Kampala 2004

The role of private not for profit health service providers, especially the church related ones, in the developing countries is of great impact. Today, in some countries these institutions provide 30-40 percent of health care. The decentralisation of the administration of the health systems to the District level is a challenge for these private health care providers.

The District Health System (DHS) as such a decentralised health care delivery system has been accepted by most developing countries since the WHO Harare Conference in 1987. Many governments had already formulated a national policy on Primary health Care (PHC) oriented towards a health care delivery according the Alma Ata Conference principles (1978).

However, the practical implementation of PHC did not succeed with a rather rigid centralised health system. Therefor WHO moved to a more decentralised system from national to district level. At this level NGO (Church) health care institutions are expected to cooperate in the District Health System.

The Soesterberg meeting of African bishops during the Memisa 75 Jubilee at Rotterdam revealed the strong and weak points of the Church health institutions. Co-ordination of the institutions could be improved, the immense problem of fading out experienced health personnel could nearly be handled, and good stewardship was badly needed. Bishops responsible for health care institutions should evolve from owners to stewards. The Soesterberg African bishops strongly recommended a follow-up of this meeting at regional levels in Africa in order to implement and co-ordinate the recommendations of Soesterberg.

At the same time the Pontifical Council for Pastoral Health of the RC Church pointed out many shortcomings in the management and performances of church-owned health institutions as well as in their co-ordinating network. (Dolentium Hominum no 52, 2003).
Governments are encouraged by the international donor community to involve civil society organisations in implementation of public services while strengthening their own role in policy formulation, regulation and quality control and limiting themselves to that one in particular.

In countries where healthcare providers founded by the church play a substantial role, there does not exist always an effective collaboration and co-ordination between them and other providers (e.g. the state, regional or countrywide: multilateral programmes). As the coverage and complexity of the health sector is growing the institutions and their programmes have to grow in scope and size to meet increasing demand. The stakes are growing as well, for example network of 7 district hospitals in one African diocese, with a total workforce of over 1000. This makes it not only the largest healthcare system but also the single largest employer in the entire province. To administer and to manage such large organisations, high professional qualities and standards (administration, accounting, reporting, planning and performance) have to be observed. This is required to render best services and to achieve optimal results for the population in its target area. Simultaneously the adherence to professional quality and standards is required to qualify for external funding by the state, by donors, by the Global Fund. Fees paid by patients and users are insufficient and additional income (subsidy by the state; contribution by donors) is indispensable to assure quality of care, continuity of service and to guarantee continuity of employment to highly skilled staff.

Demands for professionalism

The ongoing phasing out of missionary personnel (congregations) and expatriate lay professionals, happens to coincide with these increasing demand from donor side on the church related health care institutions and networks. In stead of seeking assistance and funding for each individual bottleneck and constraint, these healthcare institutions are requested to define their medium and long term vision and mission as healthcare providers and to adopt professional techniques for M&E and for planning to put their long term objectives into practice (strategy plan, operational plans). This also applies to transparency in their administration, reporting and accounting. These demands are the more stringent if the funds are (even only in part) obtained from World Bank (WB), the European Union (EU) or other international back donors. To access funds available for the health sector in connection with debt relief or from the Global Fund for Malaria TB and Aids control, truly professional programme activity plans, budget proposals and accounting methods have to be produced.

There is a growing consensus amongst healthcare professionals, institutions and networks on the urgent need to invest in their Organisation Development in order to be able to meet the challenges and address the demands ahead.

The role of leadership

The needed adjustments are yet so profound that they are only attainable with the full support of the leadership in the churches. Therefore one has to start the process of change and adjustment by informing and capacity building of this leadership in this particular case at the top level in order to ensure and to facilitate that a structural and systematic process of organisational change and development can be effected in their institutions and networks within the health sector.

Although most likely church related organisations, active in other sectors, could warrant a similar OD intervention, the urgency in the health sector networks might be greatest at present in view of current initiatives in decentralisation (decision making on attribution of funds), con public-private partnership, SWAP, etc.

Besides Medicus Mundi International (MMI) and Cordaid have some additional considerations:

-The member organisations of MMI feel particularly compelled by this change in context and new challenges as they have always been actively supporting these private not for profit healthcare institutions. It is MMI's vision and ambition that they should be recognised as an integral and integrated part of the implementation of the National Healthcare policy of the host country.

