ReformingOperational

Policies:A Pathway to Improving

Reproductive HealthPrograms

Harry CrossKaren HardeeNorine Jewell

December 2001

7P O L I C YOCCASIONAL P A P E R S

POLICY

POLICY is a five-year project funded by the U.S. Agency for International Development underContract No. HRN-C-00-00-00006-00, beginning July 7, 2000. The project is implemented byThe Futures Group International in collaboration with Research Triangle Institute (RTI) andThe Centre for Development and Population Activities (CEDPA).

POLICY

POLICY Occasional Paper #7

Reforming Operational Policies:A Pathway to Improving

Reproductive Health Programs

Harry CrossKaren HardeeNorine Jewell

December 2001

iii

Acknowledgments iv

Executive Summary v

Introduction: Impact of Operational Policies on Reproductive Health 1

The Policy Roots of Operational Barriers 6

Methods for Addressing Operational Policies 12

Conclusion 22

References 24

Contents

iv

POLICY Occasional Papers areintended to promote policy dialogue

on family planning, reproductive health,and HIV/AIDS issues and to presenttimely analysis of issues that will informpolicy decision making. The papers aredisseminated to a variety of audiencesworldwide, including public and privatesector decision makers, technical advisors,researchers, and representatives of donororganizations. An up-to-date listing ofPOLICY publications is available on theweb at www.policyproject.com. Copies ofthese publications are available at nocharge.

This paper is the result of a cooperativeeffort to which many people contributed.

The following staff of the POLICY Projecthave been particularly helpful inpreparing this document: Jeff Jordan,Koki Agarwal, Bill McGreevey, NancyMcGirr, John Ross, John Stover, JoeDeering, Gadde Narayana, AngelineSiparo, Sue Richeidei, Taly Valenzuela,Varuni Dayaratna, Suneeta Sharma,Imelda Feranil, and Maureen Clyde. Thepaper would not have been possiblewithout the pioneering studies byPOLICY ’s overseas staff, including GaddeNarayana, Issa Almasarweh, and AndriyHuk. Finally, we would like to thankElizabeth Schoenecker of USAID for herhelpful comments. The views expressed inthis paper, however, do not necessarilyreflect those of USAID.

Acknowledgments

v

Many countries around the worldhave made great progress in

improving reproductive health programsthat now reflect the principles of the1994 ICPD Programme of Action.Governments and donors have pursuedtwo main routes to improvingreproductive health. First, they haveenacted national policies and laws aimedat expanding services and raising thequality of available services. Second, theyhave implemented a wide range ofservice projects and demonstrations toshow how services can be enhanced andclient education improved. Too often,however, national policies and laws arenot translated into systemwide programsand improved reproductive healthservices, especially for the poor. Becausethese doctrines are necessarily broad andencompassing, they neglect thestructures and systems that serve as abridge between national policies andlocal programs. Projects anddemonstrations are often not replicablebecause they are not financiallysustainable in the long run. Moreimportant, they generally do notsystematically address the underlyingpolicy constraints in the structures andsystems that affect the service deliveryenvironment. This paper focuses on thevast arena between national policies andthe point of service delivery, which is thedomain of operational policies.

Operational policies are the rules,regulations, codes, guidelines, andadministrative norms that governments useto translate national laws and policies intoprograms and services. While nationalpolicies provide necessary leadership andguidance, operational policies are themeans for implementing those policies. Inmany cases, program deficiencies, such as alack of trained service providers and otherresources, can be traced to operationalpolicies that are inadequate, inappropriate,or outdated. Poor operational policiesresult in wastage and inefficiency thatpervade every clinic, health post, andhospital and adversely affect healthpersonnel and every client. When draftedor modified appropriately, operationalpolicies can help enhance the quality ofreproductive health programs by makingmore efficient use of existing resources.

The paper discusses the nature ofoperational policies, stresses the importantrole they play in the continuum fromnational decrees to local services, andprovides a framework for operationalpolicy reform. The operational policyreform process calls for

◗understanding the public sector, whichgives rise to the policies that shape theservice environment;

◗ setting up a collaborative system withmanagers and providers for identifying

Executive Summary

vi

operational barriers to high-qualityreproductive health care;

◗conducting analyses to determine theoperational policy roots of thosebarriers; and

◗adopting recommendations andstrategies to remove the operationalpolicy barriers.

The process of analyzing operationalpolicies and devising reform strategies ismost effective as a participatory endeavorthat draws on the insights and perspectivesof those who manage and providereproductive health care services andthose who set policies.

The paper also provides evidenced-based examples of how operationalpolicy analyses have illuminated thedebilitating effects of outdated ornonexistent policies on reproductiveservices in a number of countries,including Guatemala, Haiti, India,Jordan, the Philippines, Romania, andUkraine. The analyses led to reforminitiatives that helped governments atall levels. Analyzing operational policiesand supporting policy reform is ahighly effective tool for improving thedelivery of much-needed reproductivehealth care services in developingcountries.

The purpose of this paper is to developan increased understanding of an area

of public sector policies that must beaddressed in order to improve reproductivehealth services. No matter how they aredefined, operational policies can be foundalmost everywhere in the health systemsliterature, and their consequences areapparent in every clinic, health post, andhospital. In simple terms, operationalpolicies are the rules, regulations, codes,guidelines, plans, budgets, procedures, andadministrative norms that governments useto translate national laws and policies intoprograms and services1 (Cross, 2000).Operational policies govern the “operatingsystem” for public sector programs. To usea computer analogy, operational policiesare the “language” that governs therelationships between health system inputsand outputs. If the “language” does notgovern efficiently, the operating system isbound to fail. The symptoms of failure arenot unlike the computer crash where themachine simply stops functioning asintended.

Operational policies also have a criticaleconomic aspect. Operational policies areone of the determinants of how inputs tothe health care system (e.g., resourcessuch as personnel, equipment, andtransportation) are deployed once healthcare priorities have been determined.Poor operational policies can limit theproduction of high-quality health careoutputs and lead to inefficiency2 andwastage in health care programs.

