HSRP is a process aimed at introduing substantive changes in the different structures and fuctions of the sector, with a view to increasing the equity of its benefits, the efficiency in its management, and the effectiveness of its actions; and through this to achivee the satisfaction of the health needs ofthe population. It is an intense phase of transformation of the health systems based on situations that justify and make it viable.Key areas of the program are:
- Efficiency in resource allocation
- Expansion and diversification of of sources of financing
- Sector design and policies
- Development of the private sector
- Organization and delivery of health services
- Human resources policies and management
- Information systems
- Access to health services
- Management and functioning of support systems
The following is a brief overview of the Health Sector Reform Project (HSRP), including an outline of the current activities under the HSRP.
To raise the health status of the population by improving the efficiency, equity and quality of health care services and by promoting healthier lifestyles, through a health Sector Reform Project.
- Restructuring and strengthening the organizational and regulatory capacity of the central and regional level of the public sector to plan, organize, produce, procure and deliver a high standard of care on a cost efficient basis.
- Rationalizing and improving the coverage and quality of services of public and private sectors by:
a. restructuring public facilities,
b. purchasing selected services from the private sector to support the public supply,
c. providing mobile services and transport in less accessible areas,
d. training community nursing aides and other health professional; and
- Achieving an equitable and sustainable system of sector financing by helping to set up a National Health Insurance Fund and focusing public spending on the poor.
Breakdown of the Components:
Component 1. Sector Restructuring
1a. Reorganization MOH
1b. Deconcentration Operational Authority to Health Regions
1c. Piloting autonomy with Karl Heusner Memorial Hospital Authority (KHMHA)
1d. Public Information Strategy
1e. Promoting Knowledge and Behavioral Change
Component 2. Services Rationalization and Improvement
1. Civil Works
2. Medical and Administrative Equipment
4. Ambulances/Mobile Units
Component 3. Support to the National Health Insurance Fund (NHIF)
3a. Technical Development of the NHIF
3b. Innovation Fund
Total Cost and Financing for HSRP:
|IDB (Loan)||US$9,800,000||10.04.01||10.04.05||Two years to 10.0.07|
|CBD (Loan)||US$4,716,000||26.06.01||26.06.05||Three years to 26.06.08|
|Total Loan||US$14,516,000|| || || |
|GOB Counterpart Contribution||US$2,010,000||N/A|| ||N/A|
|MIF (Grant)||US$771,650||8.12.00|| ||N/A|
Duration of Project: The duration of the project was initially for four (4) yrs, but was extended on April 22, 2005 by IDB; and on March 17, 2005 by CDB as indicated in the table above.
Component 1: Sector Restructuring
The purpose of the this component is to restructure and strengthen the organizational and regulatory capacity of the central and regional level of the public sector to plan, organize, produce, procure and deliver good quality health services based on the best value for money spent. Activities will include the following.
1a: Reorganization of MOH: This component has piloted the removal of some services from the civil service and their provision by an autonomous agency (Karl Heusner Memorial Hospital Authority) under contract. Within the civil service, management authority will be deconcentrated to new Regional Health Managers. The planning and regulatory function of the Ministry of Health will be strengthened and a focused staff training programme will be undertaken
The new role of MOH will cover the following:
i. Providing health services (without running the KHMH)
ii. Strengthening policy development and its implementation
iii. Purchasing services form the KHMH Authority
iv. Purchasing services form the private sector and regulating its standards
Other activities to be carried out under this component include:
- Procurement of TA/PAPU Training Facilitators: A training facilitator is to be procured to conduct three one-week training workshops in Logframe, situational analysis, strategic planning, and one four-week training program in an area to be determined.
- Procurement of Legal Draftsman: The Legal Draftsman is to develop legislation to support the implementation of the Separation of Functions (i.e. Stewardship, Service Provision and Purchasing) Policy Document.
