and in particular donors. It is rarely explicit,

with no single document, and often has more varying aims, with efficiency a key one.

Figure 3. A diagnostic checklist for strategic health planning systems (Green et al., 2002)


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The challenge for health systems is to find an accommodation between these two

processes. The least productive scenario is where the two work at odds with each

other. The most optimistic is the, as yet unrealised (and in some views, unrealisable)

potential of SWAps, as a mechanism for seeking an integrated form of the political

and the technical processes. Somewhere between these is the need for planners,

whose prime responsibility is to facilitate the process of decision-making, to

recognise the reality of the political process and seek means of harnessing the formal

processes to this.

ACKNOWLEDGEMENTS

The authors acknowledge the input of the following in the development and conduct

of the research reported in here: Craveiro I, Escola Nacional de Saude Publica, Av

Padre Cruz, 1600-560 Lisboa, Portugal. Gebresellasie S, MoH, Division of Research

and Human Resource Development, Eritrea. Abdullah M, Universidade Eduardo

Mondlane, Faculdade de Medicina, Av Salvador Allende, Maputo, Mozambique.

Part of the fieldwork of this research project was carried out with the support of the

Escola Nacional de Saude Publica de Lisboa, where Paulo Ferrinho worked for some

time as Assistant Professor of Health Administraion.

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Documents

The role of strategic health planning processes in the development of health care reform policies: a comparative study of Eritrea, Mozambique and Zimbabwe