Governments Remain Pivotalto Reproductive HealthServices

Despite growth in the private sectorprovision of health care in developingcountries, the public sector still plays acritical role in the delivery of reproductivehealth services. In many countries, thepoor rely exclusively on governmentprograms for family planning. In almost70 percent of the countries surveyed inthe past five years, the public sector

1

Introduction: Impact of Operational Policies onReproductive Health

1 The policy working group of the USAID-funded Evaluation Project defined four components of operational policiesdirectly related to the operation of national family planning programs: organizational structure and process; thelegal and regulatory environment; provision of resources; and pricing (Bertrand, Magnani, and Knowles, n.d.).This definition did not include the rules that govern how systems operate, which are the vital “glue” that holdssystems together.2 Microeconomic efficiency refers to the scope for achieving greater efficiency from existing patterns of resource use.Wastage and inefficiency occur in all health systems. Allocative inefficiency occurs when resources are devoted to thewrong activities while technical inefficiency occurs when too many resources are used to achieve a given healthintervention or outcome (WHO, 1999).

accounts for 50 percent or more of familyplanning services (DHS, 2001). Similarly,for maternal and child health services,poorer groups depend heavily ongovernment services. Not only dogovernments provide a large share of theservices thought to be most effective inpreventing deaths and illness, but theyalso pass and enforce the laws, regulations,and codes that greatly influence theprovision of these same services bycommercial providers and othernongovernmental organizations (NGOs).

Although the public sector plays animportant role in providing reproductivehealth services, most efforts to improvefamily planning and reproductive health(FP/RH) programs have addressed onlynational public sector policies and focuson service delivery performance and theprivate sector (Seidman and Horn, 1991;Ross and Frankenberg, 1993; PopulationCouncil, 1998a, 1998b; Shane and Chalky,1998; Miller et al., 1997; MSH, 2000). Thegap between national policy and improvedservice delivery performance has been thelack of attention to operational policies.

Consequences of FaultyOperational Policies:Inefficiency and Wastage

The past 50 years have witnessedtremendous expansion of government-runhealth care systems accompanied byburgeoning bureaucracies that havebecome rigid and inefficient (WHO,2000). Initially responsible for financingand operating public hospital and primarycare systems, ministries of health are nowlarge, hierarchical bureaucraciescharacterized by unwieldy administrative

rules and a permanent staff protected bycivil service regulations (Bossert et al.,1998). The problems faced by ministriesof health are exacerbated by inefficientlyrun government systems on whichministry operations depend, includingcivil service regulations and public worksand transportation norms, among others.As a result, policies and procedures thatmay be burdensome, conflicting, obscure,outmoded, and difficult to change oftengovern quality, access, and workingconditions at the point of serviceprovision. Many of these operationalpolicies create conditions that act asdisincentives for health workers toperform their duties, or even show up forwork.

The consequences of flawed operationalpolicies are well documented. In Kenya,Owino and Korir (1997) estimated anaverage inefficiency level of 30 percent inthe public health sector as a consequenceof factors such as a shortage ofprofessional staff, a poor combination ofinputs, irregular or nonfunctioningoperating theaters and laboratories,transport problems, lack of or poordistribution of drugs and medical supplies,frequent breakdown of equipment,and/or poor servicing of machines andequipment. In Bungoma District, Kenya,district health management boards areresponsible for supervising the healthsystem in the district. However, the boardslack a budget, transportation, and theauthority to discipline any medicalpersonnel (BDMI, 2000). Nurses who runhealth posts in Kenya have to travel to thedistrict hospital to receive their monthlypay; some travel as much as one day eachway, thus losing 10 percent of theirpotential work time (Sharif, 2001).

2

In Uganda, an expenditure trackingexercise revealed that a significant portionof funds allocated to basic social servicesnever reached the intended health clinicsor schools, particularly in rural areas (Abloand Reinikka, 1998). In Ghana in the early1990s, 70 percent of Ministry of Health(MOH) vehicles were reported to bewaiting for repair in governmentworkshops. Reorganization of maintenanceand repair arrangements and budgetpractice led to rapid improvement, butGhana’s recent experience is widespread(WHO, 2000). A study of the managementinformation system in Uttar Pradesh,India, found that too much information iscollected on too many forms, and most ofit is never used. At the subcenter level,auxiliary nurse midwives had to fill in 13registers and four forms each month(POLICY Project, 1998a).

Operational Policies AreNeglected

Over the past 30 years, governments anddonors have overwhelmingly focused onnational policies and general programdirections as well as on community-levelservice delivery performance anddemand. Efforts to improve nationalpolicies have included follow-up strategicplanning and, in some cases, programplanning and budgeting. As illustrated inFigure 1, these efforts have not extendedto analysis and correction of operationalpolicy barriers that might impede theimplementation of a national policy or

strategic plan. Program effort scores3

(Ross and Stover, 2000) demonstrate thatnational policies do not necessarilytranslate into program action, such asfamily planning method availability—animportant proxy for access and oneindicator of quality. Figure 1 also showsthat in the “policy” category of the 1999program effort survey, all nine countriesscore between 50 and 70 points out of apossible 100. In contrast, the “methodavailability” category shows scores rangingfrom 13 to 80 points—a huge deviationfrom the patterns in the policy category.This deviation illustrates that the mereexistence of laws, policies, nationalpopulation councils, and official programdocuments does not guarantee familyplanning access and use.

3

0

20

40

60

80

100 Bangladesh

Cambodia

Egypt

Ghana

India

Malawi

Nepal

Nigeria

Tanzania

Policy Availability

Percent of Maximum

Figure 1. Program Effort Scores byCountry

3 The Program Effort Score (PES) study has a 30-year history (Ross and Mauldin, 1996). The PES contains acomponent on operational policy that measures three subdimensions that are directly related to the operation of thenational program. The three subdimensions include organizational structure and processes, the legal andregulatory environment, and the provision of resources.

There are significant operational policybarriers to ensuring sustainable access tohigh-quality reproductive health services.Hardee et al. (1999) identified thefollowing difficulties in implementation ofthe 1994 ICPD Programme of Action: (1)prioritization of reproductive healthinterventions to provide programguidance, (2) initiation of FP/RH programexpansion, and (3) mobilization offinancial resources. Others have madesimilar observations (Ashford andMakinson, 1999; Forman and Ghosh, 2000;Tantchou and Wilson, 2000). Whiledeveloping countries need nationalpolicies to provide leadership anddirection at the national level, they alsomust have the political will and the meansto implement them. They need money,other resources, and operational policiesto make implementation possible.

