Changing Relationships Govt Church Africa

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international journal of health planning and management

Int J Health Plann Mgmt 2002; 17: 333–353.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hpm.685

A shared mission? Changing relationshipsbetween government and church healthservices in Africa

A. Green1*, J. Shaw1, F. Dimmock 2 and Cath Conn1

1 Nuffield Institute for Health, University of Leeds, Leeds LS2 9PL, UK 2 Regional Health Consultant, East and Southern Africa, Presbyterian Church, USA

SUMMARY

This article reviews the relationships between government and church health providers withinsub-Saharan Africa with a particular focus on East and Southern Africa. This is of particularinterest at this time, given the changing configuration of the health sector in many countriesas a result of health sector reform policies. The article provides a historical overview of the development and emerging role of the church health services within this changingenvironment.

The factors affecting the relationship between the government and church sector are identi-fied. These include differences in objectives, types of service provided, and the organizationalculture and management styles. The paper then explores key issues seen to affect the future pat-

tern of relationships including the changing scene, and identifies different models for relation-ships and implications for key actors including the Ministry of Health, church health agenciesand coordinating bodies. The article concludes that church health services will continue to playa key role in health care in sub-Saharan Africa; however, there are challenges facing them andboth parties need to develop a response to these. Copyright# 2002 John Wiley & Sons, Ltd.

key words: NGOs; church and mission health services; health policy; planning; health sector

reform

INTRODUCTION

The last decade has seen intense interest in a number of developing countries in

changing the structure and internal relations of the health sector. Health sector

reform policies, promulgated initially by the World Bank (1993) and picked up

enthusiastically by a number of other donors and governments, have often included

the promotion of a public/private mix. Though the precise meaning of this policy

element is not always clear it generally endorses recognition of the actual and poten-

tial contribution of the non-State sector and the need to develop clear roles for, and

relationships between, the different health care actors.

Copyright# 2002 John Wiley & Sons, Ltd.

* Correspondence to: Prof. A. Green, Nuffield Institute for Health, University of Leeds, 71–75 ClarendonRoad, Leeds LS2 9PL, UK. E-mail: [email protected]



The term ‘non-State health care’ covers a wide range of providers including the

individual/family, traditional practitioners, private practitioners operating alone,

corporate private clinics and hospitals, and NGOs including both secular and

faith-based organizations. Within this group there has been significant attention paid

to the private sector (see, e.g. Bennett et al., 1997) and, to some degree, the generalNGO sector (Green and Matthias, 1997). However, there has been less attention paid

to the faith-based health care organizations including church providers, despite the

fact that in many countries, and in particular sub-Saharan Africa (the focus of this

paper), such organizations have a long history and continue to provide a significant

proportion of the overall health care.

This paper focuses on this group of providers. It aims to explore their current con-

tribution to the health sector and the particular challenges that they face particularly

in terms of their sustainability, and their relationships, both amongst themselves,

with the public sector, and with their donors in the light of the changing configura-

tion of the health sector. It is intended to inform policy-makers within both the publicsector and the church sector who are attempting to optimize the contribution of each

party. It draws on a number of sources. Firstly published literature in the area.

Secondly on the particular experience of the authors including work in and research

on the general issue of NGOs in health care for some years and in the case of one

author, consultant support to Presbyterian church health services in East and

Southern Africa. It was triggered by work carried out in Malawi by the authors,

in support to the Ministry of Health in the implementation of its strategic plan,

which emphasized the development of a stronger public–private mix. However,

though the analysis in the paper is illuminated by this particular experience, it is

not confined to it.

The paper starts by outlining the overall current policy context with particular

reference to health sector reforms and funding changes. It then turns to the contribu-

tion of the church sector and its historical development. Against this background the

paper analyses issues affecting collaboration between church and government ser-

vices and the factors underlying this. This is followed by an examination of possible

future opportunities and threats facing this element of the health sector.

POLICY CONTEXT OF HEALTH SECTOR REFORMSAND EXTERNAL FUNDING

It is important to view the current situation of church health services against the

wider policy context and this section focuses on two current features of the environ-

ment within which the church is operating— health sector reform policies and fund-

ing changes. It views these against developments over the past two decades.

Prior to the 1980s, although there was widespread church-based health care in

many African countries, it was largely provided independently of the State sector.

The Alma Ata Declaration of 1978 (WHO, 1978)—which was itself partly the pro-

duct of church experiences with community outreach programmes—and follow-uppolicies stressed a broader concept of health leading to both multi-sectoralism and a

recognition of the multi-agency nature of the health care sector.

334 A. GREEN ETAL.

Copyright# 2002 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2002; 17: 333–353.



Both of these shifts led in the 1980s to greater policy interest in NGOs, in part

related to their greater institutional flexibility and their ability to cross sectoral

boundaries. The financial strains on the public sector faced by most African coun-

tries not only led the State to seek other sources of funding (World Bank, 1987) but

also forced more active engagement with the non-State sector’s contribution.However, it was the advent of health sector reform policies that has led to the

widest opening of the window of opportunity for a reconfiguration of relations

between the church and public sector. The initial impetus for health sector reform

as a specific named policy initiative can be traced back to the World Bank Develop-

ment Report of 1993 (World Bank, 1993). During the rest of the past decade, a num-

ber of African countries developed health sector reform policies (Gilson and Mills,

1995) which typically contained the following components:

* creating a more open and ‘competitive’ environment including a separation of the

roles of planning/commissioning from direct provision and contracting for

services.

* enhancing the opportunities for non-State sector role (often known as the public–

private mix)

* a reduction in central state control through decentralization and development of

more autonomy for institutions such as hospitals

* new forms of financing and in particular user charges

* greater use of ‘private’ sector management styles

* new prioritizing approaches linked to minimum essential clinical packages

* enhanced orientation towards users

* stronger regulatory mechanisms

All of these either have implications for the church health sector or can draw on

experiences of this sector. Some examples are given in Table 1.