1b: Deconcentration of Operational Authority to the Regions: GOB is introducing a number of measures to maximize management authority within the public service. In this line, four Regional Health Management Teams have been created:
- Northern Health Region (Corozal and Orange Walk)
- Western Health Region (Belmopan and San Ignacio)
- Southern Health Region (Stann Creek and Toledo)
- Central Health Region (Belize City)
Regional Health Managers have been appointed to co-ordinate all resources and to integrate programme budgeting and planning. Specifically, they will:
- Report to the Director of Health Services
- Be responsible for the coordination of all personal and public health services within the health region – planning, deliver and quality
- Manage all professional, technical and administrative human resources within the region – all staff will report to the RHM
- Manage the finances allocated to the health region with responsibility for implementing new financial control and cost accounting systems to operate alongside (and then replace) the traditional public service cash accounting methods
- Manage support services including the logistics of supplies and repairs and maintenance of buildings and non-medical equipment including planned maintenance programmes.
The regionalized structure for services delivery will aim to provide as much managerial autonomy as possible within the public system. Regions will operate as much as possible as if they were autonomous.
Regional Health Managers head Regional Health Management Teams comprising:
- a community representative (a new voluntary role)
- a Regional Primary Care Coordinator
- a Regional Hospital Administrator
- a Regional Public Health Coordinator
These positions are filled form existing staff and will not generate significant new recurrent costs. Support staff is a Finance Officer and a secretary.
Activities to be executed under this sub-component are:
- Procurement of Regional Management Expert: The purpose of this activity is to develop the management capability in the regions including regional structure, protocols, standards and procedures and also to provide training to the RHM staff in the areas of: Public Relations, Quality Assurance, Preparation of Administrative Manuals, Customer Satisfaction, and Management.
- Technical and Integration Workshops: The purpose of this activity is to exchange experiences and integration of workshops to foster social participation and public information.
- Procurement of Computers and Related Equipment for RHMTs.
1c: Piloting Autonomy with the KHMHA: The purpose of this sub-component is to develop within the KHMHA the capabilities to effectively perform as an autonomous provider of health care services.
- Technical Assistance: This activity involves the commissioning of technical assistance for the formulation and development of a human resource strategy. The IDB will fund the services of a consultant to undertake such works.
- Development of New Information System: This activity, funded by IDB, involves the engagement of consultants to develop a new and more effective information systems tool and comprehensive and long-term information systems plan that will address the need of the newly reformed MOH.
Belize Health Information System: At the request of the Ministry of Health, Accesstec Inc., A Canadian IT consulting firm, in close collaboration with MOH information technology personnel, conducted a Joint Application Development Workshop in April 2003 to identify and define the requirement for a new Health Information System. “The objective was to design a system that was national in scope and inclusive of all participants in the system from MOH, NHI, KHMH, to health posts and private providers.” Further to this workshop a three-phased implementation strategy was proposed.
- Phase 1: Patient Registration, Admission, and Discharge System: Due to the breadth of services and availability of the necessary IT platforms, the KHMHA was the ideal candidate for the first deployment of the proposed system. All aspects of the Admission/Discharge associated with health record, data collection and registration system can be assembled, with the system and user being tested in the same close geographical vicinity.
- Phase 2: Regional Information System and Transfer Function: Design of the Health Regions Information Systems including the Regional Health Management Offices, The Regional Hospitals, Community Hospitals and Health Posts.
- Phase 3: Public Health Activity, Administrative, Regulatory, Reporting, Interfaces, and External Stakeholders: Establish data store CLAB, Cpharm – referral services, inventory control, human resources, interface to standard third party accounting package, activity inspection; deployment of reporting engine, accounting interface, interfaces with external stakeholders (NHI/SSB; BMDA; CSO; NGO’s; Police; Vital Statistics; Prison; MOF; PAHO/WHO; CAREC); includes inventory, human resources, reporting and training
Phase 1 was funded by the Government of Belize. Phases 2 and 3 are funded through the reallocation of funds under Piloting Autonomy with Karl Heusner Memorial Hospital Authority, which became available with the signing of the Amendatory Contract No. 1 between the Inter-American Development Bank and GOB.
