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international journal of health planning and management
Int J Health Plann Mgmt 2002; 17: 333–353.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hpm.685
A shared mission? Changing relationshipsbetween government and church healthservices in Africa
A. Green1*, J. Shaw1, F. Dimmock2 and Cath Conn1
1Nuffield Institute for Health, University of Leeds, Leeds LS2 9PL, UK2Regional Health Consultant, East and Southern Africa, Presbyterian Church, USA
SUMMARY
This article reviews the relationships between government and church health providers withinsub-Saharan Africa with a particular focus on East and Southern Africa. This is of particularinterest at this time, given the changing configuration of the health sector in many countriesas a result of health sector reform policies. The article provides a historical overview ofthe development and emerging role of the church health services within this changingenvironment.
The factors affecting the relationship between the government and church sector are identi-fied. These include differences in objectives, types of service provided, and the organizationalculture and management styles. The paper then explores key issues seen to affect the future pat-tern of relationships including the changing scene, and identifies different models for relation-ships and implications for key actors including the Ministry of Health, church health agenciesand coordinating bodies. The article concludes that church health services will continue to playa key role in health care in sub-Saharan Africa; however, there are challenges facing them andboth parties need to develop a response to these. Copyright # 2002 John Wiley & Sons, Ltd.
keywords: NGOs; church and mission health services; health policy; planning; health sector
reform
INTRODUCTION
The last decade has seen intense interest in a number of developing countries in
changing the structure and internal relations of the health sector. Health sector
reform policies, promulgated initially by the World Bank (1993) and picked up
enthusiastically by a number of other donors and governments, have often included
the promotion of a public/private mix. Though the precise meaning of this policy
element is not always clear it generally endorses recognition of the actual and poten-
tial contribution of the non-State sector and the need to develop clear roles for, and
relationships between, the different health care actors.
Copyright # 2002 John Wiley & Sons, Ltd.
* Correspondence to: Prof. A. Green, Nuffield Institute for Health, University of Leeds, 71–75 ClarendonRoad, Leeds LS2 9PL, UK. E-mail: [email protected]
The term ‘non-State health care’ covers a wide range of providers including the
individual/family, traditional practitioners, private practitioners operating alone,
corporate private clinics and hospitals, and NGOs including both secular and
faith-based organizations. Within this group there has been significant attention paid
to the private sector (see, e.g. Bennett et al., 1997) and, to some degree, the general
NGO sector (Green and Matthias, 1997). However, there has been less attention paid
to the faith-based health care organizations including church providers, despite the
fact that in many countries, and in particular sub-Saharan Africa (the focus of this
paper), such organizations have a long history and continue to provide a significant
proportion of the overall health care.
This paper focuses on this group of providers. It aims to explore their current con-
tribution to the health sector and the particular challenges that they face particularly
in terms of their sustainability, and their relationships, both amongst themselves,
with the public sector, and with their donors in the light of the changing configura-
tion of the health sector. It is intended to inform policy-makers within both the public
sector and the church sector who are attempting to optimize the contribution of each
party. It draws on a number of sources. Firstly published literature in the area.
Secondly on the particular experience of the authors including work in and research
on the general issue of NGOs in health care for some years and in the case of one
author, consultant support to Presbyterian church health services in East and
Southern Africa. It was triggered by work carried out in Malawi by the authors,
in support to the Ministry of Health in the implementation of its strategic plan,
which emphasized the development of a stronger public–private mix. However,
though the analysis in the paper is illuminated by this particular experience, it is
not confined to it.
The paper starts by outlining the overall current policy context with particular
reference to health sector reforms and funding changes. It then turns to the contribu-
tion of the church sector and its historical development. Against this background the
paper analyses issues affecting collaboration between church and government ser-
vices and the factors underlying this. This is followed by an examination of possible
future opportunities and threats facing this element of the health sector.