The other broad contextual change of growing significance concerns external

funding flows. For the majority of church health services that originated as part of

a wider missionary movement, there has always been a significant level of external

support whether in the form of direct grants or as contributions in kind, and in par-

ticular funded technical staff or equipment and drugs. Many churches found that

indigenization led to a reduction in external support—as Hastings observed ‘As

the number of African bishops multiplied in the 1970s, the practicability of a suc-cessful appeal for funds from abroad greatly diminished’ (Hastings, 1979). This has

caused significant resource shortages for many church health services at a time when

they face both demands for increased services and rising costs. It has also encour-

aged them to explore alternative sources of income generation which, when success-

ful, has strengthened their financial base through diversity and risk-spreading.

In parallel, though unrelated, has been a tendency within the public sector for the

mechanisms for donor support to the health sector to move away from projectized

support to more general sectoral support through what has become known as Sector

Wide Approaches (SWAps) (Cassels, 1997). The development of SWAps may pro-

vide both opportunities for, and threats to, the church sector. The emphasis withinthe SWAp philosophy on whole system thinking provides a potential opportunity for

closer integration of the church and government sectors in the health strategy which

GOVERNMENT AND CHURCH HEALTH SERVICES 335




is seen as a key ingredient of a successful SWAp. However, in the short term there

may be pressure on bilateral donors and indeed in extreme circumstances on external

private funders to channel all resources through the central government-controlled

‘basket’ thereby limiting one potential source of ear-marked funding for church

health services.

HISTORICAL DEVELOPMENT OF THE ROLE OF THE CHURCH

IN HEALTH CARE IN AFRICA

For well over a century, missionary organizations have played a significant role in

the development and provision of health care in many African countries. Although

Table 1. Links between elements of health sector reform and church health servicesexperiences

Health sector Linkage with church sectorreform element

Contracting Church hospitals in a number of countries have a history of subventionsfrom government sometimes formalized into a service agreement (seefor example the district designated hospital model in Tanzania) orcontract

Use of non-public The church health sector is already one of the largest single providerssector outside the public sector in many countries with potential for further

growth, and free of the political constraints of government servicesDecentralization This will lead to the need for new local mechanisms for collaborationand greater between the public sector and church organizations includingautonomy opportunities for the church organizations to be more involved in

planning. Church health services are used to autonomous working andhave experience to share. It also requires new resource allocativemechanisms to levels such as districts and from there to subventedorganizations

New forms of Church health services have many years’ experience of user charges asfinancing and in a form of revenue and this experience can be invaluable to the publicparticular user sector. Furthermore there is an increasing number of community basedcharges prepayment schemes operated by church health facilities which provide

a rich source of experience for the wider health sectorGreater use of Within the church sector there is wider experience of a variety of ‘private’ sector different management. There may also be greater flexibility tomanagement introduce different management approaches potentially of use to thestyles private sector

New prioritizing Church health services’ priorities will be related to their missionapproaches linked statement and their community rather than national policies.to minimum The State may both draw on NGO experience of differentclinical packages packages and potentially enforce their usageOrientation Experiences within the church sector of community participation andtowards users governance by local church body or officials may be of interest to public

sectorStronger, Some Christian Health Associations (e.g. in Ghana) have beenregulatory and developing quality frameworks and accreditation systems andpolicy frameworks have experience to share

336 A. GREEN ETAL.




church health services may be overlooked by health policy makers and indeed often

may seem to fit uncomfortably within broader NGO systems and structures, they

are probably the type of NGO most widely involved in health care, and especially

hospital care, in Africa today.

What is often forgotten is that, historically, the process of Christian mission and theprovision of health care were not always seen as related activities. Indeed, despite

devastating levels of mortality amongst both their own workers and the local popula-

tion, most missionary societies were slow to recognize the need for trained medical

people. Some missions actively resisted the involvement of medical workers.y

Nevertheless, from the beginning of the twentieth century and often much earlier,

mission personnel were often the sole source of allopathic medical care in many Afri-

can countries, particularly in rural areas.

Church-based medical care developed as part of the Christian mission ‘to pro-

claim the Kingdom of God and to heal’, (Luke 9:2) and the traditional mission sta-

tion included a church, a school and a hospital. But there were other motivations too.Schulpen (1975, p. 100) suggests that these included:

* compassion for the people in need, out of pure Christian charity

* contact with the population, especially where verbal communication was difficult

* to look after the health of their own missionaries

* as a prestige object for the church

* to help build the ‘Kingdom of God’ and to establish ‘visible signs of God’s

presence’.

* as a source of income to finance other missionary activitiesz

There were variations between Christian Missionary societies in the precise

motivation to develop their medical work. Some considered the provision of medical

services to be merely a practical expression of their Christian faith; and as such

sought no specific returns for their altruism. Others held the view that medical care

could be used as a method of evangelism to bring individuals and communities to

belief in Christ. Because health care was seen as a means of promoting the faith,

many missions required all staff to be professing Christians, and prayers would be

said on the wards as well as in the chapel or church. Furthermore, the power of med-

icine to defeat demons and bad spirits was an argument for the power of the

Christian God and a strong motivational force for conversion; surgery and ‘miracle’drugs were therefore the preferred mode of care, rather than preventive health work.

Finally, some organizations, many of which are still involved in relief and develop-

ment work today, considered it a social duty to meet medical or social needs, view-

ing health as a human right.