1d: Public Information Strategy: The objectives of this activity are to gain support for reform of the Health Sector. This sub-component will involve the design and implementation of a public information strategy to promote the success of the HSRP. It will also involve the raining of key personnel of the MOH in implementation and evaluation of public information strategies.
The strategies will be:
- To invite the general public to consider issues of why reform is desirable and what directions reforms might take so that they are aware that efforts are being made and so that they feel they are being informed and consulted at an early stage.
- To inform health sector stakeholders of what work has been done and is continuing so that they feel well informed and that their views are being taken into account.
Technical assistance, funded by the CDB, will be procured to conduct the design, implementation and evaluation of the communications strategy.
1e: Promoting Knowledge and Behavioral Change (PKBC): As MOHs focus shifts from running services to ensuring that quality services are available, it will develop major new initiatives seeking to improve the health status of the population by improving knowledge of health risks, adoption of healthier behavior and care-seeking behavior. This will target priority population groups including women, young children, the poor, isolated groups and those with special needs including indigenous groups. Community, school and national education mechanisms will be supported and all services contracts with providers will include health promotion activities and targets (including providing reproductive health education to women and their partners). Community health workers will be trained and supported to participate in the promotion programme. Separate national promotion activities will aim to raise environmental awareness and appreciation of its importance to health and economic development (the growing importance of environmental tourism and the standards demanded by agri-product importing countries).
Base-line studies are to be conduced to identify the need for particular health behavioral change and associated social and individual constraints on healthier lifestyles, so that the promotion stage can appropriately focus on specific conditions and groups. After the promotion campaign and at the end of the project, monitoring and evaluation will be performed to measure the effectiveness of the intervention in terms of knowledge gain, perception and behavior changes. A local communication agency will be contracted to implement this component with support from the Pan American Health Organization.
Another activity under this subcomponent is:
- Procurement of Vehicle for HECOPAB: This will be in support of the PKBC consultancy.
Component 2: Service Rationalization
This component is intended to improve capacity utilization and quality of service, infrastructure development and investment in medical equipment. The coverage and quality of services of public and private sectors will be rationalized and improved by restructuring care delivery in public facilities, purchasing selected services from the private sector to support the public supply, providing mobile services and transport in less accessible areas, training of community nursing aides, and other health professionals, and encourage behavioral changes towards healthier lifestyles among beneficiaries, especially women, children and the poor population.
Activities will include complete reorganization and upgrading of the public facilities and equipment.
Completed Civil Works Projects are:
- Renovation/Extension of Cleopatra White Polyclinic II
- Renovation/Extension of Matron Roberts Polyclinic II
- Renovation/Extension of San Pedro Polyclinic II
- Rehabilitation of Northern Regional Hospital Sewage Treatment System
Pending Civil Works Projects are:
- Construction of New San Ignacio Community Hospital
- Construction of New San Antonio Polyclinic II
- Construction of Belmopan Halfway House
- Electrical Rewiring and Painting at the Western Regional Hospital in Belmopan
- Acute Psychiatric Unit Extension at Port Loyola Health Center
- Corozal Community Hospital Renovation and Retrofitting
- Northern Regional Hospital Renovation
Other Activities under this component:
- Procurement of Seven (7) Patient Transportation Vehicles
- Procurement of Medical Equipment and Administrative Equipment and Furniture
Component 3: Support to the NHIF
Component 3 is financed by the Inter-American Development Bank (IDB) and the Government of Belize (GOB). This component of the Health Sector Reform Project (HSRP) is intended to achieve an equitable and sustainable system of sector financing by supporting the setting up of a National Health Insurance Fund (NHIF) and focusing public spending on the poor.
The development of the NHIF is intended to focus primarily on ensuring that health spending results in achieving the national goal of equity and health service purchasing at highest quality for money, not on how to raise money for health care. The NHIF will have great purchasing power which will enable the Fund to generate change in service providers. The Fund will have the power to demand improvement in the quality and efficiency in the delivery of health care.