-Cordaid in particular is moving from ad hoc project funding to programme or organisational support. The prevailing administrative and managerial weakness of many a church related healthcare partners is just as embarrassing to Cordaid as it would be in an eventual partnership with the National public sector. The fear is clearly, moreover that such weakness might maintain or even enhance donor dependence rather than to permit financial autonomy and sustainability.

Experiences and Lessons learned

Medicus Mundi and its members have a long tradition in promoting co-ordination and co-operation between partner institutions (i.e. healthcare institutions) and in public-private partnership, e.g. by fostering:

Many of these organisational structures in Africa, were founded and nurtured by Cordaid and its fellow members of MMI in order to become firmly rooted in their context and environment.

MMI members jointly with the then Christian Medical Commission were able to pass through the World Health Assembly a resolution (1985, WHA83.31)) calling upon WHO and its member states to facilitate regular participation of the networks of not for profit healthcare institutions in the implementation of Member States' National Healthcare Plans. Representatives of such networks, should be invited in their national planning committees and in their delegations to the World Health Assembly. It was already then realised that a considerable effort in capacity building of Christian (private) Healthcare Associations would be needed to make such increased co-operation feasible. Various constraints were a hindrance to a rapid enhancement of their role:

Occasionally one or a few church leaders could be convinced of the need for a more professional approach in administration and management of their public service oriented institutions. But this led rarely to implementation of a sustained agenda for organisational change and development.

Even senior staff of the associations and Diocesan offices who share these concerns, are just not in a position to call upon and convince church leadership (whose employees they are after all) for a change for a more professional performance of their institutions and organisations and hence the need for new forms of governance and stewardship on their part.

Given a number of disappointing outcomes in capacity building of church related networks Cordaid even started to reconsider its relations with them and commenced to look for possible alternative partners for healthcare in some countries.

The Soesterberg meeting

In 1999 Cordaid took the initiative to call a meeting of 15 bishops who in their county were involved in overseeing the health related institutions and activities either in their church province or at the national level. The meeting took effectively place in 2000 and was devoted to:

A number of resource persons (health systems expertise, OD-background, donor representatives, pastoral-background and combined experience) were present. Case studies were presented and examined. Relevant conclusions were sought and reached in a strongly participatory process, in which all participants including the bishops present did not miss the opportunity to critically question all presentations and the relevance of each case presented for the situation in their own country and in their own church province.

The Rotterdam declaration

As mentioned already before, the resulting statement, they made up, was presented and very positively received during a following conference on Health Care and Development held in Rotterdam with a wider range of participants in the last 2 days of the same week. The statement of the Soesterberg meeting was very much appreciated as a good step towards improvement and update of faith-based healthcare administration. Yet it was observed that, in the absence of follow-up meetings aiming at practical application at regional and, preferably, national level, the declaration might remain without much noticeable impact.

Follow up action

The first initiative for follow-up was taken by the Pontifical Council for Health Pastoral Care, inviting MMI representatives to participate in a conference in Rome (2001.) with over 2000 participants stemming from the global community of Catholic Healthcare Institutions.

The declaration made by the conference in Rotterdam was distributed.

This conference led to discussions between the Pontifical Council and MMI on the possibility to organise regional meetings in Africa as was originally meant, to discuss the outcome of the Rotterdam declaration (2000) in their own setting among the African bishops.

The initiative met with immediate positive response notably on the part of the Archbishop of Mbarara (Uganda) – Chairman of the Uganda Episcopal Conference – Mgr Paul Bakyenga, also Chairman of Amecea, the East African Association of Catholic Episcopal Conferences (who was also among the participants of the original Rotterdam meeting).

For practical purposes it was considered best to going to invite not only Episcopal Conferences, members to Amecea, but also all other Episcopal Conferences from English speaking African countries (IMBISA and AECAWA), whereas a separate meeting (in Cotonou?) could be called at a later date for the Episcopal Conferences of Francophone and Lusophone countries.

The declaration and conclusion formulated in Rotterdam called for an enhancement of the knowledge and vision of church leaders of faith based organisations for health care in matters of organisational sustainability, administration and management. The meeting called as well for a clear vision on and for a strengthening of the viability of these health care institutions (technically, financially, organisationally) in order to achieve maximum recognition with the Public Administration while maintaining the essential elements of being faith based including inspiration and commitment of their staff. It is understood that this will lead towards a decrease in 'donor-dependency'.