Irrespective of their motivation, important and often pioneering work was done by

medical missionaries such as Stanley Browne’s work on leprosy and Chesterman’s

ySee Brown (1992, pp. 233–239) for discussion of the difficulties encountered by those first wishing toinclude medical activities in Baptist Missionary Society work.zWhile these are mostly understandable, the last one may seem surprising in view of the financialdifficulties faced by most church hospitals now. But it remains the case that some church leaders stillexpect the hospital to be a source of income for other church activities; this may partially explain whysome church hospitals are so discreet about their external donor funding.





on sleeping sickness (Brown, 1992). Innovative practice was not restricted to clinical

medicine. Morley’s work on child growth monitoring was developed at the Wesley

Guild Hospital, Ilesha in Nigeria from 1956, but the hospital had developed a net-

work of village dispensaries from 1934 onwards (Pearson, 1996). Mengo Hospital in

Kampala developed, from 1919, a total of 23 rural maternity and child welfare cen-tres (Billington, 1993). The training of medical orderlies, nurses and auxiliary health

staff was also an important service provided by some Church hospitals.

Missionary organizations grew significantly during the early part of the twentieth

century and by the time of independence were a significant part of the health care

services in many African countries. Matomora (1995) notes that, in 1971, Protestant

churches alone operated medical programmes in 81 countries, including over 1200

hospitals; in sub-Saharan Africa church hospitals provide a substantial part of the

service: 43% of medical work in Tanzania, 35% in Malawi and 34% in Ghana.

However, the independence movement in Africa in the 1950s and 1960s was par-

alleled by a similar desire to indigenize churches. In part this came from the parenthierarchies, for whom it was driven by the commitment to the principles of devel-

opment and democracy. As Hastings comments ‘The older and better-established

churches, with few exceptions, were Africanizing hard in these years, at the same

time reducing missionary personnel pretty drastically’ (Hastings, 1979, p. 227). In

the case of the Roman Catholic church the process was greatly accelerated by the

‘aggiornamento’ which followed the Second Vatican Council in 1962. But as the

African clergy developed confidence supported by the flowering of black theology,

they increasingly expected to take charge of their own affairs. The Moratorium

movement in 1975 called for the withdrawal of all Western mission personnel and

resources from Africa ‘to allow the receiving churches a time for critical questioning

of the inherited structures . . . and to prophetically challenge their governments . . .

on the evils of our dependence on foreign resources’ (Uka, 1989). In some countries,

such as Zimbabwe, some mission hospitals played an important role in supporting

the liberation struggle, a fact that has not gone unnoticed by government officials in

the post independence era (Green and Matthias, 1997).

Today, especially in Africa, these church health facilities continue to play an

important role in health care delivery with three significant changes from their origi-

nal foundation. First, they are part of a more complex array of health care providers

including central government, local authorities, private-for-profit providers, secularNGOs and traditional practitioners. This has implications for their role both as pro-

viders and as policy influencers and for their relations with other agencies. Secondly,

as we have seen, most of these facilities are no longer owned, managed and staffed by

international missionary organizations, but by the national church or similar indigen-

ous body. Lastly, sources of funding have also changed, with a shift away from a

structure where the majority of external income comes from those motivated to pro-

mote religious activities, to one where there is a greater contribution from secular

sources such as bilateral and multilateral donors, international NGOs and national

government as well as user charges. Although such changes have been accepted as

inevitable by many organizations, they can be challenging to the autonomy of churches and, in particular, individual missions are often still reluctant to align them-

selves with government. This may be for a variety of reasons including a mistrust of

338 A. GREEN ETAL.




government, a desire to retain autonomy or a belief that medical care remains an

important evangelistic tool. Although church health facilities are no longer isolated

and autonomous institutions representing the sole source of allopathic medical care,

many retain their erstwhile (though often untested) reputation for quality care, despite

the struggle to maintain previous standards with diminishing resources.

RELATIONSHIPS BETWEEN GOVERNMENT AND

CHURCH HEALTH SERVICES

We turn now to look at the current relationships between government and church

health services.

It is increasingly recognized that effective policy-making needs to involve stake-

holders outside the traditional government mechanisms, including NGOs of which

church providers are, as we have seen, a significant group. Historically, however,such involvement has been minimal. For years many governments effectively

ignored church health services in their planning and funding of care, despite the

large proportion of health care resources that they represented. Church organizations

were also often mistrustful of governments. However, the 1960s saw the develop-

ment of national level coordinating bodies often known as Christian Hospital/Health

Associations, CHAs (such as PHAM in Malawi 1966 (now CHAM), CHAG in

Ghana, 1967, CHAL in Lesotho 1974). This was often as the result of initiative from

the Christian Medical Council which was established in Geneva in 1968 as part of

the World Council of Churches.{

The development of relationships between Government and church health ser-

vices at a policy level has been assisted by the establishment of such coordinating

bodies. They can engage in policy dialogue and funding negotiations with govern-

ment on a collective basis, as well as providing specialist advice and information

services to members and managing church drugs procurement and distribution. A

survey of CHAs carried out in 1999 provided useful comparative information about

their role and demonstrates the variations (see Tables 2 and 3).

One of the fruits of the establishment of CHAs was the development in a number

of countries of country-wide agreements on policy. The content of such agreements

has varied but usually includes the payment of government subsidy, often informallyrecorded with no contractual obligations but sometimes framed in a written agree-

ment or memorandum of understanding (e.g. Ghana, Kenya). In Lesotho, for exam-

ple, the concept of a Health Service Area, in Tanzania and Zimbabwe, the agreement

of Designated District Hospital status for some church hospitals, provide for a hos-

pital to supervise all the community health services in its area, regardless of owner-

ship. This integration, or at least coordinated supervision, of service within a district

makes sense in circumstances of stretched resources, provided the hospitals are

{At the international level, a regular exchange of ideas and views between the CMC, and WHO, the leadUN agency, was developed. One product of this intercourse was the formulation of the principles of PHCin 1975, which was warmly welcomed by many mission organisations, perhaps more than bygovernments (Paterson, 1998).