Component 3 is subdivided into two subcomponents:
- Technical Development of the NHIF: This subcomponent focuses on technical assistance and training and setting up the NHIF Company as purchaser of services.
- Innovation Fund: This subcomponent included an Innovation Fund where loan resources were to be used to finance payments to health care providers on a pilot basis in Southside Belize City. The pilot would facilitate the testing of the system for contracting health care providers and acquiring contract health care skills at KHMH and health regions. The pilot project was designed to demonstrate the Government's commitment to long-term participation with the private sector.
3a: Technical Development of NHIF: The Technical Development subcomponent was comprised of twelve (12) sub-activities.
- Appoint Health Policy Committee
- Design Performance Contracts
- Establish NHIF Company
- Appoint Management Team
- Labour Market Assessment Mechanism
- National Income and Expenditure Survey
- Identification of the Poor Population Survey
- Financial Model/Simulation
- National Health Insurance Fund (NHIF) Legislation
- Social Security Board (SSB) Legislation
- Appoint concurrent auditing
- Install Financial and Management Control Systems
3b: Innovation Fund: The objectives of the Innovation Fund were:
- To enable the NHIF to initiate purchasing (through two pilots) from the private sector before contributions are collected;
- To signal the private sector regarding the type, volume and quality of services required, thereby reducing resistance and motivating providers to adopt required changes.
Update: SSB funds were used to finance the pilot instead of Loan funds. The goals of the Innovation Fund have been achieved under the Pilot Project. In this light, MOH as the executing agency for the HSRP applied for the reprogramming of those funds (originally intended for the Innovation Fund) to support activities under Components 1 and 2 of the Project. The reprogramming was granted with on October 20, 2004 under cover letter from IDB with the signed Amendatory Contract No. 1.
European Union Grant
Remedial Works at the Karl Heusner Memorial Hospital: The main purpose of the remedial works undertaken at the Karl Heusner Memorial Hospital was to increase the quality of the KHMH health services delivery in a sustainable manner, through the restoration of functionality of the building. The civil works component was completed in 2003, and the Ministry of Health accepted the Final Report from Burrell and Burrell Associates, the Architecture and Engineering Consultant in April 2003. The scope of works under this component was as follows:
- Roofing & Waterproofing: To prevent water from seeping into the building. Johnson International was contracted to conduct the roofing and waterproofing works at a total value of BZ$1,038,089.04.
- Repairs to the external walls: To prevent water from seeping into the building. Usher Construction was contracted to carry out the repairs to the external walls at a total value of BZ$169,535.87.
- Drainage Works: The waste water system was in a state of disrepair and many of the sanitary facilities were not functioning properly. Mr. Joel Mollinedo was contracted to conduct the drainage works at a value of BZ$705,749.91.
The MIF Technical Cooperation
Establishment of the Regulatory Framework and the Development of Capacity for the Procurement of Health Services form the Private Sector: In addition to the three components of the loan, the complementary MIF Technical Cooperation supports the creation of a policy, regulatory and purchasing environment, which will facilitate the expansion of the Belize private sector in publicly and privately funded health services. It will also provide technical support for the development of health services purchasing plan, market organization for private health care providers and design of an Operational Manual for the Innovation Fund. Specifically, it will support the following activities:
- The development and implementation of strategies and mechanisms that will formally enable private providers, by contract, to deliver various health and medical services to the general public – services which have historically been offered by the Ministry of Health through its service delivery network (or services that have not been available).
- The development and implementation of licensing and accreditation programs and a regulatory/legislative framework that shall ensure that minimum standards for providers, services, and facilities are established and achieved on an ongoing basis.
- A maximum of twenty (20) clinical protocols for the delivery of quality health services.
- An assessment instrument for evaluating provider compliance with the clinical norms, standards and protocols.
- An assessment tool and procedure for the accreditation of health facilities.
- The development of an overall training plan for quality management in conjunction with the Belize Medical and Dental Association (BMDA).
- The development and implementation of strategies to encourage the private sector providers to be more effective administratively, organizationally and financially and to improve their capacity to compete and prosper in a more price and quality-competitive environment