The conference has the full support of the Pontifical Council for the Pastoral of Health Care. MMI has been invited several times to meetings of the Pontifical Council to give technical advice on health matters, integrated primary care and contractual arrangements in health care implementation.

The organisation is delegated to the UCMB (Uganda Catholic Medical Bureau). Cordaid (Memisa) and MMI (Medicus Mundi International) are requested to give the technical and professional support. The UCMB is an well-organised co-ordinating body for Uganda, initiating institutional empowerment by good stewardship.

AMECEA will be the official convenor of the Conference. Archbishop Bakyenga will invite the other Anglophone Regional Episcopal Conferences (IMBISA and AECAWA).

Besides the above mentioned objectives of improving the health care performances of church health institutions, specific theological objectives are formulated for church leaders in vision of the holistic Healing Ministry today:

Human Resources and Primary Health Care at lower (district) level

Very often the obstacle to implement contracts for the development of adequate basic health services and to run facilities and programs accordingly, is as well the lack of technically competent medical personnel as the lack of stewardship at all levels, the insufficient capacity of the available manpower to analyse the system and to steer their component into the chosen direction.

Previous experiences of topping up schemes and granting of other advantages by Memisa/Cordaid and other MMI branches have had some effect on the length of stay of local doctors in rural hospitals, but more performing approaches for the maintenance of competent medical personnel at the district level should be explored.

The development of the capacity of the local human resources at the intermediate level becomes urgent the more as a change in organisational set-up is witnessed in many funding organisations towards a progressive de-professionalisation. We are seeing this in CIDSE, Medicine du Monde, NOVIB, Misereor, CRS and CORDAID. The risk that this might lead to proper management of the wrong projects is real.

While many local partners are church related NGOs, the MMI members have made great efforts to demonstrate the relevance of fitting the church related health facilities into a good functioning health district. Several national co-ordinating agencies (mainly Christian Health Associations) have been approached and supported in order to guide their members in this direction. The influence of these agencies on their members varies from country to country. The capacity of stewardship of the persons in charge is an important factor. At the peripheral level the owners of the health facilities (local bishops as well as foreign societies have other expectations as far as these agencies are concerned: in stead of a policy direction they often expect from a central co-ordinating body some services in order to realise their own strategy: health facilities which are purely philanthropic or are functioning “for profit” in order to finance other social or religious activities. The inconsistent behaviour of donors (charity perceptions in stead of a consistent policy development with a professional approach at the national level and a firm human resource development policy) is also weakening these co-ordinating agencies.

This does not mean that all experiences are negative: the set up of the Ugandan Catholic Medical bureau is one of the positive examples, showing that good results can be reached if such a bureau is properly and professionally staffed and fulfils the needs of the members.

MMI’s aims and views on health care are based on the concept of Primary Health Care and ensuring strategy for Health for All. Her partners in the developing countries throughout the world are mainly Non Governmental Health Care Providers, mostly of church related origin. Experiences have taught MMI that these partners aim to provide public interest services, in line with their social aims, and they have an enormous potential to complete district health care systems. In spite of recognition at the level of the MMI partners and their governments that district health systems should integrate all parties, NGO’s are hardly taking up or obtaining clear roles and functions at this level. Related and ensuing problems are numerous. Many reasons can be enumerated for this but a key issue is the independence and autonomy the NGO’s feel necessary to accomplish their mission.

As MMI is committed to assisting her partners to improve health care for the underprivileged, she looked at ways, which allow the NGO institutions to become part of their respective district while retaining maximum autonomy. The principle of delegation of tasks and responsibilities proved a valuable departing point. The changed international views regarding the role of governments in health care provision, ‘ensuring but not executing’, opened up new possibilities to pursue this approach.

Delegation of responsibilities however needs to be formalised to ensure that the expected results can be obtained. New strategies and instruments need to be developed. Close scrutiny of the Contractual Approach convinced MMI of its value to assist both governments and MMI’s partners to complete district health systems and rendering them more capable of providing Health for All.
MMI dares to “Rock the Boat” of the NGO’s because of the need to improve health care provision for all and because the Contractual Approach offers possibilities to do this. In spite (or because) of the prevailing problems as well as the obstacles and possible pitfalls that can be recognised this approach is worth pursuing to realise effective health districts. However, as always, this approach cannot solve all the problems and should not become a panacea.