T a b l e 2 . K e y i n d i c a t o r s o f s e l e c t e d C h u

r c h H e a l t h A s s o c i a t i o n s

O r g a n i z a

t i o n

Y e a r

N u

m b e r o f

M e m b e r s h i p

N

o o f

% o f n a t i o n a l h

e a l t h

A g r e e m e n t o r

L i a i s o n o

f fi c e r o r

f o u n d e d

s e c r e t a r i a t

h

e a l t h u n i t s

s e r v i c e p r o v i d e d

M e m o r a n d u m o f

c o m m i t t e e

s t a f f

( fi g u r e s a r e

U n d e r s t a n d i n g

a p p r o x i m a t e )

C h r i s t i a n

H e a l t h

1 9 6 7

1 9

C a t h o l i c a n d

4

9 H o s p i t a l s ; 7 9 H C s ;

4 0

Y e s

Y e s , M

i n i s t r y o f H e a l t h /

A s s o c i a t i o n o f G h a n a

P r o t e s t a n t c h u r c h e s

5

t r a i n i n g s c h o o l s

P r i v a t e

s e c t o r S t e e r i n g

c o m m i t t e e

C h r i s t i a n

H e a l t h

1 9 4 6

1 6


1

4 H o s p i t a l s ; 2 0 H C s ;

4 0

Y e s

Y e s , l i a i s o n o f fi c e r i n

A s s o c i a t i o n o f K e n y a

( P C M A )

1

8 0 þ

d i s p e n s a r i e s

M i n i s t r y o f H e a l t h

1 9 8 2 ( C H A K )

C h r i s t i a n

H e a l t h

1 9 7 4

1 7


9

H o s p i t a l s ; 7 5 H C s ;

4 0

U n d e r

Y e s , c o

n s u l t a t i v e

A s s o c i a t i o n o f L e s o t h o


4


r e v i s i o n

c o m m i t t e e

C h r i s t i a n

H e a l t h

1 9 6 6

2 7


1

8 H o s p i t a l s ; 1 0 R u r a l

3 5

I n p r e p a r a t i o n

N o

A s s o c i a t i o n o f M a l a w i


H

o s p i t a l s ; 1 2 0 þ

H C s

6


C h r i s t i a n

S o c i a l S e r v i c e s

1 9 9 2

A p

p r o x 2 7

C a t h o l i c a n d P r o t e s t a n t

4 8

1 7 D e s i g n a t e d D i s t r i c t

C o m m i s s i o n o f T a n z a n i a

c h u r c h e s u n d e r ( C M B T )

H o s p i t a l w i t h c o n t r a c t s

U g a n d a P r o t e s t a n t

1 9 5 7

3 5


1 7 H o s p i t a l s ; 1 1 5

5 0

Y e s , g e n e r a l

Y e s , h e a l t h p o l i c y

M e d i c a l

B u r e a u

H

C s a n d d i s p e n s a r i e s

M o U a n d A

i m p l e m

e n t a t i o n

n n u a l S e r v i c e -

c o m m i t t e e

l e v e l a g r e e m e n t s

U g a n d a C a t h o l i c

1 9 5 7

C a t h o l i c c h u r c h e s

2 7 H o s p i t a l s 1 9 3

M e d i c a l

B u r e a u

H C s a n d d i s p e n

s a r i e s

C h u r c h e s H e a l t h

1 9 7 0

3 2


3

0 H o s p i t a l s ; 6 6 r u r a l

3 0

U n d e r r e v i s i o n

Y e s , r e

g u l a r c o n s u l t a t i v e

A s s o c i a t i o n o f Z a m b i a


H

C s ; 1 7 o t h e r

m e e t i n

g s

p

r o g r a m m e s

Z i m b a b w

e A s s o c i a t i o n o f

1 9 7 4

9


7

9 H o s p i t a l s ; 4 6 H C s

4 5

I n f o r m a l m u t u a l

Y e s , w

o r k i n g g r o u p

C h u r c h - r e l a t e d H o s p i t a l s


a g r e e m e n t

c o m m i t t e e

H C , H e a

l t h C e n t r e ; M o U , M e m o r a n d u m o f

U n d e r s t a n d i n g .

340 A. GREEN ETAL.




districts reported in literature’ (Matomora, 1995). The Designated District Hospitals

in Tanzania (which include church hospitals) also have supervisory functions; while

relationships between government and other (non-designated) church health services

in Tanzania are less formal, the church health services are often involved in District

Health planning consultations. In Zimbabwe arrangements for formal contracting of church hospitals worked effectively, although Mills et al. (1997) report concern ‘that

explicit contractual arrangements would damage the culture of missions that underlay

their good level of performance’. This concern may be overstated.

Elsewhere, as indicated above, collaboration seems to depend on the individuals

concerned rather than on structural arrangements. Relationships at an individual pro-

fessional level can be strong even in the absence of formal links. Competition,

despite the World Bank’s advocacy (World Bank, 1993), appears to be seldom a rea-

lity and, in circumstances where technical and professional resources are so scarce,

has few supporters, though as we have seen, there may be ‘competition’ between

different denominations for patients.

FACTORS AFFECTING COLLABORATION BETWEEN CHURCH

AND GOVERNMENT HEALTH SERVICES

As we have seen, health sector reform policies in many countries clearly stress the

importance of developing a greater public/private mix. What is less clear, however,

is the exact meaning of the policy and the relationships that are desirable between

the two sectors. Indeed it is increasingly difficult (partly as a result of such policies)

to demarcate between the two sectors. Green and Matthias (1997) develop a frame-

work (see Figure 1) for analysing interagency relationships which sets out a conti-

nuum. In this section we examine three key factors that affect the position along this

continuum and which inhibit or encourage positive relationships between the State

and NGOs: the organizational objectives; types of service, and in particular the roles

and location; and lastly, organizational culture and management styles.

Objectives

The prime rationale for service provision may vary between providers. State servicesare primarily provided as part of Government’s responsibility to promote the welfare

of its citizens. As we have seen the original objectives for church health service pro-

vision varied, with some coming close to the welfare/rights model and others seeing

it as a vehicle for evangelism. Where there is congruence between the objectives of

the State and church then there is clearly a genuine opportunity for collaboration.

