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igidities in the budget that prevent the efficient use of resources; the roles of the MOF vs MOH in deciding on what policies and services to finance; and arrangements for returning revenue to the entities earning it. Suggestions are made in Appendix G to improve current arrangements, including strengthening the analysis of the share of the budget received by the MOH and promoting the health sector as an early pilot for some elements of performance based budgeting, which can support a case for increased flexibility in the use of resources, if certain conditions are met. Linking planning (Health Strategy) to budgeting (medium term expenditure framework and annual budget), MOH strategic and operating plans, annual plans of hospitals and others, reporting and monitoring. The Health Strategy needs to be put into operation through the plans of various institutions. Some suggestions on this are made in Appendix G, including the use of plans by institutions that reflect the health strategy and the medium term expenditure framework projections. Also the incorporation of key parts of the Institutional Development Plan for the MOH in its operational plan is covered. With regard to the Master Plan, it is suggested that it be presented for formal approval as a high level document with less detail, so the MOH has the necessary scope to refine it as information emerges, and in response to changing financial and other conditions. 3. With regard to the structure of the Ministry of Health, the current arrangements in terms of working practices, systems, processes, staffing and structure are not adequately supporting the Ministry to deliver on its mandate and to deal with the significant challenges noted in the draft Strategic Plan and in the Medium Term Expenditure Framework. Key problems include: lack of sustained leadership with many changes of the Permanent Secretary (PS); gaps in policy and planning; poor access to information for policy making, planning and monitoring; limited ability to monitor performance given the information problems; lack of sharing of information and cooperative working practices; many vacant positions; lack of skills in some areas; and a structure that is not well designed to support the key functions of the Ministry. 4. Improvements could involve changes to structure, systems, processes, staffing, working practices and the culture of the Ministry towards more flexible working arrangements where information flows are improved and staff can work in teams that are more effective than the current working arrangements. The main changes discussed in this review are: Streamlining the structure to release the PS from operational management. Around 30 positions reporting to the PS are too many. Reporting positions for corporate functions could be reduced and the reporting by agencies to the PS could be refined to focus on high level matters. Stronger policy, planning, and monitoring in an integrated way for main service areas rather than being fragmented in different departments, divisions, and offices. Also policy making and strategic management could be developed to support ministry-wide policy and planning. Developing a strong corporate services function to support the MOH policy, planning, and monitoring services, as well as the direct services provided. Realigning some functions to avoid duplication and separations that are not working well. Streamlining the internal structure of departments to facilitate cooperative teams with more flexibility to respond to changing demands and rationalising the structure of divisions, centres, and offices. Changing the relationship with hospitals and other agencies with the MOH fulfilling a policy, regulation, purchasing/funding, and monitoring role and agencies being set up with more robust governance and accountability frameworks to provide stronger incentives for performance. 4
5. There are many constraints on making these changes that need to be dealt with at the government level. The working arrangements and structure of the Ministry has evolved in response to issues such as: Current governance and accountability framework for the hospitals and other agencies that are not creating sufficient incentives for performance. Method of setting pay levels which provide incentives to create divisions, centres, and agencies. Incentives for doctors and other technically skilled staff to be managers to get into the higher paid management positions. This reduces breadth of other skills at senior levels. There is insufficient recognition in the civil service classifications and pay scales of the value of technicians in the public sector compared to managers. The draft Civil Service Law and the proposed Law on Salaries continue these problems. Government-wide administrative instructions that require a legal department, an information department, and other government requirements such as the European Integration Office and the Gender, Human Rights and Quality office. These instructions specify positions and staffing but a “one size fits all” approach is not suitable for all ministries. Frequent changes of senior leaders. There have been four ministers and six PSs since 2002, with three changes in PSs in the past year. The current PS is acting in the role. Some key departments have acting directors. Funding decisions by the government. In some areas there has been insufficient investment to support critical changes and improvements. Rigidities in the allocation and management of finances that make it difficult for health institutions to manage effectively (see World Bank report’s comments on hospitals in Appendix D). 1 6. Changes need to be sequenced in a way that will build on current capabilities without putting the organisation at risk of failing at its key roles during the changes. The organisational arrangements and structure are the way they are in response to the environment. If changes are forced without dealing with the barriers mentioned earlier, there will be unintended consequences, such as losing key people. Best practice ideas could be bad practice if the constraints affecting the MOH are not addressed. The reforms must be designed to deal with the unique conditions in Kosovo and not simply transport models from other countries. While there are many valuable lessons from other countries, the best design will be the one that fully taps into the potential for rapid development, given the situation in Kosovo. Recommendations for the short term- next three months 1. Develop a process to consider the reform options for MOH functions, structure, systems, processes, staffing and culture with a timeline for analysis and decision making, resulting in the production of the Institutional Development Plan. As part of this process, consider the options and variations presented in this report alongside others that may emerge from the internal work on the reform options. If possible, conclude this plan within three months and start implementing it as soon as possible. 2. Contribute to the policy and preparation of the changes to the laws on civil service, labour and pay to address the potential problems emerging in these draft laws, including the civil service job classifications; the pay mechanism; and the implications for workers in the wider health sector who will not be civil servants. Consider if there are opportunities to influence the law and policies impeding good design for the MOH relating to the form of 1 World Bank, “Kosovo Health Financing Reform Study”, page 11. 5
Page 1 and 2: Functional Review and Institutional
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Two projects on Health and Environm
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local government in relation to the
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Hospital prepares its own budget an
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Appendix E: Number of Staff and Bud
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Agency for the control of health ca
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Appendix G Additional advice provid
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Improving the health status analysi
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3. Accountability. Incentives and s
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50.2 Section 1.2 of the Law on Pubi
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