Strengthening decentralization in the health sector in Benin
USAID/Benin has invested funds in PHRplus since 2001 to support effective transfer of authority and finances to the decentralized operational unit of the Ministry of Health (MOH), the health zone. This activity follows a USAID funded study of decentralization, health zones, and co-management implemented by PHR in August-September 2000.
The MOH outlined a decentralization policy for the Health Sector in 1999, based on the WHO concept of the health district. However, implementation of these reforms met with several obstacles, such as continuing central-level management of technical programs, control of financial and human resources at the central and department levels, problems with the quantity and distribution of qualified personnel to staff the health zones, marginalization of the decentralization support unit (the CADZS), lack of donor coordination on health decentralization reform, lack of clarity about how to implement the transition to a more decentralized system, and pockets of resistance to health sector decentralization. PHRplus’ support was designed to help ensure that policies and procedures established by the government were consistent with effective decentralization of the health sector, and that stakeholders supported the health sector decentralization process.
PHRplus began by organizing a study tour in November 2001 to help key stakeholders see the positive effects decentralization could have and mitigate their reluctance to change. Twenty-four key stakeholders in the MOH (including the Minister) and related government institutions (Ministry of Planning, Ministry of Finance, National Assembly) took part in a weeklong study tour in Senegal to observe how the roles of central and regional offices changed with decentralization. The participants learned about and evaluated Senegal’s experience through field visits to health districts and presentations by the Senegalese Minister of Health and decentralization experts. The participants also discussed the impact of health sector decentralization in the Benin context.
Upon her return from Senegal, the Minister of Health decided to convene a forum on decentralization with technical support from PHRplus and financial support from the Belgian Cooperation, USAID, and the Ministry itself. The forum (April 16-18, 2002), with 93 participants from the MOH and other relevant stakeholder institutions, resulted in a series of recommendations for ensuring effective decentralization of authority and financing to the health zone. The recommendations included the creation of a follow-up committee (Comité de Suivi) and five subcommittees to follow through on the forums recommendations. PHRplus provided additional guidance for the formation of the committee: terms of reference for the committee and suggested membership of subcommittees. These terms of reference were shared with other donors and the MOH.
In early January 2003, the Minister passed decrees to create the Comité de suivi and the five subcommittees. The Comité de suivi is made up of the Advisor to the President for Health, representatives of the MOH, the Ministry of Finance, the Ministry of Labor, the Ministry of Decentralization, and the donors. The Deputy Minister of Health chairs the Comité de suivi. The five subcommittees had to address a specific set of recommendations: 1) human resource management, 2) management of financial resources, 3) revision of texts, 4) integration of programs and planning, and 5) information and sensitization.
Although the process has been long, implementation of the recommendations from the 2002 Forum has facilitated important advances in the decentralization process:
- The MOH's Document of Policies and Strategies for the Health Sector 2002-2006 endorsed the major conclusions of the 2002 Forum.
- The MOH and the Ministry of Finance decided to decentralize financial resource management to the zonal level. This decision has been in implementation since 2004.
- The MOH approved the Health Sector Human Resource Policy document.
- The follow-up from the Forum led to a more dynamic coordination among donors in the health sector.
- The Cellule d'appui au developpement des zones sanitaires (Health zone development support unit) was elevated to the level of a technical division in 2003, which means its director is part of the top management of the MOH and can no longer be so easily marginalized by the other directors.
The work of the sub-committees themselves has had the following results:
- Proposals for modifications in the human resource management texts have been developed that would decentralize some powers from the central to the departmental level and others to the zonal level.
- New mechanisms for decentralized planning have been proposed.
- One presidential and two ministerial decrees have been drafted that give the health zone coordinators real authority over health workers in their zones that include local elected officials in the health centers management committees, and that increase the number of community representatives in the zonal management committees. The last decree will also include one representative of the associations of women of each commune in the health zone management committee (a health zone can include from one to four communes).
- A communication plan for the health sector decentralization reforms will be validated and implemented as soon as the new decrees are passed.
Another presidential decree was drafted by the MOH within the framework of the current reform / reorganization of the ministries, with input from the subcommittees. The presidential decree includes some key organizational issues within the MOH:
- The Cellule d'appui au developpement des zones sanitaires, which was elevated to the level of a technical division in 2003, will become a full technical division. It will be called Direction du développement des zones sanitaires.
- A Division (Direction) of Hospitals will be created to help manage the new system of zonal hospitals.
- At the department (regional) level, the number of divisions will be reduced in order to rationalize actions according to the needs of the health zones, not according to the needs of central-level programs and divisions.
Establishing and strengthening mutual health organizations in Northern Benin
The second area of intervention by PHRplus is related to providing support in the creation and development of mutual health organizations (MHO). Its implementation began in February 2004 with the objectives of creating viable MHOs in the Sinendé and Banikoara communes. The objective for the first year (2004) was to create 10 MHOs (one MHO in each of the four arrondissements (counties) of Sinendé and one in six of the 10 arrondissements of Banikoara) and this was achieved. Already, seven MHOs have begun to provide care to their members at the health center level.
In Benin, PHRplus is recognized for the important role that it plays in the support and the development of MHOs by working with both the local elected officials and the health authorities and with the range of community actors: local development associations, agricultural producers associations (e.g., cotton), associations of women, and the health center management committees.
For the year 2005, activities to support the creation and the development of MHOs will constitute the main focus of PHRplus intervention in Benin. The following areas of intervention are planned:
- Support the development of commune-level associations of functional MHOs that can negotiate with and maintain relations with the zonal hospitals
- Support to the creation of MHOs in the four remaining arrondissements of Banikoara
- Support to sustainability and expansion of these innovative approaches in support of MHOs by the Ministry of Health
By special request from USAID, PHRplus has also conducted a donor mapping exercise which identifies the areas of interventions for each partner in the health sector of Benin. This donor map is critical for providing the Ministry of Health the mechanisms for improving donor coordination, and it helps partners by allowing them to understand well the interventions of others so they can direct their own efforts where it is needed. It is intended that such a donor map will be updated periodically.