However, where there is significant divergence of prime objective this may present

Figure 1. The competition–control continuum (Green and Matthias, 1997)





a genuine obstacle to collaboration with mistrust on both sides. There may also be

differences between attitudes over specific health objectives. Church health services

may also have a commitment to a local area and its objectives.

Types of service

The second potential factor encouraging or inhibiting collaboration is the similarity

or difference between the type of service offered, including its location.

Government hospitals are usually located in centres of population such as the

main district town. Church hospitals, however, are often located in more remote rural

areas and are visibly the only health care providers in that locality. Where a govern-

ment hospital and church hospital are close enough to have overlapping catchment

areas, it has been observed that patients may bypass a poorly resourced Government

hospital to seek care at a church hospital (Airey, 1989). This may lead to resentment.

Similarities in the type of service offered may make it easier for government tounderstand the service; paradoxically differences and the resultant potential for

complementarity may be attractive. Many church hospitals have perceived the need

for preventive programmes in the communities around them. One example is

Ekwendeni Hospital in Malawi with not only community-based health care and

preventive health programmes but shallow wells and sanitation, communal grain

banks, credit and savings schemes, a fertilizer revolving fund and nutrition pro-

grammes involving fortified flour and micronutrients (Ekwendeni Hospital, 1998).

Some hospitals, however, retain the more traditional vision of healing, regarding it

as essentially a curative model of care—the van Lerberghe and Lafort (1990) model

in which the hospital’s role is defined as complementary to community health ser-

vices, providing a referral service and concentrating on excellence and quality of

care within the hospital.

The range of services provided may be affected by the policies of the governing

church body (the most frequently cited example being family planning services

which are not usually offered by Roman Catholic health services) and this may be

a point of contention with Government.

Organizational culture and management styles

Although church and government health services may have a superficially similar

structure and function, the culture and management style may be very different.

Government health services are often still governed by the civil service culture, with

a strong sense of hierarchy and procedure, of the importance of good records and the

health services’ standing within the community. Jobs are valued for status, for ben-

efits such as uniform, housing and pension rights, and possibly, given low salaries,

for the opportunities of unofficial practice or income generation. The administra-

tion’s concern is to keep the service going and to ensure it works as smoothly as

possible with good relationships internally and externally. Staff management and

patient welfare may be less high priorities. Budget and staff appointments will bea source of concern, but as they often both arrive unpredictably from headquarters

it is likely to be a passive concern. The health service, whether supervised by the

344 A. GREEN ETAL.




District Health Officer (or equivalent) or managed directly by the Ministry of Health,

seldom enjoys proactive management (though, for hospitals, the shift towards semi-

autonomous status should change this). The curative work is perceived as a technical

function performed by professional staff, for which the organization provides an

administrative context.The strength of the government health service is its undisputed location as part of

the public system and the status of its staff as government employees; access to the

resources of Government such as Central Medical Stores, legal and audit services;

and an assumption of full funding from the State. The weaknesses frequently obser-

vable are those shared by all Government services when revenue funding is uncer-

tain and supervisory capacity is limited— a shortage of funds and material resources,

lack of management support and training, and a sense of isolation.

The church health service is likely to have a distinctive culture derived from the

religious organization of which it is part, and this will inform staff relationships,

the pattern of the day, planning priorities and charging policies—every aspect of the organization. Management may be more proactive in directing activity, and in

obtaining external funding. It is noticeable that those health services with expatriates

on the staff seem to be more successful in attracting outside funding; the ‘sending

churches’ overseas often continue to assist the hospital even after former mission-

aries have returned home (Asante, 1998). In many health services there is a culture

of positive striving after high standards of care and concern for the patient’s well-

being; staff may perceive the hospital as a ‘therapeutic community’ in which all

members of the organization contribute to the supportive environment which facil-

itates healing. This is sometimes matched by a critical attitude towards neighbouring

health institutions which do not share the same perspective. The health services

might cover local costs from user charges, in urban areas especially, but it is more

likely to have several sources of income apart from user charges. Sources may

include government grant, government support in kind such as secondment/posting

of staff or provision of fuel, drugs, tax exemptions; gifts from donors in or out of

country; payments under pre-payment or community insurance schemes; funds from

income generation schemes, ranging from poultry and cattle-keeping to petrol sta-

tions, restaurants, office blocks. This diversity may be considered a weakness and

certainly challenges administrative capacity, but may also be seen as a strength in

that it spreads the funding risk over many areas.Amone et al. (2000) reporting on a study of 10 Catholic mission hospitals in

Uganda, record that for all hospitals together the sources of revenue were: user fees

40%, delegated funds 10%, external aid 28% and other sources 22%.

The strengths of the church health services are perceived, especially by donors, as

being a capacity for efficient and ethical use of resources; a commitment to quality

of care even with limited resources; access to external funds and a diversity of

income sources; a sympathy with, and support from, the local community. These

are, however, only perceived as such; there is little hard evidence that church health

services are more efficient, and quality differences may be the result of higher

resource levels, including subsidized staff.Church health service weaknesses are seen as their potential isolation from

national health policy and planning mainstream; subordination to an independent





religious body with its own agenda; and dependence on Government for qualified

staff, for subsidy and sometimes other resources as well. Such organizational cul-

tural differences can lead to mistrust between government and church organizations.

One factor that may mitigate this (or in some circumstances heighten it) is the fact

that many civil servants have been educated in church schools.

KEY ISSUES AFFECTING THE FUTURE PATTERNS OF RELATIONSHIP

The final section looks to the future. It starts by examining the key changes likely to

be experienced by the health sector. It then outlines possible models for relationships

between the church and government sectors and ends by examining the implications

for the three key players—government, church providers and coordinating bodies.