Human resources development has been among the key issues pursued since the foundation of Medicus Mundi and for most of its National members, to contribute to the overall sustainability of the healthcare programmes and institutions supported.

The object of most of the technical assistance was precisely the transfer of know-how and each of the many volunteers posted was implicitly or explicitly instructed to make him/her self redundant within the contract period by working on local capacity building. The provision of training and/ or enhancement of local recruitment efforts plus systematic improvement of the working environment for local qualified staff, were among the main strategies applied to promote local human resources development.

Undoubtedly this policy, pursued in conjunction with so many other partners, has been successful in most of the developing countries and led to the phasing out of missionary and volunteer workers in many paramedical functions and their replacement by local workers with relevant diploma’s.

However it had been noted already, that among the higher educated medical staff, particularly when trained by medical schools in developed countries, there was a strong tendency not to return to the country of origin or to emigrate some time afterwards. Africa has thus provided far more personnel assistance to Europe than vice versa. There are more doctors of Benin origin working in Paris alone than in the whole country of Benin. India and the Philippines are among the main suppliers of doctors and state registered nurses of the USA and the UK. Doctors of Zambia, of the DRC (ex- Zaïre) and even from Liberia and Sierra Leone can be found in South Africa, while highly qualified people from the latter country tend to migrate to Australia, to New Zealand, to the USA or to European countries.

Recruitment of local staff to make expatriate staff redundant is frustrated by a growing gap between supply and demand.
Increasing the output of training institutions, unless accompanied by measures to enhance the likelihood of qualified staff to stay in jobs in their country of origin, may only lead to increased losses of trained staff and not to a reduction of the gap.

Three additional developments tend to enlarge this gap even more:

- The considerable increase in the economic gap between the rich countries in the North and the poorest developing countries all too often combined with actual or menacing civil strife in those countries

- The ambitious new emphasis placed e.g. by the Global Fund and even more so in PRSP formulation on Healthcare investment as a viable strategy to boost economic growth. This in turn increases the burden on available staff and leads to an increased demand for highly qualified staff.

- The evolution of the HIV/AIDS epidemic and its impact on medical staff: Not only the sheer numbers of incurable patients to be confronted every day, tend to affect their motivation to a point where many even decide to quit the profession. Moreover a staggering percentage (above average cp. to general adult population) of the medical staff got infected themselves! The attrition rate is rising to a level unheard of in any other profession.

With a more or less stable output of new trainees, HRD now appears to lead merely to a battle against odds in most of the developing countries, particularly in Africa.

Given the fundamental contextual changes mentioned above, there is little to be expected from just continuing (even much more vigorously) the traditional practice of systematic transfer of know-how at work floor level, combined with investment in schools and in bursaries to win this uphill battle in the long run. Innovative approaches to HRD have been devised in many places to achieve more effective and viable strategies for HRD. They may apply only to a specific context, but some might be applied more generally, if only adjusted to the local setting.

Of peculiar interest, moreover for a sector, in which decentralisation and privatisation are in full swing, is the evolution in the relationship between the qualified staff and the local employers (institutional authority) and the consequences in terms of
- Career planning
- Participatory management
- Possibilities for ongoing education in line with both personal aspirations and with institutional development needs.
- Retirement benefits
- Fringe benefits and other additional terms of employment.

Clearly HRD, especially within the healthcare context and with a focus on its highly skilled manpower, cannot be envisaged successfully in isolation by each employer, neither on a regional or even national level. Both the employers and the individual diploma holders need to take into account the many complex aspects and complicating factors, even international trends, which influence the expectations and the decisions of qualified staff in planning their moves and their career.

Having considered the growing health problems in low-income countries and the responsibilities of the church owned health institutions, the Aim of the Kampala conference is specifically:

Three themes have been chosen to lead the conference. There will be given ample opportunities to the participating bishops that they can discuss their proper concerns and questions among themselves.

Theme 1.: The Healing Mission of the Roman Catholic Church in East Africa:
Why is the involvement of the Roman Catholic Church in Health Care still important and relevant?
The health problems of the poor; the national health systems; the implementation of the Mission in Partnership with others.

Theme 2.: Enabling the Catholic Health Care Facilities to implement their Mission to the full.
The challenges at facility level;
The District Health Care System and the role of RCC health units;
Developing the contractual approach to support the implementation of the mission at each level.