POLICY CONTEXT OF HEALTH SECTOR REFORMS
AND EXTERNAL FUNDING
It is important to view the current situation of church health services against the
wider policy context and this section focuses on two current features of the environ-
ment within which the church is operating—health sector reform policies and fund-
ing changes. It views these against developments over the past two decades.
Prior to the 1980s, although there was widespread church-based health care in
many African countries, it was largely provided independently of the State sector.
The Alma Ata Declaration of 1978 (WHO, 1978)—which was itself partly the pro-
duct of church experiences with community outreach programmes—and follow-up
policies stressed a broader concept of health leading to both multi-sectoralism and a
recognition of the multi-agency nature of the health care sector.
334 A. GREEN ET AL.
Copyright # 2002 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2002; 17: 333–353.
Both of these shifts led in the 1980s to greater policy interest in NGOs, in part
related to their greater institutional flexibility and their ability to cross sectoral
boundaries. The financial strains on the public sector faced by most African coun-
tries not only led the State to seek other sources of funding (World Bank, 1987) but
also forced more active engagement with the non-State sector’s contribution.
However, it was the advent of health sector reform policies that has led to the
widest opening of the window of opportunity for a reconfiguration of relations
between the church and public sector. The initial impetus for health sector reform
as a specific named policy initiative can be traced back to the World Bank Develop-
ment Report of 1993 (World Bank, 1993). During the rest of the past decade, a num-
ber of African countries developed health sector reform policies (Gilson and Mills,
1995) which typically contained the following components:
* creating a more open and ‘competitive’ environment including a separation of the
roles of planning/commissioning from direct provision and contracting for
services.
* enhancing the opportunities for non-State sector role (often known as the public–
private mix)
* a reduction in central state control through decentralization and development of
more autonomy for institutions such as hospitals
* new forms of financing and in particular user charges
* greater use of ‘private’ sector management styles
* new prioritizing approaches linked to minimum essential clinical packages
* enhanced orientation towards users
* stronger regulatory mechanisms
All of these either have implications for the church health sector or can draw on
experiences of this sector. Some examples are given in Table 1.
The other broad contextual change of growing significance concerns external
funding flows. For the majority of church health services that originated as part of
a wider missionary movement, there has always been a significant level of external
support whether in the form of direct grants or as contributions in kind, and in par-
ticular funded technical staff or equipment and drugs. Many churches found that
indigenization led to a reduction in external support—as Hastings observed ‘As
the number of African bishops multiplied in the 1970s, the practicability of a suc-
cessful appeal for funds from abroad greatly diminished’ (Hastings, 1979). This has
caused significant resource shortages for many church health services at a time when
they face both demands for increased services and rising costs. It has also encour-
aged them to explore alternative sources of income generation which, when success-
ful, has strengthened their financial base through diversity and risk-spreading.
In parallel, though unrelated, has been a tendency within the public sector for the
mechanisms for donor support to the health sector to move away from projectized
support to more general sectoral support through what has become known as Sector
Wide Approaches (SWAps) (Cassels, 1997). The development of SWAps may pro-
vide both opportunities for, and threats to, the church sector. The emphasis within
the SWAp philosophy on whole system thinking provides a potential opportunity for
closer integration of the church and government sectors in the health strategy which
GOVERNMENT AND CHURCH HEALTH SERVICES 335
Copyright # 2002 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2002; 17: 333–353.
is seen as a key ingredient of a successful SWAp. However, in the short term there
may be pressure on bilateral donors and indeed in extreme circumstances on external
private funders to channel all resources through the central government-controlled
‘basket’ thereby limiting one potential source of ear-marked funding for church
health services.
