Sunday 22 September

1600-1800

Registration of Participants

1800

Welcome address: S. Nyachae M.P., Kenyan Minister of Finance
Jackson Kalweo M.P., Kenyan Minister of Health
Vinod Thomas, Director, WBI
David Bloom, Deputy Director HIID and Professor of Population and Health Economics, Harvard School of Public Health

Dinner Keynote Speech: Dr. Olive Shisana Executive Director, Family and Health Services World Health Organization

Monday 21 September

Introduction

Welcome and Introduction of Participants

Senior Government Ministers welcomed the participants. Participants introduced themselves. Forum Task Manager and Forum Facilitator provided a brief overview of the course. Learning objectives for the week's training was mapped out to relate the objectives to each subsequent presentation.

0930-1000

Learning Objectives/ Design of Forum

Speaker: Kwesi Botchwey (HIID)

1000-1030

Coffee Break

I. The Landscape

1030-1130

Adapting to Change: New Challenges and Opportunities for Reproductive Health Programs

The purpose of this session was to provide an understanding of the changes which are occurring in national health systems and the implications for reproductive health (RH) programs. It presented an overview of progress in RH programs since the 1994 International Conference on Population and Development (ICPD) in Cairo focusing on the move from a MCH/FP approach to a broader reproductive and sexual health approach, as advocated by the ICPD Programme of Action (POA). The backdrop against which countries are delivering RH services: the macro HSR and decentralization trends (including the sector-wide approach) and the trend toward increased use and inclusion of the private and NGO sector in health, were mapped out. This session was designed to situate the country case studies presented during the course of the week. It introduced many of the themes that weredeveloped in greater detail during subsequent sessions.

Speakers: Allan Hill, Harvard School of Public Health
Tom Merrick, The World Bank

Papers: Allan Hill: Making the Case: Rationale for RH
Tom Merrick: New Challenges for RH
Arlette Campbell White: The Status of Reproductive Health post Cairo

II. The Modalities of Reform

1130-1300

Diversity of Approaches

Reproductive Health programs face substantial challenges in light of the significant changes that have been brought about through health sector reform, the demand for client centered, expanded high-quality services and the severe resource constraints found in most countries in Africa. These challenges have prompted many countries to reexamine the way that reproductive health services are organized and delivered in an effort to find better, more efficient modalities of service delivery. The session examined this experience via the approaches used, and the implications of each of these approaches in terms of quality, efficiency and outcome requirements. It served as an introduction to the case studies from The Gambia, Ghana, Zambia, Malawi, Uganda and Mali that illustrate the varying modalities of reform.

Approaches that will be discussed include:

• Integration
• Decentralization
• Privatization and use of multisectoral approach
• Cost sharing and use of costing information
• Sector wide planning and program development

Speaker Iain Aitken, HSPH

Paper: Iain Aitken: The Diversity of the Integration Process

1300-1430

Lunch

1430-1530

The Structure of Reform in the Republic of Karibuni

Participants were introduced to the Republic of Karibuni, a fictional country in East Africa going through a series of health system reforms. The case was introduced with a role-play and with participants then breaking into small groups to discuss the case. Each group was assigned one of the following characters from the case. They were asked to take the perspective of that character and be ready to represent the character to the other members of the audience:

• The Minister of Health, Dr. Mkubwa
• The Assistant Secretary for Health Sector Reform, Dr. Tumaini
• The Assistant Secretary for Health Services, Dr. Kupiga
• A Provincial Health Officer
• A Provincial Administrative Officer
• A patient of a health clinic asking for help with her infertility.
• A member of the World Bank team monitoring progress of the new project.

Facilitator: Marc Mitchell, Harvard Institute for International Development (HIID)

Paper: Marc Mitchell, HIID

1600-1630

Tea Break

1630-1800

The Structure of Reform in the Republic of Karibuni (continued)

The group met in plenary session to discuss the case of Karibuni.

Tuesday 22 September

III. The Experiences

0830-0900

Theme 1: Integration

Integration is seen by many as the answer to a number of problems that have traditionally plagued the health system of developing countries. Many experts believe that integrating different types of health services in one program will serve the needs of the client better and makes services more cost-effective. However, integrated programs require a much stronger management capacity to be truly effective and they create other problems in terms of how to set and maintain priorities within the health system. This session looked at some of the management needs for effective integration, and then presented the experience of several countries that have implemented an integrated health/reproductive health program.

