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SECTION I: Legal, policy and medium term planning framework
The legal framework for the health sector is described in Appendix C. There are significant changes
being considered that will impact on the MOH, including the role of private and public providers and
health insurance. Regardless of whether health insurance is adopted via the use of a Health
Insurance Fund, the legal framework has requirements which need to be reviewed, including roles,
responsibilities and reporting arrangements for many health sector institutions (see Appendix C).
Advice on possible changes to the Health law was provided in response to a request from the
Ministry of Health’s Working Group (see Appendix G).
The draft Strategic Plan sets out a very challenging agenda of major changes in the health sector
with far reaching implications for the MOH in terms of developing its role in policy, planning,
monitoring and review. While it retains its responsibilities for the providers of public health,
secondary and tertiary health, pharmaceuticals and mental health services, it carries considerable
responsibilities for leading improvements in the providers of services in these areas.
Appendix D provides an overview of the MTEF, the draft Health Sector Strategy, and some major
policy issues affecting the structure of the MOH and other institutions in the health sector.
SECTION II: Barriers to change
There are many constraints on making changes to the structure, functions and operations of the
MOH 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 the ones set out below.
The method of setting pay levels is providing incentives to create divisions, centres, and
agencies with many management positions.
There are incentives for doctors and other technically skilled staff to be managers to get into
the higher paid management positions. This reduces the 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 proposals to
change the Civil Service Law include four levels of civil servants with the top two being
managers and the third level being professionals.
Many officials are holding more than one position by being responsible for their usual
position plus fulfilling an acting management role for a higher position. This situation can
continue for some time with no active efforts to recruit vacant positions. Some contributing
factors to this problem identified by officials include: rigid job structure; low funding levels
resulting in multiple vacant positions that are being covered by one person; and narrow jobs
resulting from government or donor policy decisions.
Government-wide administrative instructions require a legal department, an information
department, and other government requirements such as the European Integration Office;
the Gender, Human Rights and Quality Office, etc. This results in many offices and positions
with narrow roles and an inability to use these people for other priority work. It can overload
a ministry with staff of lower priority, for example, the MOH is not filling some of the positions
in the administrative instructions as it has more pressing needs in other areas. It also
overloads the PS as many of these functions have to report to the PS according to the
administrative instructions.
The political situation and the civil service arrangements do not support an adequate level of
continuity in ministers and PSs. There have been four ministers and six permanent
secretaries since 2002. Many senior positions have staff in acting roles, including the PS. In
these circumstances it is difficult to provide leadership for a sufficient period to design and
implement necessary reforms.
Government entities do not appear to be incentivised to consider contracting out options. For
example, the Department of Pharmacy is refurbishing a government owned building instead
of continuing to contract out the warehousing service. While there is an analysis of the
comparative costs, this analysis does not ye4t cover the cost of owning the building and
other assets. There is an opportunity cost to owning buildings and vehicles, maintenance
including repairs and insurance costs, and depreciation costs. Some countries levy a capital
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