HISTORICAL DEVELOPMENT OF THE ROLE OF THE CHURCH
IN HEALTH CARE IN AFRICA
For well over a century, missionary organizations have played a significant role in
the development and provision of health care in many African countries. Although
Table 1. Links between elements of health sector reform and church health servicesexperiences
Health sector Linkage with church sectorreform element
Contracting Church hospitals in a number of countries have a history of subventionsfrom government sometimes formalized into a service agreement (seefor example the district designated hospital model in Tanzania) orcontract
Use of non-public The church health sector is already one of the largest single providerssector outside the public sector in many countries with potential for further
growth, and free of the political constraints of government servicesDecentralization This will lead to the need for new local mechanisms for collaborationand greater between the public sector and church organizations includingautonomy opportunities for the church organizations to be more involved in
planning. Church health services are used to autonomous working andhave experience to share. It also requires new resource allocativemechanisms to levels such as districts and from there to subventedorganizations
New forms of Church health services have many years’ experience of user charges asfinancing and in a form of revenue and this experience can be invaluable to the publicparticular user sector. Furthermore there is an increasing number of community basedcharges prepayment schemes operated by church health facilities which provide
a rich source of experience for the wider health sectorGreater use of Within the church sector there is wider experience of a variety of‘private’ sector different management. There may also be greater flexibility tomanagement introduce different management approaches potentially of use to thestyles private sectorNew prioritizing Church health services’ priorities will be related to their missionapproaches linked statement and their community rather than national policies.to minimum The State may both draw on NGO experience of differentclinical packages packages and potentially enforce their usageOrientation Experiences within the church sector of community participation andtowards users governance by local church body or officials may be of interest to public
sectorStronger, Some Christian Health Associations (e.g. in Ghana) have beenregulatory and developing quality frameworks and accreditation systems andpolicy frameworks have experience to share
336 A. GREEN ET AL.
Copyright # 2002 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2002; 17: 333–353.
church health services may be overlooked by health policy makers and indeed often
may seem to fit uncomfortably within broader NGO systems and structures, they
are probably the type of NGO most widely involved in health care, and especially
hospital care, in Africa today.
What is often forgotten is that, historically, the process of Christian mission and the
provision of health care were not always seen as related activities. Indeed, despite
devastating levels of mortality amongst both their own workers and the local popula-
tion, most missionary societies were slow to recognize the need for trained medical
people. Some missions actively resisted the involvement of medical workers.y
Nevertheless, from the beginning of the twentieth century and often much earlier,
mission personnel were often the sole source of allopathic medical care in many Afri-
can countries, particularly in rural areas.
Church-based medical care developed as part of the Christian mission ‘to pro-
claim the Kingdom of God and to heal’, (Luke 9:2) and the traditional mission sta-
tion included a church, a school and a hospital. But there were other motivations too.
Schulpen (1975, p. 100) suggests that these included:
* compassion for the people in need, out of pure Christian charity
* contact with the population, especially where verbal communication was difficult
* to look after the health of their own missionaries
* as a prestige object for the church
* to help build the ‘Kingdom of God’ and to establish ‘visible signs of God’s
presence’.
* as a source of income to finance other missionary activitiesz
There were variations between Christian Missionary societies in the precise
motivation to develop their medical work. Some considered the provision of medical
services to be merely a practical expression of their Christian faith; and as such
sought no specific returns for their altruism. Others held the view that medical care
could be used as a method of evangelism to bring individuals and communities to
belief in Christ. Because health care was seen as a means of promoting the faith,
many missions required all staff to be professing Christians, and prayers would be
said on the wards as well as in the chapel or church. Furthermore, the power of med-
icine to defeat demons and bad spirits was an argument for the power of the
Christian God and a strong motivational force for conversion; surgery and ‘miracle’
drugs were therefore the preferred mode of care, rather than preventive health work.
Finally, some organizations, many of which are still involved in relief and develop-
ment work today, considered it a social duty to meet medical or social needs, view-
ing health as a human right.