The changing scene

It is observable in many countries that government/church health service relation-

ships are changing. At national level, relations, even where previously good, have

often become more difficult. A lack of trust, complaints about ‘lack of transparency’,

demands for more information as a condition of agreement often characterize cur-

rent relations. Finance is more difficult as Structural Adjustment programmes mean

governments have less money for subsidies or grants, while patients are less able to

pay for care. Government officials may complain that church health services do not

fully report donor funding when asking for Government grants and the suspicion of

double-funding or shadow accounting is raised. Church health services may com-

plain that agreed levels of grant subsidy are not paid, causing difficulties with pay-

ment of staff and suppliers. Where a formal agreement has never been signed, there

are calls for one as a demonstration of goodwill; where a Memorandum of Under-

standing has been signed, there are complaints that it is not being observed. Mechan-

isms such as regular joint meetings, a liaison officer in the Ministry, Government

representatives on the coordinating body, are effective when there are committed

individuals and high level support, but these are often lacking. From our experience,

the involvement of CHAs in national health planning and policy discussions is better

in some countries than others. For example they are closely involved in Uganda buthardly at all in Malawi. In Nigeria, there is no relationship at all, either in funding or

in policy.

At individual health institution level conditions are also challenging. External

donor funds are harder to raise, and user fee income, especially in the rural areas,

is low; professional staff are hard to attract to rural areas, and costs, especially of

supplies, continue to rise. Meanwhile patient demand continues to rise reflecting

in part the growing needs of long-term conditions such as AIDS and TB.

One of the major factors affecting change is that of funding flows, sources and

levels. The future of the churches’ diverse and fragile funding seems uncertain. In

poor countries user fees are likely to continue to bring in limited income. Donorsmay withdraw funds from individual church organizations or services in favour of

funding SWAps. Governments may reduce or remove subsidies. On the other hand,

346 A. GREEN ETAL.




church providers may actually attract more funds in future because of their positive

reputation and the desire of the international community to fund institutions other

than public services. They may become recipients of decentralized SWAps budgets

(although perhaps with limited independence and subject to conditionality). They

may benefit from a possible global upswing in resources for health partly manifestedin the increase in private (both local and international) sources of charitable funding.

For countries benefiting from debt relief initiatives, additional finance may be avail-

able through government. There seems no reason why funding contributions from

church organizations and individuals overseas should not continue.

Even if more funding is available for church organizations to continue and even

expand their operations they are likely to face additional pressures. They may need

to conform to the priorities of government and the standards and norms including

accreditation and licensing set out by contracting authorities. There may be only

limited funds for being innovative, for example for controversial work, such as facil-

itating community ownership, which might not have clear health outcomes. Theymay not be able to support and represent the poor if they have limited financial inde-

pendence and lack of commitment from the church hierarchy. They are also likely to

continue to find it difficult to recruit staff to rural areas. They may find difficulties in

harmonizing fee levels with government health services.

As well as changes in the health sector, future opportunities will also be very much

shaped by the particular nature of church organizations as religious entities. ‘Today

the Christian church is probably the most powerful institution in sub-Saharan Africa’

(Lamb, 1985). This position is not only due to historical influence but also to the

churches’ capacity for growth and change: ‘Christianity is assuming an increasing

significance in the creation of a modern, pluralistic African society’ (Gifford,

1998). The willingness of church leaders to act politically; the education of many

of the ruling classes at church schools, the international links between churches—

all these contribute to the regard in which many church organizations are held. But

this does not guarantee special status, much less secure funding, to church health ser-

vices. Indeed, increasing collaboration with government on a contractual basis may

further diminish their special position. Within the church, too, senior church leaders

may continue to lack understanding and knowledge of the key concerns and

dynamics of health policy and management; especially as health care becomes more

complex. This may explain a continuing traditional preference for hospitals ratherthan primary health care. However, greater involvement in decentralized services

may offer church staff the opportunity to innovate and modernize, addressing local

needs—without opposition from a remote church hierarchy— so as to meet contrac-

tual or partnership obligations.

The role of the church hierarchy in overseeing health activities is also likely to

change. In some countries an active church leadership is mobilizing overseas

resources, initiating developments, linking health issues into wider development

concerns and taking a high profile in national negotiations. In others, church leaders

have little interest in health activities (except as a source of revenue) and seem to

resist change. In such cases the local church health services leadership will struggleto respond to changing needs, and to develop partnerships across and outside the

health sector.





The growth of other providers including other religions (Islam particularly) and

private for profit sector may add to a competitive environment for the churches;

again, one where they no longer are seen as special. Church providers, as a result

of adopting new models of health care, may become more business-oriented in a

competitive market and therefore it could be increasingly difficult to distinguishthem from the private for profit sector (Tibandebage and Mackintosh, 1999). Again,

this endangers the churches’ special status because they may be less value driven. In

such a situation, the poor are likely to suffer because of reduced access to more

costly, less appropriate services.

Models for relationships

The changes in the structure of health systems that was outlined at the beginning of

the article suggest various possible future models including the following which

move through a spectrum from minimal collaboration through a variety of modelsof collaboration:

* Continued independence of church services with no formal relationship other

than NGO registration with government

* Continued independence but with a grant-in-aid from Government, either central

or local

* Collaboration between Government services and church services on the lines of

Health Delivery areas with shared supervision, shared responsibility for service

delivery and quality

* Collaboration in a formal partnership to provide comprehensive coverage acrossthe district

* A contractual relationship, either competitive or (more probably) negotiated, with

funding provided by Government for specific services and even specific levels of

service to be delivered by church health services

* Merger between government and church health services to integrate services for a

district population

* Nationalization by government of non-government hospitals (as in Nigeria in

1975).

While these two last options may seem less likely in the 2000s, it is significant thata mission doctor, was quoted at a Medicus Mundi conference in 1999 as saying that

‘the choice for becoming part of the public health system [rather than privatization]

will probably mean, in the long term, that the distinctions between governmental and

church institutions may fade away’ (Verhallen, 1999).

The new models of collaboration outlined above offer a number of potential

opportunities for church health services but also potential threats.