Similarly, investments in service deliveryhave focused on certain inputs such astraining of staff or procurement ofcommodities. Much of the time, an

investment is made without examining therelevant operational policy environment tomake sure that the health system uses theinvestments productively. Jordan providesan instructive example. A major donor hastrained some midwives to insertintrauterine devices (IUDs), but theinterpretation of the public health lawgoverning the medical professions allowsonly physicians to insert IUDs (JNPC andPOLICY Project, 2000). At a minimum,the training program should not havebeen undertaken without some indicationfrom government policymakers that theoperational policy barrier would beaddressed.

Governments and especially donors haveattempted to overcome implementationproblems by carrying out demonstrationprojects and operational research inspecific areas, such as a district. In thesecostly interventions, demonstrations oftenattempt to overcome operational barriersnot by changing the policies that createthem but rather by “financing” aroundthem, as shown in Box 1. As an example,instead of addressing operational policiesthat keep vehicles in perpetual states ofdisrepair, a demonstration projectpurchased new vehicles. Not surprisingly,many such interventions are successful forthe duration of the demonstration orresearch. However, if the demonstration’sdesign does not address underlyingoperational policy barriers, there is a highlikelihood that the health system willreturn to its original state as soon as thefinancial assistance is withdrawn.

In sum, until recently, governments anddonors seem to have focused on policy atthe highest level and performance at theservice level. They implicitly assumed that

4

Box 1. Operational Policies: A Key toScaling Up Pilot Projects

“To address a basic breakdown in the primary healthsystem as a result of decentralization, USAID funded apilot project in Cameroon to introduce a new approach tofinancing and delivering health services. Thanks to theprovision of a steady drug supply, a system of revolvingfunding, and an upgrade of free primary health care, theproject was a major success when it concluded in 1994.However, it has not been scaled up. The new aspects ofthis pilot [project] required obtaining temporary waivers ofnormal procedures. These temporary waivers were nottranslated into the operational policy reforms necessaryfor the project to be replicated.”

(World Bank, 1998)

implementation automatically followspolicy reform and that technicalinterventions lead to permanentsystemwide improvements absent anyother changes. These assumptions wereoften erroneous and highlight the needfor greater awareness of operational policybarriers and their consequences in allstages of policy and program design and atall levels of management.

Undermining Investments inHealth Sector Reform

Increasingly, experts in the field arereaching the conclusion that the neglectof policies and procedures that areresponsible for inefficient practicesundermines the investments of ever-scarceresources needed to expand services tomeet rising demand for health care.Health sector reform initiatives tend tofocus on the macroeconomic context, onfinancing issues, and on the use ofincentives and disincentives to motivatehealth care managers and staff (Cassels,1995; Berman, 1995; WHO, 2000). Expertshave determined, however, that moreneeds to be known about the healthsystems environment in which staff work(Berman, 1999; Shaw, 1999; WHO, 2000;

Manning, Mukherjee, and Gokcekus,2000). Indeed, operational policies arecentral to understanding the healthsystems environment.

It is vital that governments work toimprove operational policy efficiency as anintegral element of health reform. Thechallenge is daunting not only because ofthe complexities of operational policiesand bureaucratic inertia but also becausesome policies preserve longstandingpatterns of improbity. However, thecentral role of the public health sectorand the impact of its policies on thenongovernmental sector make itimperative that reform initiatives focus onthe “nuts and bolts” of those cumbersomeand detailed administrative rules thathinder the operation of health systemsand the ability of health care managersand providers to perform their jobs.Therefore, health reform initiatives,especially those affecting reproductivehealth, must explicitly understand thepolicy roots of operational barriers andfind workable ways of resolving them.Without such understanding and actions,it will be difficult to implement healthreforms successfully, and it will be almostimpossible to improve public sectorreproductive health services.

5

National policies, such asreproductive health policies,

provide the broad vision and frameworkfor government action. To succeed,national policies must be translated intoprograms that will achieve the goals setforth at the national level. Such goalsinclude, for example, a reduction in

maternal mortality or the incidence ofHIV/AIDS or expanded access to familyplanning. Moving from national policiesto local programs requires the design andimplementation of operational policiesthat, in turn, have a determininginfluence on health management andservices (see Figure 2).

6

The Policy Roots of Operational Barriers

◗ Constitution/laws◗ National health/ reproductive health policies

Operational policiesRules, regulations, guidelines, operating procedures, and administrative norms that governments use to translate national laws and policies into programs and services.

Public sector regulations(budget, civil service, general

services administration)

Health systems management(centralized, decentralized)

Reproductive health service delivery

Policy roots

Impact of operational

policy barriers

Figure 2. Conceptual Framework for Operational Policies

7

Box 2. Levels of Policies Governing Public Sector HealthPrograms and Examples of Operational Policies

Constitution/Laws/National Policies

◗ National laws affecting reproductive health ◗ National reproductive health-related policies ◗ Human rights guarantees

Operational Policies

Public Sector Regulations◗ Budget (process for determining annual funding, level and allocation, flexibility)◗ Taxes and duties (excise, import, value-added tax (VAT), exemptions) ◗ Personnel (rules for hiring, firing, transfer)◗ Buildings and grounds (utilities, building and maintaining the physical infrastructure)◗ Transportation/vehicles (resources and rules for obtaining and maintaining vehicles, fuel)

Health Systems Management◗ Policy, planning, and evaluation (process and procedures) ◗ Organization (centralized and decentralized responsibilities)◗ Facility-based services organization (location, distribution, lines of authority)◗ Community-based service organization (location, distribution, lines of authority)◗ Standards and accreditations (personnel, facilities)◗ Fees for service (levels, exemptions)◗ Procurement/logistics (procedures, regulations)◗ Management information systems, monitoring (regulations, circulars, procedures)◗ Referral systems (guidelines, circulars)◗ Client rights (regulations, norms)◗ Regulation of the private health sector

