Harare -- Governments in the WHO African Region have been urged to ensure the strengthening of health systems by improving their stewardship role, and the role of development partners and stakeholders, in implementing health sector reforms.

The call is contained in a report to be presented by the WHO Regional Director for Africa, Dr Ebrahim M. Samba, to the 52nd session of the WHO Regional Committee for Africa taking place from 8 to 12 October in Harare, Zimbabwe.

"There is a pressing need to revive and refocus reform efforts, mainly on the enhancement of the stewardship role of government. Policy debate and research should also focus on improving this role in future," Dr Samba says in the report which focuses principally on how the health sector reform process can focus attention on improving the stewardship role of government.

Dr Samba states that although most countries in the Region had developed and implemented health sector reforms, including Sector-Wide Approaches (SWAps) to certain levels in the last ten years, a number of factors continued to impede the reform process.

These include: weak institutional and human resource capacities, the brain drain phenomenon, lack of incentives, inefficient use of potential national expertise, weak co-ordination of partners in health development, frequent and often inconsistent changes in government policies, inadequate legislation, weak accountability and lack of transparency, and non-maximization of international agreements and regulations.

The Regional Director maintains that one way of effectively dealing with these and other challenges was for governments to assume full stewardship role for health development.

He explains that the role being advocated transcended conventional leadership in the health sector (which places greater emphasis on areas directly under the jurisdiction of the health ministry), but stewardship - a function that impacts on all aspects of health development, focusing not only on responsibilities and tasks for the strategic management of the health, but also on factors in the broader social, political and economic environment within which the health system operates.

Components of stewardship

According to Dr Samba, the concept impacts on all aspects of health development and encompasses: stewardship of health systems responsibilities that mainly fall directly under the jurisdiction of the ministry of health (stewardship in health); stewardship in setting the direction of health development leading to the strategic management of the health system (stewardship of health); and stewardship of factors in the broader social, political and economic environment within which the health system operates (stewardship for health).

Stewardship in health

Stewardship in health is concerned with ensuring the effective undertaking of the other three health system functions.

• Stewardship in health financing is concerned with establishing and maintaining an organizational and regulatory environment in which effective and equitable financing can take place.
• Stewardship in health resource generation is concerned with ensuring that activities such as human resources development, health intelligence, production, purchasing and distribution of pharmaceuticals and equipment and building and maintenance of infrastructure are effectively carried out.
• Stewardship in health service provision encompasses a variety of tasks that must be carried out to ensure that the type, quality and accessibility of services are in line with national policies and plans.

Stewardship of health

Stewardship of health refers to the strategic management role and is concerned with developing a broad vision and setting a policy direction for health development as well as deciding how the health system should evolve to respond to the changing social, demographic and economic environment. It is also concerned with the establishment and maintenance of the health system's overarching organizational and institutional framework, and with issues such as the allocation of functional responsibilities to individuals and organizations within the system, including operationalization of district health systems.

Stewardship for health

• Stewardship for health deals with activities that go beyond the health system to impact upon the main determinants of health and with other issues that are external to the health system but which either foster or constrain its effectiveness. Stewardship in this area seeks to influence the broader environment in which the health system operates.

  Dr Samba outlines seven conditions that must be met to enable governments to effectively undertake their stewardship role. These are:

• peace and security; 

• continuity in health policies and personnel and institutional arrangements in ministries of health; 

• co-ordination and participation of partners in the implementation of health policies and plans;

• participation of civil society in improving the design and implementation of public programmes;

• evidence-based decision making;

• transparency and accountability; and 

• inter-sectoral collaboration.

Dr Samba explains that despite its broad focus and its central role in any health system, stewardship does not exclusively require the government or the ministry of health to become directly involved in financing, resource generation and service provision. In his words: "Stewardship involves the government in the establishment and maintenance of an environment in which NGOs, private enterprises and individual health practitioners can operate effectively, efficiently and with minimum bureaucratic interference." This, he stresses, is especially crucial in an era witnessing the emergence of multiple players, including international agencies and NGOs which often have more resources and may have values and policies different from those of government.

While stewardship tasks may be delegated, special care should be taken to ensure that this delegation is coherent and well defined, and that the public good is not compromised. Governments must maintain oversight over those expected to carry out these tasks, monitor how well they are being undertaken, and intervene where necessary.

The orientations contained in the report are expected to be endorsed by the Health Ministers. 

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