As part of a decentralized system they can be included as active partners in local

level planning with the potential for greater involvement in policy and resource allo-

cation. In terms of organizational survival, they may find opportunities for increased

and more secure funding. Also, they offer possibilities for diversification into newactivities, exploiting the traditional role of the NGO in pioneering innovation in

service delivery, and thus generating new skills as well as scope for building new

348 A. GREEN ETAL.




alliances and relationships. In terms of benefits to users, these models offer oppor-

tunities for more effective existing services as well as access to new services.

Increased effectiveness may result from better collaboration between health service

providers and the additional demands made of church providers in terms of account-

ability and quality assurance.However, these potential gains are unlikely to be without a price. There is the risk

that too rapid or badly planned change may weaken the provider and damage the

quality of service. A contractual or integrated health delivery area relationship

may compromise the independence of the churches to implement their own policy,

by tying them to government financing and systems to such an extent that they are

unable to function without government. They may lose the benefits of their unique

style, becoming one of a number of homogeneous provider organizations.

If the preferred new model of health care is to identify church providers as desig-

nated health services and contractees for existing services there is a danger that there

will be reduced incentives for church providers to develop new PHC or other inno-vative activities. On the other hand, it may be that models such as the integrated

health delivery area will offer incentives to churches to provide the most appropriate

services (i.e. combination of first and second level services) for the population they

have agreed to cover.

There may also be an opportunity for increased effectiveness as a result of the

SWAp model of donor support leading to closer integration of the church and gov-

ernment sectors. Increased access to donor funds through SWAps to fund activities,

joint planning, sharing experiences and resources may all lead to improved services

for users.

However, the channelling of funds through a central ‘basket’ may actually reduce

funding to churches rather than increase it. Donor funds, which were previously pro-

vided directly to churches may instead be channelled to the central basket and

decentralized government may choose not to fund churches. Where churches are

actively involved in planning and allocation of the ‘basket’ they may have a better

chance of benefiting from funds. However, a recent report (Foster et al., 2000) noted

that there has been limited participation of NGOs in the development of SWAps.

Reform may also offer opportunities to address the staffing difficulties faced by

many church providers. Higher government salaries and bonus systems may attract

staff to rural facilities (especially if church providers are currently pegged to govern-ment pay levels). There may be scope to share good human resource management

and development practice—such as recruitment standards, performance systems,

human resource planning and training.

Churches may, however, need to look at ways of providing increased incentives to

meet the standards expected from contracts, regulation and quality assurance sys-

tems. Also, churches will need additional skills (in management) for implementing

new models of health care and for inputting into government policy mechanisms.

Lastly, some church providers have demonstrated a particular concern for the

poor. It is possible that the current interest amongst international donors in alleviat-

ing poverty will offer opportunities for new sources of funding though such fundingmay have limitations. Funders may want to see results in the form of direct improve-

ments in health outcomes. However, church health staff working with communities





may believe that more controversial empowering and enabling outcomes are key for

giving the poor a voice as a way of securing longer term gains in health (Edwards

and Hulme, 1995). Increasing donor awareness concerning participation and

empowerment of communities and the poor in health may offer opportunities for

churches to fund such projects. Already churches find it easier to secure donor sup-port for PHC programmes such as nutrition support, than for curative care.

Implications for key actors

The above potential changes in the nature of the relationships between church and

state health services have implications for the various key actors which are outlined

below. For all the actors there needs to be a recognition that the past situation is no

longer tenable and that change is inevitable. What is then critical is the degree to

which each of the actors is prepared to shape future relationships in a pro-active

fashion, or is likely to adopt a policy of reactivism, or resistance to all change.

MINISTRIES OF HEALTH

For Ministries of Health, there needs to be broadening of the perception of the health

sector away from a focus on those public sector elements that were previously

directly managed. Strategic plans and policies on, for example, quality assurance,

or medical staff deployment need to foster consistent standards across both govern-

ment and NGO health units, and also incorporate clearly defined roles for NGOs

including church organizations. As such new tools, including both carrots and sticks

(Bennett et al., 1994) are needed. Changing attitudes towards the NGO sector are also

required. The development of policies and plans at all levels in the health sector need

also to be opened up to allow the views of key stakeholders such as church health

agencies to be heard. Ministries need to consider how to incorporate the key ingre-

dients to better relationships. Written formal agreements such as a Memorandum of

Understanding may be helpful. Top level political support from within the Ministry of

Health (or above) seems to be a deciding factor, and is linked to the need for mutual

respect (with or without formal agreements). Helpful mechanisms include a regular

liaison meeting and a designated liaison officer at the Ministry. Competent negotia-tors (with the necessary authority to commit their organizations) need to be supported

by good information systems, both to provide detailed figures on human resources,

patient activity and finance, and also to communicate with constituent members who

need to be party to evolving agreements. At a more general level, a culture of partner-

ship rather than either a narrow public service focus or policing-style regulation needs

to be fostered.

CHURCH HEALTH AGENCIES

We have argued earlier that the churches in many countries are also facing signifi-

cant change. It is important that in the light of these changes, churches come to a

350 A. GREEN ETAL.




considered understanding of their desired role in health, and communicate this to

government, entering into dialogue concerning relative roles and relationships. This

will inevitably mean compromising the independence of such agencies and opening

up their often closed decision and budget processes, but this is essential if churches

are to continue to provide a key role. Furthermore different denominations need todevelop greater cooperation despite differences of dogma if they are to present a uni-

fied policy front to government on common issues.

COORDINATING BODIES

The prevailing trend for devolution of health care services to district-level manage-

ment (whether by a District Health Team or an elected District Assembly), in laying

new responsibilities on the health services management, to work with Government

officers within the District, now calls into question the role of the national church

health coordinating body (CHA). It may no longer have a quasi-managerial role

in passing on policy directives and distributing money from central government

nor be the national voice and representative for all constituent units.