Service Delivery (including reproductive health) ◗ Organizational structure (lines of authority)◗ Personnel (clinic and community-based: job descriptions, allocation of time, recruitment,

deployment, professional development, training, supervision, performance appraisal)◗ Tangibles (equipment, materials/supplies, procurement and maintenance of

pharmaceuticals)◗ Logistics management (transport, warehousing, inventory, cold chain, ordering)◗ Facilities maintenance (circulars, regulations, guidelines)◗ Financial management (guidelines on retention of fees, management of funds, facility

budgeting, local procurement)◗ Clinic organization/patient flow (hours of operation, availability of medical personnel) ◗ Clinic records, management information systems, including service statistics (guidelines,

circulars on compiling and reporting information)◗ Service delivery guidelines/protocols/norms/standards (medical, counseling, education

services, informed choice/consent)◗ Quality assurance system◗ Client outreach/follow-up

Levels of OperationalPolicies

Box 2 shows the hierarchy and range oflaws, regulations, and policies that affectthe provision of reproductive healthservices as organized by governmentallevel. Laws, regulations, codes, andpolicies affecting the operations of ahealth system range from those governingimport duties and budget allocations,tenders, and purchases of contraceptivesat ministerial levels to those influencinghow health personnel at the primary carelevel spend their time and the quality oftreatment clients receive at the facilitylevel.

Operational policies derive from all levelsof the governmental system—from theconstitution and laws to the servicedelivery point—and are within thepurview of several ministries andexecutive agencies. Addressingoperational policy barriers may requireattention to one or more levels ofgovernment; to one or more laws,regulations, or policies; and to one ormore agencies or ministries.

Categories of OperationalPolicies

In addition to understanding the differentlevels at which operational policiesfunction, it is useful to categorizeoperational policies according to thecomponent of the health care deliverysystem they govern. With a barrier toservices identified at the operations level,the categories of policies can be used as achecklist to determine which policies mostlikely create the barrier.

For example, assume that beneficiaries incommunity X are not receiving theattention they expect from healthworkers because the health workers arenot visiting villages as often as theyshould. To understand the operationalpolicy roots of the problem, it would beimportant to first ask why the workers arenot showing up. Depending on theanswers, the next step would be to lookfor possible operational policy roots inthe categories of personnel,transportation, training, and supplies.Inevitably, one would expect to find oneor more operational policies that arebehind a workers’ failure to visit thecommunity and hence are affecting theworker’s performance.

Figure 3 shows the categories ofoperational policies that might be foundin a governmental health system.

Box 3 shows examples of operationalbarriers for the various categories ofoperational policies in Figure 3.

Determining the Policy Rootsof Operational Barriers

Problems with operational policies canmanifest themselves in different ways. Thecause of some operational barriers isinappropriately attributed to operationalpolicies that are only presumed to exist.For example, providers may imposeconditions of spousal consent or agelimitations on certain contraceptivemethods in the mistaken belief that lawsor regulations specify such conditions.

Operational policies may interfere withservice delivery as a result of misguided

8

policy design as, for example, in the caseof lack of clarity in the law. In Jordan, theMOH and the medical professioninterpret a provision of the public healthlaw to mean that only licensed doctors ofmedicine may insert an IUD, although noexplicit prohibition exists on insertion bynurses and midwives.

In other cases, there is a policy vacuumsuch that policymakers must developoperational policies where none existedpreviously. With India’s target-freeapproach implemented during the 1990s,the country failed to develop operationalpolicies to guide programimplementation. A policy vacuum may alsoexist when health sector reform isintroducing major changes to a country’shealth system (POLICY Project, 1998b;2001b).

An operational policy vacuum continuesto exist in many countries as they embarkon expanded national HIV/AIDSprograms. Owing to its completeness andadherence to international HIV/AIDSprinciples and agreements, thePhilippines’s national HIV/AIDS policyand strategic plan provides a model thatother Asian nations have followed. Yet, theplan’s operational policies actually fosteran environment that is contradictory tothe Philippines’s national policy. Forexample, while the Sanitation Code of1975 requires all female sex workers to beregularly tested, it places an age restrictionon clients of government health clinicsresponsible for detecting and treatingSTDs and HIV/AIDS (Government of thePhilippines, 1975). Thus, female sexworkers under the age of 18 (who are themajority of sex workers in some places)

9

$£

CommunicationsOrganizationalStructures Personnel

TrainingTaxes

Finance

InformationVital Statistics

Maintenance Vehicles/Transportation

MedicalNorms

Facility Use/ Construction

Supplies

OperationalPolicies

Figure 3. Categories of Operational Policies

have little if any access to preventive andtreatment services (POLICY Project,2001a).

Cambodia has promulgated a nationalpolicy and a corollary policy statementspecifically protecting the human rights ofits citizens with HIV/AIDS. Yet, thecountry has no labor policy for thetreatment of workers with respect toHIV/AIDS. Employers can dismiss withimpunity workers with HIV/AIDS. Asimilar situation exists in the Philippines,where the Department of Labor has noworkplace policy for businesses withrespect to HIV/AIDS.

Other operational policies areinappropriate because they are out of date.In India, for example, midwives continueto fill out forms with information that is nolonger even used. Once introduced,registers are never withdrawn, resulting ina misuse of labor by the most essentialhealth worker (POLICY Project, 1998a).

Some operational policies are sound, buttheir implementation is slowed by the lagbetween the time that the policies aredeveloped and the time they arecommunicated to relevant levels of thehealth system. For example, in thePhilippines, a World Bank assessment in

10

Box 3. Examples of Operational Barriers by Category ofOperational Policies

Barrier

◗ Frequent absence and turnover ofpersonnel

◗ Disproportionate urban-rural or regionaldistribution of doctors and nurses

◗ Medical barriers such as restrictions onthe personnel permitted to distributegiven contraceptives or to administerdrug treatment and the requirement forspousal consent for services

◗ Limited choice of contraceptives ◗ Stock-outs of contraceptives, drugs, and

supplies ◗ Wastage of commodities◗ Inadequate pre- and in-service training

◗ Lack of transportation for emergencyobstetric cases

◗ Weak referral systems◗ Burdensome reports for management

information systems (and lack ofunderstanding of how the informationfrom service statistics can be used)

◗ Long delay in new directives from thecentral level reaching local levels

Category of Policy

◗ Personnel, financing

◗ Organizational structures, personnel,financing, resource allocation

◗ Medical norms

◗ Medical norms, financing, taxes◗ Supplies, financing, vehicle/transport

◗ Supplies, information, financing◗ Training, personnel, organizational

structures◗ Vehicle/transport, resource allocation

◗ Organizational structures, training◗ Information

◗ Organizational structures,communications

the late 1980s noted that eight monthselapsed for a directive to go from theDepartment of Health to the local level(Feranil, 2001). The process ofcommunicating a policy or directive is initself an important operational policy.