Theme 3.: Strengthening the inter-country RCC Network to improve expertise by learning from each other.
Regional co-ordination.

Sake Rypkema
MMI november 2003

Conference Report (pdf):
English - French

Bishops' Declaration (pdf):
English - French

The following documents are available online (.htm, .doc, .pdf) and can be accessed or downloaded from this site

1. The Alma Ata Declaration on Primary Health Care
WHO-Unicef, 1978, (ISBN 92 4 180001 1)

2. Contracting NGOs for Health
MMI advocates contracting as an efficient method for the integration of NGO health services into the District Health system.
Address of MMI to the WHA, Geneva, 2000.

3. MMI Newsletter no 69, 2002
Human Resource Development (HRD), a continuous concern.
Brain drain and health professionals
HRD at level of Diocesan Health Co-ordination
Promotion of “Contracting”, a framework of activities
Public Private interactions for Health, WHO 2002.
Profit versus non-profit. Catholic Social Services, Chicago 2003.

4. MMI Newsletter no 70, 2003
The role of contractual arrangements in improving health systems performance
Report by WHO and Resolution WHA 2003.
Which role for MMI in Human Resource Development?
Cordaid’s policy on Health Care and Care and Technical Assistance

5. The NGO-Hospital and the District Health System in Africa
Memisa – WHO, by R.Santingh, S.Rypkema, 1994

6. Involving private voluntary health care providers in Better Health for Africa
by Marieke Verhallen. MMI Newsletter no 61 page 9-21

7. Updating health care Co-operation
MMI – Cordaid. Partner Consultation in East Africa,
Dar Es Salaam, 1999

8. The Contractual Approach. Vol. I and Vol.II
Guidelines for contract procedures for a health care structure in a district
MMI – CIDR (Centre International de Developpement et Recherche, Paris),

9. The Church and its Involvement with Health: the healing ministry
Statement by the participants of Memisa’s 75 Jubilee
Working Conference,
Rotterdam 2000, MMI Newsletter no 66

10. The Healing Ministry
Paper by E.Widmer at the Memisa 75 Jubilee working conference of African bishops.
Rotterdam/Soesterberg 2000

11. Bishops Conferences and Catholic Health Institutions
A survey of Roman Catholic Health Services by Dr Fiorenza Deriu.
Dolentium Hominum no52, Vatican, Rome, 2003

12. Health and Power. Practical Actions to be promoted in Relation to the Power of Pharmaceutical Industries. XVI International Conference, Pontifical Council for Health Pastoral Care, Vatican City, 2001. B.Pastors, MMI Newsletter no 68

12b. Health and Power. Practical Actions to be promoted in Relation to Hospitals and other Health Centres. XVI International Conference, Pontifical Council for Health Pastoral Care, Vatican City, 2001. E. Widmer, MMI Newsletter no 68

13. Which role for MMI in Human Resources Development (with annexes)
A research study by G.Kegels and B.Marchal.
MMI-Tropical Institute Antwerp 2003

14. Health is Wealth, a community based health insurance scheme
by John Kipo Kaara/Stefan Marx, Action Medeor, AGEH, 2001

15. The International Ministry
Reflections on the XVII International Conference
of the Pontifical Counncil on Health Pastoral Care by Fr Michael D. Place STD
Dolentium Hominum 52, 2003

16. Structuring Public – Private collaboration in Health Care:
Review of experiences and lessons.
By Marieke Verhallen

17. Formalizing Partnership relationships and working arrangements
between Public Health Authorities and Private Not for Profit Health Care Providers.
By Marieke Verhallen

18. Contracting in Health Care
a Tool to enable NGO partners to play a significant role in Health Care provision.
By Marieke Verhallen

19. Contracting with Christian Health Associaton District Hospitals in Ghana
Mr S.Nuamah Donkor, Minister of Health Ghana
MMI Technical Meeting, World Health Assembly 1999.

20. Partnership between Government NGOs and WHO in the AFRO Region
The Dakar declaration. Conference on improvement tripartite cooperation for health development in Africa. Dakar 1997

21. The Future of Christian Hospitals in Developing Countries: The Call for a New Paradigm of Ministry
A publication of Christian Connections for International Health Promoting International Health and Wholeness from a Christian Perspective. CCIH FORUM, Issue #8 - August 2000 (online on the CCIH website)