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Appendix C: Legal Framework
Legal framework
The legal framework contains the roles, responsibilities and accountabilities for the various institutions
operating in the health sector. It represents a health system where policy and provision are integrated
and where the MOH has a very broad role. Under the law the MOH has key roles in policy, regulation,
oversight of providers including the hospitals and other health institutions, licensing, monitoring and
control. Municipalties are responsible for primary care and in some limited cases, secondary care
services.
There are insitutions created under the law with various status, reporting lines and decision rights, with
most of them being directly accountable to the MOH, including three reporting directly to the Minister.
Their abilities to manage resources are limited, including many aspects of managing human resources
and other inputs. The staff in the health sector are civil servants and subject to the provisions applying
to the civil service, which is unusual and brings a large number of personnel into the core civil service
(5,878 hospital employees and 227 mental health service employees, as well as other health sector
employees in the 2009 budget).
There are changes being proposed to the Civil Service Law and a Law on Salaries is being prepared.
These proposed laws could have far reaching impacts on the the health sector including:
Removing health sector workers from the designation of civil servants, while MOH staff would
still be civil servants. It is not clear what conditions will apply to the new class of public sector
workers and the impact on the ability to attract and retain staff, remove staff and finance the
payroll.
Creating two categories of positions: “career civil servant positions – that exercise functions on
a permanent basis, for the achievement of general institutional objectives; and non-career civil
servant positions – that exercise functions of a limited duration up to two years, for the
implementation of specific projects, replacement of permanent civil servants and in cases of
work overload.” This impact on the health sector needs to be assessed.
Defining four functional categories of employees: 1. Civil servants, senior-level management;
2. Civil servants, management level; 3. Civil servants, the implementing and professional
level; 4. Civil servants, the administrative level. A consequence of this will be to continue the
incentives for doctors to be managers and to create difficulties in adequately rewarding
technicians and professionals. The draft law provides for special categories to be treated
differently. The impact of this law change on the health sector needs to be assessed.
Creating 15 grades which are combined with the functional categories to derive the pay level.
There are provisions creating automatic entitlements to pay rises based on satisfactory
performance reviews. The latter point is a concern as it means that the MOH cannot control
its wage bill as there will be automatic increases flowing through each year. These impacts
need to be assessed.
A Health Insurance Law was formulated some years ago and is still in the process of development, but
many of the basic building blocks for health insurance are absent, such as the purchaser/provider split.
Other changes are underway including setting up a new agency for food safety reporting to the Prime
Minister under a law that has been recently passed. This would place the services of the Sanitary
Inspectorate currently reporting to the Permanent Secretary (PS) of the MOH, under the Office of the
Prime Minister.
The possibility of developing a general law covering agencies that provides a sound accountability and
governance framework is discussed in this report as a possible tool to assist with a purchaser/provider
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