It is also important to identify whichoperational barriers may not have policyroots. Some barriers, for example, can beresolved by delivering training or tools toimprove knowledge, skills, and practice(e.g., contraceptive technology updates ortraining on existing norms and standardsor improving management practices).Other barriers are the product ofsociocultural attitudes or result from

inadequate resources (e.g., resourceallocation policies are sound, but thelimits in funding prevent acquisition ofneeded equipment, supplies, ormaintenance). Barriers associated withinadequate resources must be eliminatedby setting appropriate priorities orincreasing resources. Still, numerousproblems that occur at the operationallevel result from policy barriers.

Operational barriers often seemformidable and intractable; yet, there areproven ways to identify and address thepolicy roots of operational barriers. Thefollowing section outlines methods foraddressing operational policy barriers.

11

Addressing operational barriers andtheir links to operational policies

requires four broad steps as follows:

◗understanding the public sector; ◗ setting up a collaborative system for

identifying barriers; ◗conducting analyses to identify the policy

roots of the barriers; and ◗ following through with the

recommendations of the analysis toremove the policy barriers.

The sections below describe each of thesesteps in more detail.

Understand the Public Sector

An assessment of operational policies mustbegin with a thorough understanding ofthe public sector. We are interested inwhat Donabedian termed the “structure”of care,4 “the relatively stablecharacteristics of the providers of care, ofthe tools and resources they have at theirdisposal, and of the physical andorganizational settings in which they work”(Donabedian, 1980: 81). The first step isto obtain a clear picture of the policyenvironment of the public sector within

which a health care system operates—andhow health service operational policiesrelate to national laws and policies, publicsector regulations, health systemsmanagement, and reproductive healthservice delivery (see Figure 2 and Box 2).Operational barriers can be traced tothese four levels, and many barriers areaffected by policies at multiple levels. Asshown in Box 4, a range of agencies isinvolved in setting operational policies.

The second part of understanding thepublic sector is to include the perspectivesof the managers and staff mostknowledgeable about operationalproblems and their impact on access andquality. Often, managers and staff within ahealth care system do not know or do notexplore the underlying policy causes ofthe operational problems they encounter;however, when asked the right questions,they can provide invaluable insights intothe workings of the public sector.

Not all policy barriers have the sameimpact on access, quality, and efficiency;not all policy barriers require the sameresources for their elimination. Box 5presents an example checklist that can beused for setting priorities for addressing

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Methods for Addressing OperationalPolicies

4 Donabedian’s (1980) classic framework for assessing quality in health care served as the basis for the Bruce/Jainfamily planning quality of care framework (Bruce, 1990). Donabedian included three components in hisframework: the structure of the system, the process of care, and the outcome of care.

13

Box 4. Levels of Operational Policies and Responsible Agencies

Policy Agency or Ministry

Public Sector Regulations

Taxes, duties, patents, approval for Legislative and executive branch, ministries manufacture, import, sale of pharmaceuticals of finance and commerce

Appropriation, resource allocation Legislature, ministry of finance

Financial management Treasury, ministry of finance

Regulations to implement laws in fields of Ministries of health, finance, administration, health (including insurance), finance, labor, food and drug administration, human rights agencies with judicial oversight

Personnel Civil service authority

Public facilities and equipment (planning, use, Public works construction, maintenance)

Executive orders Chief of state

Health Systems Management

Public health system executive orders and Minister of health, secretary general/principal management policies (manuals, circulars, secretary, bureau/division chiefs (of medical directives) services, primary health care, procurement,

pharmacy, training, IEC), regional/departmental medical directors

Licensure, accreditation, government medical/ Government accreditation boards, professional pharmaceutical professions, standards of associations of physicians, nurses, midwives, care medical/pharmaceutical professions pharmacists

Admissions, curricula, standards in facilities/ Faculty/school staff, professional associationsschools of medicine, nursing, midwifery auxiliaries

Insurance norms Minister of health, regulatory commissions

Service delivery guidelines/protocols/ Bureau/division responsible for norms norms/standards and standards

Types of services to be provided by various Professional associations of physicians, nurses, health care personnel midwives and pharmacists, ministry of health

Service Delivery (including reproductive health)

Personnel deployment within a jurisdiction, District chief medical officer, district hospital scheduling, assignments, budgeting, supervisor, director of nurses, supervisor of performance monitoring, collection of fees health workers, clinic medical officer, chief nurse,

manpower/personnel officers, politicians

Planning workloads, equipment, supplies, District chief medical officer, district hospital commodities supervisor, director of nurses, supervisor of

health workers, clinic medical officer, chief nurse

Clinical procedures Regional/departmental medical directors, clinic managers, chief nurse

operational policy barriers. The checklistcan be used throughout the process ofidentifying and analyzing operationalbarriers and their policy roots.Information on the checklist can be filledin as it becomes available in the process.Figure 3 and Box 3 can be used to identifythe type, scope, and impact of theoperational barriers (the barrier; potentialimpact on access, quality, and efficiency ofthe barrier to be removed; and complexityof the barrier). Other information usefulto determining which operational barriersto address includes potential support oropposition to addressing the barrier, thetime and resources required to make achange, what needs to be changed aboutthe operational policy (policy vacuum,policy presumed to exist, policy exists but

implementation is slow, policy is out ofdate), and the ease of the decision tochange the operational policy (e.g., anexecutive order or an act of parliament).With this information, operationalbarriers can be ranked by priority.

Take a CollaborativeApproach

Collaboration is one of the mostproductive strategies for ensuring that allgovernment policymakers, localinstitutions, and donor agencies focus oncomplementary approaches to solvingoperational problems. Most of theseindividuals and organizations neither havethe mandate to address policies beyond

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Barrier

(Use Figure 3 and Box 3to classifyand describe barrier)

Potentialimpact onaccess,quality,efficiencyin repro-ductivehealthprograms

(Strong,medium, low)

Complexityof thebarrier

(High,medium, low)

Potentialsupport oropposition

(Describe)

Timerequired to change

(Short,medium,long)

Resourcesrequired to change

(Financial,human)

Whatneeds to bechanged?

