Strategic aspects

All these differences between PHC and EMA have important strategic implications for sustainability (Table 41), the role of different actors (Table 42), and accountability.

Managerial and financial sustainability

In PRIMARY HEALTH CARE (PHC) sustainability is paramount.^162-166 Different components of PHC should be developed harmoniously, and the health sector should be in harmony with other sectors of society. A programme format, becoming integral part of health and social policy, is thus preferable over a project format (Table 41).^{162,167-169 †} The project format can, however, be justified to innovate, or to facilitate management of a particular part of a programme.^* Institution building and institutional strengthening are important to obtain managerial sustainability (see also manpower policy, Table 42). In PHC, there is often cost sharing between government, international donors and users.^{83,166,170,171} Cost constraints are often overriding,³³ and even if this is not the case in the short term (e.g. when a foreign donors funds a PHC programme), efficiency and sustainability are important considerations. To be sustainable, health services should be organised at 'affordable' cost to be sustainable.

[^† The 'programme - project' typology is a simplification similar to the 'development - disaster/emergency' typology (Figure 38). Both typologies can be largely superimposed, and thus also many of their characteristics (such as time perspective, role of different actors, funding, &c).

^* Most often, however, the project format is imposed by the foreign donor to facilitate financial accountability. The problems with the project format are clearly illustrated by the experience of EPI projects in the least developed countries. They resulted in a disproportional development of vaccinations within the health sector, and once the support of foreign donors decreased, they could not be sustained, which resulted in steep drops in vaccination coverage rates.]

Table 41: Sustainability in PHC & EMA

In EMERGENCY MEDICAL ASSISTANCE (EMA), the project format is often preferable. Developing EMA as a programme, with its corollary of institution building, may hinder timely abolition or integration in the PHC programme. Institutional strengthening is thus of low priority. In EMA, efficiency is less important than in PHC.³³ To be effective in the very short term, important resources are needed, and these originate often exclusively from international donors. Funding is thus usually not the main constraint. Sustainability is not a major concern.

Actors

PRIMARY HEALTH CARE (PHC) is a local and public responsibility.^172-175 A collaboration with the local administrative and political authorities is necessary to imbed health services in overall society (Table 42). The central Ministry of Health (MOH) has an important role in resource allocation among areas and programmes; it must set norms and regulate.^176,177 MOH should develop policies on manpower and training, on health care financing, on pharmaceutical supply and quality control, &c. Outside assistance may be necessary, but there is then also a higher risk of non-appropriate solutions, with a dominance of the technical dimension over the social one. The role of foreign support should be mainly a technical assistance; otherwise, the feeling of 'ownership' may be absent.^167,178 Temporary substitution can only be justified as an interim measure in situations where local capacity is inadequate, and on the condition that there is a perspective for local take-over, otherwise sustainability could be jeopardised.¹⁶³

The long-term perspective and the necessary capacity building require long-term involvement of the same staff. Staff will thus often be health professionals on long-term contracts, with attention for career structure and promotion possibilities. Work with on-the-spot trained auxiliaries may yield some short-term results, but often leads to a dead-end in the medium term.^* Training at all levels is an important component of PHC.^118,179-185

[^* This is well illustrated by the failure of most so-called primary health care programmes based on the wide-scale training of village health workers. Although they may have generated some short-term results (e.g. when measured in terms of number of consultations, or turn-over of village pharmacies), they fast lead to a dead-end.^{12,18,126,129}]

Increasingly, PHC managers will have to come to terms with private health care.^† This does not seem to raise unconquerable obstacles for the private non-profit sector (NGOs, churches, &c).^142,143 However, the growth of private for-profit medicine in developing countries confronts public health professionals with serious challenges. Increasingly, they will have to find ways to have an impact on the quality of care it delivers, and on the inequalities it often reinforces.¹⁴⁰

[^† Private health care is a complex issue and public health professionals, both practitioners and academics, do not easily get a grip on it. It will be only marginally mentioned here.]

Table 42: Actors in PHC & EMA

In EMERGENCY MEDICAL ASSISTANCE (EMA), decision-makers will often be outsiders, and foreign substitution the rule rather than the exception.³³ Substitution is often needed. Paramount is the technical expertise and the ability to mobilise and manage the necessary resources. Links with local health authorities are useful, but lines of authority should be simple and straight. Links with administrative and political authorities are necessary. However, this is more to pay respect and to avoid obstruction than to involve them in decision making. The role of central MOH is often limited. Staff will often be recruited among beneficiaries and work with short term contracts. There may be a need to work with on-the-spot trained auxiliaries.^186,187 Training is often geared to obtaining execution of standardised key tasks from auxiliaries. EMA is presently dominated by private non-profit actors, especially international NGOs.¹⁵⁰

Accountability

Accountability is a complex and value-loaded subject. Others have tried to get a grip on accountability of health services in PHC,^21,188 and on accountability of emergency relief.^{33,51,150,189} In PHC and EMA in developing countries, the funding agency - frequently a foreign aid donor - and the clients - the recipients or beneficiaries of the aid - more often than not have different agendas and preferences. It seems thus appropriate to distinguish accountability to the donor from accountability to the beneficiaries. In relief and aid, this distinction roughly coincides with the distinction between financial accountability and social accountability.

In PHC, it is now widely accepted that health services have a responsibility to the population, and not only to the users who present to the health service. A step further is being accountable towards that population.¹⁸⁸ The style of governance and the degree of participation in the wider society will determine how financial and social accountability are valued and practised in the health services. When clients participate financially to the health services, this can be used as a lever to increase both financial and social accountability.^{102,103,190,191}

In EMA, discussions on accountability have usually focused more on financial accountability than on social accountability. Financial accountability of implementing agencies to donors, with its corollaries - bureaucratic regulations and financial audits - have steeply increased over the last decade. But social accountability remains largely on the level of good intentions. In disasters, decision-makers often feel accountable to their employers - international agencies and NGOs - who claim to be themselves accountable to the beneficiaries, the 'victims'.⁵¹ However, agencies' own agendas, bureaucratic logic and the short-time frame may hamper understanding of the beneficiaries' perspective.¹⁶⁹