Irrespective of their motivation, important and often pioneering work was done by
medical missionaries such as Stanley Browne’s work on leprosy and Chesterman’s
ySee Brown (1992, pp. 233–239) for discussion of the difficulties encountered by those first wishing toinclude medical activities in Baptist Missionary Society work.zWhile these are mostly understandable, the last one may seem surprising in view of the financialdifficulties faced by most church hospitals now. But it remains the case that some church leaders stillexpect the hospital to be a source of income for other church activities; this may partially explain whysome church hospitals are so discreet about their external donor funding.
GOVERNMENT AND CHURCH HEALTH SERVICES 337
Copyright # 2002 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2002; 17: 333–353.
on sleeping sickness (Brown, 1992). Innovative practice was not restricted to clinical
medicine. Morley’s work on child growth monitoring was developed at the Wesley
Guild Hospital, Ilesha in Nigeria from 1956, but the hospital had developed a net-
work of village dispensaries from 1934 onwards (Pearson, 1996). Mengo Hospital in
Kampala developed, from 1919, a total of 23 rural maternity and child welfare cen-
tres (Billington, 1993). The training of medical orderlies, nurses and auxiliary health
staff was also an important service provided by some Church hospitals.
Missionary organizations grew significantly during the early part of the twentieth
century and by the time of independence were a significant part of the health care
services in many African countries. Matomora (1995) notes that, in 1971, Protestant
churches alone operated medical programmes in 81 countries, including over 1200
hospitals; in sub-Saharan Africa church hospitals provide a substantial part of the
service: 43% of medical work in Tanzania, 35% in Malawi and 34% in Ghana.
However, the independence movement in Africa in the 1950s and 1960s was par-
alleled by a similar desire to indigenize churches. In part this came from the parent
hierarchies, for whom it was driven by the commitment to the principles of devel-
opment and democracy. As Hastings comments ‘The older and better-established
churches, with few exceptions, were Africanizing hard in these years, at the same
time reducing missionary personnel pretty drastically’ (Hastings, 1979, p. 227). In
the case of the Roman Catholic church the process was greatly accelerated by the
‘aggiornamento’ which followed the Second Vatican Council in 1962. But as the
African clergy developed confidence supported by the flowering of black theology,
they increasingly expected to take charge of their own affairs. The Moratorium
movement in 1975 called for the withdrawal of all Western mission personnel and
resources from Africa ‘to allow the receiving churches a time for critical questioning
of the inherited structures . . . and to prophetically challenge their governments . . .on the evils of our dependence on foreign resources’ (Uka, 1989). In some countries,
such as Zimbabwe, some mission hospitals played an important role in supporting
the liberation struggle, a fact that has not gone unnoticed by government officials in
the post independence era (Green and Matthias, 1997).
Today, especially in Africa, these church health facilities continue to play an
important role in health care delivery with three significant changes from their origi-
nal foundation. First, they are part of a more complex array of health care providers
including central government, local authorities, private-for-profit providers, secular
NGOs and traditional practitioners. This has implications for their role both as pro-
viders and as policy influencers and for their relations with other agencies. Secondly,
as we have seen, most of these facilities are no longer owned, managed and staffed by
international missionary organizations, but by the national church or similar indigen-
ous body. Lastly, sources of funding have also changed, with a shift away from a
structure where the majority of external income comes from those motivated to pro-
mote religious activities, to one where there is a greater contribution from secular
sources such as bilateral and multilateral donors, international NGOs and national
government as well as user charges. Although such changes have been accepted as
inevitable by many organizations, they can be challenging to the autonomy of
churches and, in particular, individual missions are often still reluctant to align them-
selves with government. This may be for a variety of reasons including a mistrust of
338 A. GREEN ET AL.
Copyright # 2002 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2002; 17: 333–353.
government, a desire to retain autonomy or a belief that medical care remains an
important evangelistic tool. Although church health facilities are no longer isolated
and autonomous institutions representing the sole source of allopathic medical care,
many retain their erstwhile (though often untested) reputation for quality care, despite
the struggle to maintain previous standards with diminishing resources.
RELATIONSHIPS BETWEEN GOVERNMENT AND
CHURCH HEALTH SERVICES
We turn now to look at the current relationships between government and church
health services.