(Policypresumed toexist, policybased onlack of clarityin the law,policyvacuum,slow imple-mentation,out of date)

Ease ofdecision to changeoperationalpolicy (e.g.,executiveorder rather thanact ofparliament)

(Difficult,medium,easy)

Priorityrank

(High,medium, low)

Box 5. Checklist for Determining Priority Operational Barriers to BeAddressed

their immediate operational setting noroften look at policies in other sectors thatmight affect health. Nonetheless,organizations—whether local orinternational—that work on policy issuescan address all levels of policymaking, fromthe president and parliament down to thedecentralized level. They can work onpolicy issues beyond the reach of theoperational-level staff and, in collaborationwith service delivery organizations, ensuresound problem analysis and appropriate,practical reforms.

For example, the Maximizing Access andQuality (MAQ) Initiative focuses mainlyon the reproductive health servicedelivery level by seeking interventions5

that will improve the care received byclients. However, commitment ofleadership is envisioned as the first ofmany MAQ interventions needed toensure support for change. Therefore,organizations with policy expertise shouldbe included in the design and support forMAQ activities. Otherwise, these activitiesmight not elicit support from the requisitelevel of decision makers and may bestalled, as demonstrated in some of theFrancophone region MAQ efforts.

In a Francophone MAQ conference(Dakar, March 1999), participantsreported on progress with development ofprotocols, norms, and procedures (PNPs).Despite the high quality of both thecontent of and process for developingmany of the PNPs, nearly all participantsagreed that there was little evidence thatthe PNPs were being effectively

implemented at the operations level.Reasons included “lack of resources” and“lack of training.” In other words, animportant component of operationalpolicies existed but remained “on theshelf” because commitment to PNPsseldom went higher than a division orbureau chief or the staff responsible forthe national family planning program.Policies that have an impact on theimplementation of PNPs includepersonnel deployment, changes in jobdescriptions and working conditions,training needs assessments, resourceallocation, and preservice training. Thosewith control over such policies includehigh-level ministry officials, professionalboards and associations, and faculties ofmedicine and nursing. In most cases,these decision makers were not engagedfrom the outset of the PNP process;therefore, they had yet to be persuaded ofthe need for policy reform in theirrespective areas.

As a precursor to the MAQ Initiative,several studies looked at the “medicalbarriers” to family planning services(Hardee et al., 1998; Bertrand et al., 1995;Galway, 1992; and MSPAS, OPTIONS, andUSAID, 1993). Shelton, Angle, andJacobstein (1992) listed seven types ofmedical barriers: inappropriatecontraindications, eligibility requirements,process or scheduling barriers, providerbias, regulatory hurdles, limits on who canprovide services, and inappropriatemanagement of side effects. A number ofthese barriers have policy implications. InGuatemala, for example, an organization

15

5 The 12 areas of intervention in the MAQ Synergy of Interventions framework include (1) leadership; (2) clientengagement; (3) community engagement; (4) provider rewards/environment; (5) standards/guidelines; (6) organization of work; (7) training; (8) job aids; (9) supplies/logistics; (10) supportive supervision; (11) indicators/certification; and (12) problem solving.

working on policy issues teamed withother partners in a study of medicalbarriers among providers (Jewell, 2000).By bringing a policy perspective to thestudy, the team identified the policy issuesunderlying the identified barriers. Theproviders are now addressing the policiesas they work toward making permanentand long-term improvements to accessand quality of services (MSPAS et al.,2000). In a complementary activity carriedout by the same policy organization, areport on Guatemala’s reproductive healthlaws and policies clearly set out the legaland policy basis for the right to familyplanning information and services.Consequently, advocates are using thereport as a tool in their campaign to workwith the Minister of Health, who is knownas a strong family planning supporter, topromote the elimination of medicalbarriers identified in the study.

As a complementary initiative to the MAQInitiative, international reproductivehealth organizations are undertakinganother quality improvement initiative inthe area of performance improvementthat focuses on human resources andbranches out to institutional factors whensuch factors are determined to impede theperformance of a health care worker. Forexample, if a worker is not doing his orher job, one “root cause” may beinadequate facilities, equipment, orsupplies. Inadequate facilities, equipment,and so forth have their causes inmanagement systems but also in theoperational policies that govern thosesystems. To date, performanceimprovement has focused primarily on theservice delivery level. Adding a policyapproach can extend the focus to all levelsof the public sector system.

Situation analysis studies can uncover aproblem with particular subsystems in afamily planning or reproductive healthprogram but do not necessarily identifythe operational policy issues perpetuatingthe problem. Furthermore, theorganizations conducting the operationsresearch are often not the organizationscharged with making the necessarychanges to programs or policies.

Situation analyses that show changes overtime (e.g., Burkino Faso, Kenya, Senegal,and Zimbabwe) provide an opportunityto identify areas where improvementsover a long period have not beensignificant and to determine whetherunderlying policies impede progress. Forexample, one study in Kenya found that,while more education materials wereavailable in clinics over a six-year period,there was no improvement in health talksprovided to waiting clients and noimprovement in the frequency ofsupervision—despite similar findings andrecommendations in earlier studies(Ndhlovu et al., 1997). The findingscould be further examined for policyroots that may prevent personnel fromtaking action. Do personnel policiesblock efforts to ensure that jobdescriptions, working conditions,training, and placement for clinic staffaccommodate the need for more healthtalks, more supervision visits? Do vehiclemaintenance, repair, and use policiessupport more frequent supervision visits?

Analyze the OperationalPolicy Barriers

In view of the wide array of possibleproblems and causes and the range of

16

opportunities for intervention, manymethods are available for studyingoperational policies. The selected methodshould, however, adhere to certainprinciples that are likely to lead tosuccessful outcomes. First, allmethodological approaches should bebased on two integral components of totalquality management: the principles ofmapping or diagramming operationalprocesses and root-cause analysis, whichidentifies a problem and follows it to itsprimary cause (or causes) (Juran andGyrna, 1988; Ishikawa, 1982; Omachonu,1991). Second, analysts need to collectaccurate and thorough information aboutthe barriers or inefficiencies, includingdata about the extent of the problem, itsimpacts, and the operating policies thatcause the barriers. The information mustinclude the exact operational policydocument (decree, joint circular,regulations) and information about who isresponsible for and can change theoperational policy.