Moderator: Marc Mitchell

Paper: Marc Mitchell

0900-1000

Case Study 1: The Gambia

Paper: Allan Hill

Presentation: Gijs Walraven
Ruben Mboje

1030-1100

Coffee Break

1030-1100

Theme 2: Decentralization

Moderator: Iain Aitken, HSPH

Paper: Iain Aitken, HSPH

1100-1200

Country Case Study 2: Ghana

Speaker: Julian Nkrumah

Paper: Marc Mitchell

1200-1300

Country Team Work

Each afternoon for the remainder of the workshop, country teams met to discuss the implications of the material presented to their domestic situation and develop a presentation to the plenary session for the final afternoon. As countries learned more about what other countries are doing, they were encouraged to integrate these lessons whilst developing their country specific program.

The country teams discussed and presented responses to 3 fundamental questions:

1. What is the most important issue you face in your country in the implementation of an effective reproductive health program and what were the criteria you used to define this as the most important? You may choose among the following list of issues:
   
   1. Lack of attention by senior decision-makers to reproductive health
      
   2. Skills at the MOH are not appropriate to its current needs and role.
      
   3. Level of expertise at the periphery not adequate to the management challenges of decentralization.
      
   4. People responsible for vertical programs not willing to give up power in the interest of a more integrated approach.
      
   5. Crisis management approach prevents the planning required for fundamental structural changes.
      
   6. Government unwilling to effectively use private organizations for the design and delivery of public services.
2. How is this a threat to the success of your program, and are there opportunities that arise from this situation as well?
   
   
3. What do you propose as a country team to address this issue and what will be your criteria for success?
   

1300-1430

Lunch Break

1430-1530

Discussion Groups

The participants were divided into 6-8 groups that met at this time Tuesday-Thursday. These groups discussed the previous sessions, the readings, and any topics that are of particular interest to the group members. It also provided an opportunity for participants, members of the donor community and workshop facilitators to share their understanding of the challenges which lie ahead in the implementation of reproductive health programs and the ways in which countries can address these issues.

1530-1600

Country Case Study 3: Zambia

Zambia has achieved recognition throughout Africa for its far-reaching health reform process, which began in 1991 and which has fundamentally changed the face of the health system. Zambia's previous health system was unable to identify and respond well to client needs and could not hold its providers accountable as they had no discretion to employ corporate judgment. The focus of the health reforms has been an all-encompassing, sector-wide investment approach which has decentralized decision-making, planning, implementation and monitoring to the district level. The advantages and disadvantages of the differing systems prior to and post decentralization were discussed.

Speaker: Kawaye Kamanga

Background paper: Joanna Tighe

1600-1630

Tea Break

1630-1730

Country Case Study 3: Zambia (continued)

1730-1800

Case study wrap-up: The Gambia, Ghana and Zambia

Wednesday 23 September

IV. The Challenges

0830-1000

AIDS: Intensifying Efforts for AIDS Programs Within Health Sector Reform Settings

One of the key challenges for health professionals is integrating previously vertical programs without losing the momentum gained through the intensity of a unifocal approach. HIV/AIDS programs provide a key example of this. The devastating effect of HIV/AIDS in Sub-Saharan Africa remains one of the major health challenges facing both health planners and service providers alike. It is put that the significant progress made in the fight against AIDS may now be threatened by the movement to integrate it into mainstream health programs. There are many aspects to the HIV/AIDS debate, for example: how to keep a focus on non-traditional RH clients such as commercial sex workers and transportation workers; how to reach youth and men; how to ensure adequate logistics networks for condoms and how to maintain confidentiality. In reviewing the case of AIDS, participants looked at the more general issue of integration and the challenge of maintaining the momentum while rationalizing the RH program.

This session discussed why HIV/AIDS must be an integral part of any population/RH/HSR package. Participants examined the extent to which HIV/AIDS may be effectively integrated into RH programs. The session drew on actual examples from program managers who have worked to ensure that HIV/AIDS programs have not been 'diluted' by the 'deverticalization' of programs. It also discussed how non-traditional RH groups may be reached in a non-vertical program setting.