It is increasingly recognized that effective policy-making needs to involve stake-
holders outside the traditional government mechanisms, including NGOs of which
church providers are, as we have seen, a significant group. Historically, however,
such involvement has been minimal. For years many governments effectively
ignored church health services in their planning and funding of care, despite the
large proportion of health care resources that they represented. Church organizations
were also often mistrustful of governments. However, the 1960s saw the develop-
ment of national level coordinating bodies often known as Christian Hospital/Health
Associations, CHAs (such as PHAM in Malawi 1966 (now CHAM), CHAG in
Ghana, 1967, CHAL in Lesotho 1974). This was often as the result of initiative from
the Christian Medical Council which was established in Geneva in 1968 as part of
the World Council of Churches.{
The development of relationships between Government and church health ser-
vices at a policy level has been assisted by the establishment of such coordinating
bodies. They can engage in policy dialogue and funding negotiations with govern-
ment on a collective basis, as well as providing specialist advice and information
services to members and managing church drugs procurement and distribution. A
survey of CHAs carried out in 1999 provided useful comparative information about
their role and demonstrates the variations (see Tables 2 and 3).
One of the fruits of the establishment of CHAs was the development in a number
of countries of country-wide agreements on policy. The content of such agreements
has varied but usually includes the payment of government subsidy, often informally
recorded with no contractual obligations but sometimes framed in a written agree-
ment or memorandum of understanding (e.g. Ghana, Kenya). In Lesotho, for exam-
ple, the concept of a Health Service Area, in Tanzania and Zimbabwe, the agreement
of Designated District Hospital status for some church hospitals, provide for a hos-
pital to supervise all the community health services in its area, regardless of owner-
ship. This integration, or at least coordinated supervision, of service within a district
makes sense in circumstances of stretched resources, provided the hospitals are
{At the international level, a regular exchange of ideas and views between the CMC, and WHO, the leadUN agency, was developed. One product of this intercourse was the formulation of the principles of PHCin 1975, which was warmly welcomed by many mission organisations, perhaps more than bygovernments (Paterson, 1998).
GOVERNMENT AND CHURCH HEALTH SERVICES 339
Copyright # 2002 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2002; 17: 333–353.
Tab
le2
.K
eyin
dic
ato
rso
fse
lect
edC
hu
rch
Hea
lth
Ass
oci
atio
ns
Org
aniz
atio
nY
ear
Num
ber
of
Mem
ber
ship
No
of
%o
fnat
ional
hea
lth
Agre
emen
tor
Lia
ison
offi
cer
or
fou