Third, a participatory process is critical. Inaddressing operational barriers and theirpolicy causes, the involvement ofmanagers and staff from appropriate levelsis crucial for accurately identifying themost important and the most wastefulbarriers. However, it is equally crucial toengage high-level decision makers tosecure their commitment from the outsetto tracing the barriers back to their rootcauses and seriously considering theresulting data. Once data have beenanalyzed, field staff should assist, first, inidentifying and ranking operational policybarriers that need to be addressed and,second, in offering solutions foreliminating the barriers. Researchers needto help design the studies, collect the data,

and perform the analyses required toaddress operational policy barriers.Policymakers need to be included toensure appropriate changes in the largerpolicy environment that lead toimplementation of policy reforms.

Methodologies that have been used tostudy the operational barriers and theiroperational policy roots include thefollowing:

◗Collaborative studies of operationalproblems that focus on a particularperspective (e.g., medical barriers,maximizing access and quality, situationanalyses) in which a policy organizationhas joined with counterpart institutionsfor the express purpose of identifyingand addressing the policy-related causeswhose resolution is beyond the reach ofoperations staff (Galway, 1992).

◗Legal-regulatory studies that inventoryrelevant legal and policy texts andexamine their impact at the operationallevel through key information interviews(JNPC and POLICY Project, 2000;Iknane et al., 2000; Rudiy, 1999;Ravenholt, 1999; Ministère de la SantéPublique, 1994).

◗Direct studies of specific operationalproblems that link problems to theirpolicy roots (POLICY Project, 1998a;Bailey et al., 1994; Adé, Eustache, andGuengant, 1996; Huk, 2001).

◗Financial, budget, and administrativeanalyses that show where resourceallocation policies, financing practices,and administrative procedures causeoperational inefficiencies (Olave, 2000;IIHMR and POLICY Project, 2000).

◗Policy environment and program effortstudies in reproductive health (includingfamily planning, safe motherhood, and

17

HIV/AIDS) that identify operationalpolicies needing correction (Ross andStover, 1997; Stover, 1999; Bulatao andRoss, 2000).

Follow Through withRecommendations to ReduceOperational Policy Barriers

Identifying and analyzing operationalpolicy barriers are only half of the process.Taking steps to reduce or eliminate thebarriers is equally important.

An extensive analysis of operational policyissues in Uttar Pradesh, India, followed asystems analysis approach to identifyingnumerous policy-related barriers(POLICY Project, 1998a). The researchersstarted at the facility level of the publichealth system by compiling a list ofoperational conditions at primary healthcenters and subcenters. Conditionsincluded the presence of adequatesupplies and commodities, functioningequipment, available personnel, status ofmaintenance, vehicle availability, and soforth. They then collected all circularsand memorandums issued on relevantsubjects such as transport, logistics, andstaff transfers, among other topics, over aset period of time. They also analyzeddata from available registers and reports.Finally, the researchers interviewed keyindividuals at each level to understandhow they interpreted the operationalproblems and to identify whichoperational policies caused which adverseimpacts on system performance.

Throughout the process of identifying theoperational barriers, analyzing the policyroots, and recommending solutions, the

research team briefed the appropriatepolicymakers. As a result, the 2000 UttarPradesh State Population Policy addressedall the major operational policy issuesrevealed in the Uttar Pradesh studies(Government of Uttar Pradesh, 2000).The steps to revise the policies wereincluded in the state’s detailed plan foroperationalizing the policy, and theimplementation plan was formallyadopted in 2001.

In Haiti, the mapping of facilities andpersonnel graphically illustrated thedisproportionate allocation of resources inthe national health service delivery systemas described in a widely distributed report(Adé, Eustache, and Guengant, 1996).The information from the mappingproject is now serving as a data source forpolicy analysis and as the basis for reform,including the proposed expansion ofmobile clinics by the MOH and thedevelopment of the first nationalpopulation policy.

In Jordan, as a follow-up to the study onpolicy, legal, and regulatory barriers thatidentified exclusive provision of IUDs byphysicians as a barrier to access to IUDs,advocacy activities have included aworkshop and discussions between a policyorganization and the MOH (Almasarweh,2001; JNPC and POLICY Project, 2000).The national task force charged withdrafting the Reproductive Health ActionPlan (RHAP) has recognized theimportance of this barrier and hasincluded its elimination among theactivities to be implemented during thenext three years.

In Romania, a legal and regulatoryanalysis that identified gaps in insurance

18

coverage formed the basis forrecommendations to fill the gaps. In 1997,Romania passed a social health insurancelaw that provided a general framework forinsurance. The MOH, the HealthInsurance House, and the College ofPhysicians were responsible for specifyingwhich services would be included. Amongother advocacy activities, a study of thecost-effectiveness of contraception (Jensenand Stanescu, 1998) convinced thegovernment to include FP/RH in thehealth insurance basic benefits package.Health reform made the social healthinsurance system primarily responsible forservice delivery while the MOH’s focusshifted toward operational policydevelopment and management of nationalprograms. In 2000, Romania approvedthree broad contraceptive security policiesthat together lay out a framework forcontraceptive targeting and financing.Now the government is developing clearcriteria and implementation guidelines foridentifying and verifying who shouldbenefit from government subsidies(Feranil, Clyde, and Cross, 2001).

In Ukraine, the president’s administrationadopted the National Reproductive HealthProgram 2001–2005 (NRHP) in 2001. Aworkshop on operational policy barriersbrought together a wider group ofstakeholders, including members of theMOH’s Policy Development Group, tobegin addressing the development ofclinical standards and operational plans forsuccessful implementation of the NRHP. Apaper identifying some operational policyissues in the context of health reformprovided the background for discussions

(Huk, 2001). Some of the operationalpolicy barriers identified at the workshophad well-known root causes and wereaddressed in a draft order of Ukraine’sMOH, which was submitted to the cabinetof ministers for approval in mid-2001. Forthe operational policy barriers for whichroot causes were unknown, studies arecurrently underway and focus on theinefficient use of resources—financial,human, capital, and material. A futureround of recommendations submitted tothe cabinet of ministers will address thesebarriers.