But in fact, especially for those CHAs who have always perceived their role as a

service to members rather than a management role, the new situation offers oppor-

tunities. Individual church health providers will be in need of specialist advice and

support, on information systems, financial management, quality systems; they will

still benefit from joint purchasing and procurement, for drugs and medical supplies;

and from central negotiation of tax exemptions and handling of paperwork; theywill still need advocacy with the policy community, a ‘presence at court’; they will

need an intelligence network, inter-district meetings, a forum for sharing of good

practice and good experience with government colleagues.

CONCLUSION

A number of aspects of church health services, including their relationship with

the public sector, are under-researched. Nevertheless, it is clear that church healthservices, though neglected in policy analysis and research, have had and continue

to have a major role to play in health care delivery in sub-Saharan Africa. However,

there are challenges facing them, one of which relates to the relationships between

them and government, within a changing and uncertain external environment. Under

such circumstances it would be easy for governments and church health services to

follow their separate agendas. We would suggest, however, that this is not in the inter-

est of either party. Government has a responsibility to maximize the effectiveness of

all available health resources in the country. The significant role of the church health

services, which have a long history, is needed as much now as ever. Although funding

is perceived as a challenge, the mix of funding which most church health serviceshave evolved is actually more robust than a reliance on government funding as a

single source. Furthermore, the strong service ethos, concern for quality and good





staff/staff and staff/patient relationships are critically important assets. The church

health services have much to offer and are essential to the future of health care.

Each party therefore, while developing its response to its immediate challenges,

needs to be actively exploring new means of partnership and fruitful collaboration.

The combined forces of the two sectors can go further towards achieving the objec-tives of universally available and affordable health care, which both public and

church health sectors would acknowledge as their ultimate goal.

REFERENCES

Airey T. 1969. The impact of road construction on hospital inpatient catchments in Meru.Social Sci Med 29: 95–106.

Amone J, Asio S, Cattaneo A, et al. 2000. Report of a research: user fees in private not-for-profit hospitals in Uganda. Development and Health Supplement to 2, Padua Italy,CUAMM.

Asante KO. 1998. Sustainability of Church Hospitals in Developing Countries. World Councilof Churches: Geneva.

Bennett S, Dakpallah G, Garner P, et al. 1994. Carrot and stick: state mechanisms to influenceprivate provider behaviour. Health Policy Planning 9: 1–13.

Bennett S, McPake B, Mills A (eds). 1997. Private Providers in Developing Countries:Serving the Public Interest? Zed Books: London.

Billington R. 1993. A Tune on Black and White Keys— Partnership in Healing: The Story of Mengo Hospital. Janus: London.

Brown SB. 1992. The History of the Baptist Missionary Society 1792–1992. Edinburgh: Clark.Cassels A. 1997. A Guide to Sector-Wide Approaches to Health Development: Concepts,

Issues and Working Arrangements. WHO: Geneva.Edwards M, Hulme D. 1995. NGO Performance and accountability. In Non-Governmental

Organisations—Performance and Accountability, Edwards M, Hulme D (eds). Earthscan:London.

Ekwendeni Hospital. 1998. Annual Report. Ekwendeni Hospital: Ekwendeni, Malawi.Foster M, Brown A, Norton A, Naschold F. 2000. The Status of Sector Wide Approaches

Centre for Aid and Public Expenditure. Overseas Development Institute: London.Fountain DE. 1990. In A New Agenda for Medical Missions, Ewert D, Merrill A (eds).

International Monograph, 53. MAP International: Brunswick, GA.Gifford P. 1998. African Christianity: Its Public Role. Hurst and Co: London.Gilson L, Mills A. 1995. Management and health care reform in sub-Saharan Africa: lessons

of the last 10 years. Health Policy 32: 215–243.

Green A, Matthias A. 1997. NGOs and Health in Developing Countries. MacMillan: London.Hastings A. 1979. A History of African Christianity 1950–1975. Cambridge University Press:

Cambridge, 239.Lamb D. 1985. The Africans. Methuen: London.Luke 9:2. 1991. Holy Bible (New Revised Standard Version). Oxford University Press:

New York.Matomora KSM. 1995. The district health systems approach. Contact 143: 7–14.Mills A, Hongoro C, Broomberg J. 1997. Improving the efficiency of district hospitals: is

contracting an option? Trop Med Int Health 2: 116–126.Mulanje Mission Hospital. 1998. Annual Report. Mulanje Mission Hospital: Mulanje,

Malawi.

Paterson G. 1998. The CMC story. Contact 161/162

: 40–48.Pearson CA. 1996. Front-Line Hospital: The Story of Wesley Guild Hospital Ilesha, Nigeria.FSG Communications: Cambridge.

352 A. GREEN ETAL.




Schulpen TWJ. 1975. Integration of Church and Government Medical Services in Tanzania:Effects at District Level. AMREF: Nairobi.

Tibandebage P, Mackintosh M. 1999. Managing and Regulating Mixed Health Care Systems: A Tanzanian Case Study in Comparative Perspective. Collaborative Approaches to HealthCare Regulation: A Consultative Paper Based on Recent Fieldwork in Dar Es Salaam,

Mbeya and Coast Region. Economic and Social Research Foundation. Group Behaviourand Development Workshop, Helsinki, 1999.Uka EM. 1989. Missionaries Go Home? Peter Lang: Berne.van Lerberghe W, Lafort Y. 1990. The Role of the Hospital in the District. WHO: Geneva.Verhallen M. 1999. MMI Partner Consultation Report on ‘Updating Health Care

Development Cooperation’. Medicus Mundi International: WHO; 6.WHO. 1978. Primary Healthcare: report of the International Conference on Primary Health

Care, Alma-Ata, USSR. World Health Organisation, Geneva.World Bank. 1987. An Agenda for Reform. World Bank: Washington, DC.World Bank. 1993. World Development Report 1993: Investing in Health. World Bank:

Washington, DC.



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