nded
secr
etar
iat
hea
lth
un
its
serv
ice
pro
vid
edM
emo
ran
du
mo
fco
mm
itte
e
staf
f(fi
gu
res
are
Un
der
stan
din
g
app
roxim
ate)
Ch
rist
ian
Hea
lth
19
67
19
Cat
ho
lic
and
49
Ho
spit
als;
79
HC
s;4
0Y
esY
es,
Min
istr
yo
fH
ealt
h/
Ass
oci
atio
nof
Ghan
aP
rote
stan
tch
urc
hes
5tr
ainin
gsc
hools
Pri
vat
ese
ctor
Ste
erin
g
com
mit
tee
Chri
stia
nH
ealt
h1946
16
Pro
test
ant
churc
hes
14
Hosp
ital
s;20
HC
s;40
Yes
Yes
,li
aiso
no
ffice
rin
Ass
oci
atio
no
fK
eny
a(P
CM
A)
18
0þ
dis
pen
sari
esM
inis
try
of
Hea
lth
19
82
(CH
AK
)
Ch
rist
ian
Hea
lth
19
74
17
Cat
ho
lic
and
9H
osp
ital
s;7
5H
Cs;
40
Un
der
Yes
,co
nsu
ltat
ive
Ass
oci
atio
nof
Les
oth
oP
rote
stan
tch
urc
hes
4tr
ainin
gsc
hools
revis
ion
com
mit
tee
Ch
rist
ian
Hea
lth
19
66
27
Cat
ho
lic
and
18
Ho
spit
als;
10
Rura
l3
5In
pre
par
atio
nN
o
Ass
oci
atio
nof
Mal
awi
Pro
test
ant
churc
hes
Hosp
ital
s;120þ
HC
s
6tr
ainin
gsc
ho
ols
Chri
stia
nS
oci
alS
ervic
es1992
Appro
x27
Cat
holi
can
dP
rote
stan
t48
17
Des
ignat
edD
istr
ict
Com
mis
sion
of
Tan
zania
churc
hes
under
(CM
BT
)H
osp
ital
wit
hco
ntr
acts
Ugan
da
Pro
test
ant
1957
35
Pro
test
ant
churc
hes
17
Hosp
ital
s;115
50
Yes
,gen
eral
Yes
,hea
lth
poli
cy
Med
ical
Bure
auH
Cs
and
dis
pen
sari
esM
oU
and
Aim
ple
men
tati
on
nn
ual
Ser
vic
e-co
mm
itte
e
level
agre
emen
ts
Ug
and
aC
ath
oli
c1
95
7C
ath
oli
cch
urc
hes
27
Ho
spit
als
19
3
Med
ical
Bure
auH
Cs
and
dis
pen
sari
es
Ch
urc
hes
Hea
lth
19
70
32
Cat
ho
lic
and
30
Ho
spit
als;
66
rura
l3
0U
nd
erre
vis
ion
Yes
,re
gu
lar
con
sult
ativ
e
Ass
oci
atio
nof
Zam
bia
Pro
test
ant
churc
hes
HC
s;17
oth
erm
eeti
ngs
pro
gra
mm
es
Zim
bab
we
Ass
oci
atio
no
f1
97
49
Cat
ho
lic
and
79
Ho
spit
als;
46
HC
s4
5In
form
alm
utu
alY
es,
wo
rkin
gg
rou
p
Churc
h-r
elat
edH
osp
ital
sP
rote
stan
tch
urc
hes
agre
emen
tco
mm
itte
e
HC
,H
ealt
hC
entr
e;M
oU
,M
emo
ran
dum
of
Un
der
stan
din
g.
340 A. GREEN ET AL.
Copyright # 2002 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2002; 17: 333–353.
Tab
le3
.K
eyfe
atu
res
of
rela
tio
ns
bet
wee
nC
hu
rch
Hea
lth
Ass
oci
atio
ns
and
Gover
nm
ent
inse
lect
edco
un
trie
s
Fea
ture
sof
the
curr
ent
rela
tionsh
ip
Chri
stia
nH
ealt
hB
lock
con
trac
tso
f2
yea
rsp
rov
ide
fun
din
gsu
ppo
rtfo
rst
aff
and
oth
erex
pen
ses.
Bud
get
allo
cati
on
isfo
rmula
-bas
edco
nsi
der
ing
pop
ula
tio
n,
Ass
oci
atio
no
fw
ork
load
and
staf
fin
gle
vel
san
dis
rev
iew
edan
nu
ally
and
awar
ded
atth
eb
egin
nin
go
fea
chq
uar
ter.
An
nu
alD
istr
ict-
level
pla
nn
ing
and
bu
dg
etin
gG
han
a(C
HA
G)
sess
ion
sin
clu
de
CH
AG
and
oth
erst
akeh
old
ers.
Sta
nd
ard
ized
ann
ual
repo
rts,
QA
pla
ns
and
surv
eys,
equ
alst
aff
trai
nin
go
pp
ort
un
itie
s,co
mm
un
ity
adv
iso
ryco
mm
itte
es,
fee
wai
ver
s,an
dse
rvic
eex
clu
sion
sar
ein
clu
ded
inco
ntr
acts
.C
lin
ical
and
man
agem
ent
asse
ssm
ents
are
con
duct
edan
nu
ally
Chri
stia
nH
ealt
hC
HA
Kw
asre
stru
ctu
red
in1
99
7.