Speakers: Debrework Zewdie, The World Bank
David Bloom, HIID

Papers: David Bloom and Arlette Campbell-White

1000-1030

Coffee Break

1100-1200

HIV/AIDS (continued)

The meeting broke into small groups to discuss factors for effective and practical integration (the 'how to'), with AIDS control program staff from each country acting as group moderators. Each group will develop a list of not more than five key indicators essential to the successful integration of AIDS programs. These will then be discussed in plenary by a panel of experts comprised on AIDS program representatives from each country.

Moderator: Jacob Gayle

1200-1300

Country Team Work

1300-1400

Lunch

Thursday 24 September

III. The Experiences (continued)

0830-0900

Theme 3: Costing and Resource Mobilization

Moderator: R. Paul Shaw, The World Bank

Paper: Joanne Epp, The World Bank

0900-1000

Country Case Study 4: Malawi

This session will focus on the development of robust and accurate health accounts for RH in Malawi, and how the accounts have significantly impacted the national and multilateral policy agenda.

Malawi, one of the world's poorest countries, with a 1996 GNP per capita of just $160, has a pressing portfolio of development issues. This has, in part, resulted in minimal policy interest for reproductive health issues. Despite this, the GOM has recently been able to negotiate a $25 million loan with the World Bank to initiate a community-based RH pilot project. Currently, they are focusing on the development a small component of a larger HSR blueprint for RH integration. This analysis of a country, which has focused on community level programs as an "add-on" to broader HSR initiatives, provides an example of innovative approaches to integration that have been costed out at a level affordable to even the poorest of nations.

Speaker: Norbert Mugwagwa, The World Bank

Paper: "Population and Family Planning in
Malawi: A Community Nexus Approach" Government of Malawi/The World Bank

1000-1030

Coffee Break

1030-1130

Case Study 5: Uganda

The results of this bottom-up cost analysis have presented both Ugandan and multilateral decision-makers with a tool for considering both comprehensive and piecemeal RH service implementation.

This session had a policy focus. It demonstrated the utility of cost analysis as a rational, decision-making tool which impacts the policy agenda. It demonstrated how the results of the Ugandan study may be used:

1. to identify efficiency levels within, and between, programs, and
2. as an advocacy tool for resource mobilization

Participants were introduced to a decision-making framework that situates cost analysis within the policy formulation agenda. Although touched upon, the methodology of costing was not be covered in detail.

Moderator: Joanne Epp

Paper: Joanne Epp

1130-1200

Case Study Wrap-up: Malawi and Uganda

1200-1300

Country Team Work

1300-1430

Lunch Break

1430-1530

Discussion Group

III. The Experiences (continued)

1530-1600

Theme 4: The Public-Private Mix

Moderator: David Bloom, HIID

Paper: David Bloom, HIID

1600-1630

Tea Break

1630-1730

Case Study 6: Mali

Moderator: Allan Hill, HSPH

Paper: Allan Hill, HSPH

Friday 25 September

IV. The Challenges (continued)

0830-1000

Organizational and Institutional Challenges: Effective Delivery and Coordination of Service Provision: Country Presentations and Discussion

Each country team presented the work that they have been doing in terms of their country assessment and proposed responses to the 3 fundamental questions that were presented on day 2:

1. What is the most important issue you face in your country in the implementation of an effective reproductive health program and what were the criteria you used to define this as the most important?  Following is a list of issues:
   
   1. Lack of attention by senior decision makers to reproductive health
   2. Skills at the MOH are not appropriate to its current needs and role
   3. Level of expertise at the periphery not adequate to the management challenges of decentralization.
   4. People responsible for vertical programs not willing to give up power in the interest of a more integrated approach.
   5. Crisis management approach prevents the planning required for fundamental structural changes.
   6. Government unwilling to effectively use private organizations for the design and delivery of public services.

   How is this a threat to the success of your program, and are there opportunities that arise from this situation as well?

2. What do you propose as a country team to address this issue and what will be your criteria for success?

1000-1030

Coffee Break

1030-1300

Organizational and Institutional Challenges: Effective Delivery and
Coordination of Service Provision:
Country Presentations and Discussion (continued)

1300-1430

Lunch Break

1430-1530

Evaluation
Participants will complete the evaluation form circulated at the beginning of the week.

1530-1600

Organizational and Institutional Challenges: Effective Delivery and Coordination of Service Provision: Country Presentations and Discussion (continued)

1600-1630

Tea Break

Organizational and Institutional Challenges: Effective Delivery and Coordination of Service Provision: Country Presentations and Discussion (continued)