As described in the preceding countryexperiences, it was crucial to engage high-level decision makers in following throughon recommendations to ensure decisionmakers’ commitment from the outset totracing the barriers back to their root causesand to considering seriously the resultingdata. Once the data were analyzed, theperspective of field staff became importantfor identifying and assigning priority tooperational policy barriers that needed tobe addressed and for offering solutions foreliminating the barriers. However, onlypolicymakers can ensure appropriatechanges in the larger policy environmentthat lead to implementation of reforms inoperational policies.

Summary of Steps forAddressing OperationalPolicy Barriers

Box 6 provides a more detailed list ofactivities associated with the steps foraddressing operational policy barriers.

19

20

Box 6. Steps to Addressing Operational Barriers inReproductive Health Through Policy Analysis

Step Description

1. Understand the public sector

◗ Identify issues with likely ◗ Engage managers, staff, researchers, and others operational policy roots as appropriate

◗ Use checklist (see Box 5) to determine which operational barriers to address

◗ Review existing information on reproductive health programs and health systems

◗ Obtain commitment from ◗ Engage policymakers, program managers, majorpolicymakers to address stakeholders, and donorspolicy obstacles at the ◗ Agree on methodology for identifying operational operations level barriers

◗ Agree on a plan to follow up findings

◗ Identify operational barriers ◗ Engage managers and staff and others, asand their policy level appropriate

◗ Conduct or use existing studies such as situation analysis, medical barriers, or other MAQ initiatives

◗ Make findings, draw conclusions regarding barriersat the operational level

2. Take a collaborative approach

◗ Identify priority barriers to be ◗ Use checklist (see Box 5) to help determine addressed priority operational barriers to be addressed (for

each barrier, list the potential impact, complexity, time required, resources required, and whether eliminating the barrier is a one-time decision)

◗ Explore root causes ◗ Assemble staff from appropriate levels of the organization

◗ Collaborate with other organizations addressing operational barriers to ensure that a policy perspective is included

◗ Use Figure 3 (categories of operational policies) and Box 3 (barriers by category of policy) as guides

◗ Identify and classify root causes resolvable through training, behavior change, resources, policies, and so forth

◗ Continue the process with those barriers that are rooted in policies at any level of the public health system

21

Box 6. Steps to Addressing Operational Barriers inReproductive Health Through Policy Analysis (continued)

Step Description

3. Analyze the operational policy barriers

◗ Collect and analyze additional ◗ Review texts of policies (e.g., policy statements,data to identify policy impact circulars, service records, and so forth)at the operations level in ◗ Review existing data (e.g., financial data and areas of highest priority service statistics, management information system

records, supply and commodity records, and DHSinformation)

◗ Interview key informants at all levels of the system under study

◗ Use a “case study” approach for a sample of districts, health care centers, and so forth to detail policy impacts

◗ Provide appropriate physical evidence, such as photography, to document physical infrastructure problems

◗ Conduct study or draw from existing economic analysis

4. Follow through with recommendations to reduce operational policybarriers

◗ Recommend and advocate ◗ Present the findings of the policy analysis to for changes policymakers in an understandable way

◗ Conduct policy dialogue ◗ Disseminate findings to support advocacy through

wide participation of stakeholders

◗ Help with drafting or ◗ Identify appropriate mechanisms and decisionredrafting relevant maker(s) responsible for changeoperational policies

◗ Monitor policy change and ◗ Conduct follow-up study to measure changes fromimplementation of new or baselinerevised operational policies and their impact on the operational barriers

According to World Health Report 2000,“[S]ervice quality falls when the

required inputs (physical and human) arelacking, and when proper procedures arenot used. Common symptoms in thepublic sector are a lack of essential drugs,inaccessible health facilities or absent staff,nonfunctioning vehicles and equipment,and dilapidated premises. Where thesesymptoms occur, health outcomes suffer”(WHO, 1999: 34–35). This description ofpublic sector programs applies to manyreproductive health programs around theworld. As resources become increasinglyscarce, the conditions in public sectorhealth programs worsen. Donabedian(1980: 81) noted 20 years ago, “I believethat good structure, that is, sufficiency ofresources and proper system design, isprobably the most important means ofprotecting and promoting the quality ofcare.”

Operational policies are an integral part ofthis “good structure” and make themselvesapparent every day in their impactsthroughout the health care system. To theextent that operational polices areinefficient, they cause further strain onscarce resources. Operational policies aretherefore not only central to current healthsystem performance, but they are alsocritical to successful health care reform.They occupy that vast “middle ground” ofthe policy world that is largely hidden from

observers and participants alike. Studiesworldwide show that policymakers,bureaucrats, doctors, nurses, and midwivesare largely unaware of many of the mostcritical operational policies affecting thedelivery of reproductive health services. Itis easy for them to see the symptoms ofoperational policy breakdowns (e.g., lack ofsupplies, drugs, maintenance,transportation, and the misallocation ofstaff), but few have knowledge of theunderlying policies and therefore little ideaabout how they might be changed.

The problems that constrain reproductivehealth services as described in this paperare not confined to selected componentsof the health system but rather pervade allareas, such as supplies, personnel,transport, and budget. Therefore, giventhat operational policies govern all partsof the health care system, acomprehensive understanding of suchpolicies provides a critical pathway and aclear advantage in improving performanceanywhere in the health system through asystematic policy process.

Addressing operational policies that affectreproductive health programs is clearly achallenge. It means delving into thedetails of the operations of governmentagencies or ministries in an effort tostreamline operating procedures andmake resource use more efficient. The

22

Conclusion

work is painstaking—all the more sobecause policymakers and bureaucratshave a vested interest in maintaining thestatus quo. Rather than dealing withinterest groups to revise or removeunnecessary or outdated operationalpolicies, government agencies orministries often impose new operationalpolicies on top of old operational policies.As a result, health systems have become

sluggish and increasingly inefficient. But,by following the steps outlined in thispaper to adopt a policy perspective inredressing the operational barriers to theservice delivery aspects of high-qualityreproductive health care, policyinitiatives—particularly collaborativeinitiatives—can contribute to improvingprogram efficiency and strengtheningreproductive health programs worldwide.

23

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