Are
aC
oo
rdin
atin
gC
om
mit
tees
are
giv
ena
gre
ater
role
inth
ep
lann
ing
,an
dm
on
ito
rin
gan
dev
alu
atio
no
fre
gio
nal
Ass
oci
atio
no
fh
ealt
hp
rog
ram
mes
.T
he
secr
etar
iat
isre
focu
sed
on
advo
cacy
and
tech
nic
alas
sist
ance
.N
og
over
nm
ent
gra
nts
hav
eb
een
rece
ived
sin
ce1
99
6.
Ken
ya
(CH
AK
)M
oH
set
up
join
tco
mm
itte
ein
19
59
tod
ocu
men
tre
lati
on
ship
.A
repo
rtp
ub
lish
edin
Nov
19
60
pro
vid
esg
uid
elin
esin
stan
dar
diz
ing
fees
,re
po
rtin
g,
gover
nm
ent
gra
nts
and
sup
po
rtto
trai
nin
gfa
cili
ties
.T
he
Hea
lth
Po
licy
Fra
mew
ork
stat
esth
atin
cen
tives
(e.g
.ta
xex
empti
on
,la
nd)
wil
lb
eo
ffer
edto
chu
rch
and
pri
vat
ep
rov
ider
sw
ho
serv
eru
ral
area
s.C
on
trac
tin
gis
also
bei
ng
pil
ote
d.
AL
iais
on
Offi
cer
isn
ewly
app
oin
ted
inM
oH
tore
late
wit
hch
urc
h/N
GO
pro
vid
ers
Chri
stia
nH
ealt
hG
over
nm
ent
sala
rygra
nt
tom
issi
ons
beg
anin
1984
(though
inco
nsi
sten
tunti
l1989).
Afo
rmal
agre
emen
t(M
oU
)w
assi
gned
in1991
and
has
bee
nA
sso
ciat
ion
of
rev
ised
3ti
mes
since
.C
HA
Lfa
cili
ties
enjo
yta
xex
emp
tio
n,st
aff
sala
ries
and
equ
alb
enefi
tsw
ith
gover
nm
ent
inex
chan
ge
for
man
agem
ent
of
50
%o
fL
eso
tho
(CH
AL
)L
eso
tho
’sH
ealt
hS
erv
ice
Are
as(H
SA
s)an
dre
gu
lar
rep
ort
san
dbu
dg
ets.
An
ewM
oU
excl
udes
cert
ain
cad
res
from
gover
nm
ent
sala
rysu
bven
tio
n
Chri
stia
nH
ealt
hC
HA
Man
dM
inis
try
of
Hea
lth/M
inis
try
of
Fin
ance
hav
eci
rcula
ted
dra
ftag
reem
ents
since
1992,
bu
tnoth
ing
has
bee
nfi
nal
ized
.F
or
aper
iod
of
Ass
oci
atio
no
f3
yea
rsth
ere
was
aH
ealt
hS
ecto
rC
oo
rdin
atin
gC
om
mit
tee
(un
til
12
/95
).G
over
nm
ent
reim
bu
rses
sala
ries
of
Mal
awia
nst
aff
of
CH
AM
un
its.
Du
tyM
alaw
i(C
HA
M)
exem
pti
on
isca
se-b
y-c
ase,
lim
ited
staf
fse
con
dm
ents
and
med
ical
do
nat
ion
ssh
ared
Ug
and
aC
ath
oli
cT
wo
UC
MB
ho
spit
als
serv
eas
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tric
th
osp
ital
s,o
ther
sas
sub
-dis
tric
th
osp
ital
s.T
hey
rece
ive
gover
nm
ent
sup
po
rtfo
rth
isfu
nct
ion
.G
over
nm
ent
Med
ical
Bu
reau
seco
nd
sst
aff
(med
ical
offi
cers
,m
edic
alas
sist
ants
and
tuto
rs)
and
pay
sth
eir
sala
ries
.D
eleg
ated
gra
nts
are
giv
ento
mis
sio
ns
by
gover
nm
ent
wh
ich
(UC
MB
)co
ver
on
ly5
%–
10
%o
fru
nn
ing
cost
s.C
on
dit
ion
alg
ran
tsar
eg
iven
for
spec
ific
PH
Cp
roje
cts.
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llab
ora
tio
nb
etw
een
UC
MB
and
gover
nm
entat
cen
tral
level
isver
ygood,
atdis
tric
tle
vel
the
rela
tionsh
ipis
var
iable
Chu
rch
esM
edic
alM
oU
was
sig
ned
inM
ay,
19
96
(in
acco
rdan
cew
ith
Nat
ion
alH
ealt
hS
erv
ices
Act
of
19
95
).H
osp
ital
sad
min
iste
red
by
the
chu
rch
esar
eg
iven
75
%o
fA
sso
ciat
ion
of
the
bu
dg
etal
loca
ted
toM
oH
ho
spit
als
of
the
sam
eca
teg
ory
.A
nn
ual
repo
rts
of
exte
rnal
do
nat
ion
sar
ese
nt
wit
hst
atis
tica
lre
po
rts
tog
over
nm
ent.
Zam
bia
Dis
tric
tH
ealt
hB
oar
ds
are
resp
on
sib
lefo
rp
lann
ing
and
imp
lem
enti
ng
PH
Cac
tiv
itie
sw
ith
inth
ed
istr
ict.
Sta
ffes
tab
lish
men
tso
fal
l(G
over
nm
ent
and
mis
sio
n)
un
its
shal
lb
eb
ased
on
nat
ure
of
serv
ices
pro
vid
edan
dw
ork
load
.C
on
dit
ion
so
fse
rvic
ean
dp
rom
oti
on
alcr
iter
iaar
eeq
ual
.P
lan
nin
gis
do
ne
join
tly
thro
ug
hD
istr
ict
Hea
lth
Boar
ds.
Dis
tric
t-le
vel
con
trac
tsar
ed
evel
op
edfo
rea
chin
stit
uti
on
det
aili
ng
bu
dg
et,
serv
ices
tob
ep
rov
ided
and
aud
itp
roce
du
res
Zim
bab
we
Gover
nm
ent
pay
s100%
of
staf
fsa
lari
esan
dre
curr
ent
expen
dit
ure
.G
over
nm
ent
seco
nds
som
est
aff
and
pro
vid
esm
edic
ine
and
med
ical
suppli
esto
all
Ass
oci
atio
no
fh
osp
ital
s.G
over
nm
ent
sup
po
rts
trai
nin
gsc
ho
ols
.C
hu
rch
pro
pri
eto
rsar
ere
spo
nsi
ble
for
acco
un
tin
gau
dit
s.C
hu
rch
hea
lth
un
its
are
tax
exem
pt.
Eig
ht
Chu
rch
-rel
ated
ZA
CH
ho
spit
als
are
des
ign
ated
asd
istr
ict
ho
spit
als
(DD
H)
and
rece
ive
add
itio
nal
gover
nm
ent
sup
po
rt.
Zim
bab
we
hea
lth
syst
emis
inte
gra
ted
,fe
eH
osp
ital
s(Z
AC
H)
char
ges
are
con
tro
lled
by
gover
nm
ent
for
all
pu
bli
c(g
over
nm
ent
and
NG
O/c
hu
rch)
un
its.
Sep
arat
eg
ran
tsfo
rap
pro
ved
inves
tmen
tp
roje
cts.
Gover
nm
ent
gra
nt
isre
du
ced
by
amou
nt
of
reven
ue
gen
erat
ed
GOVERNMENT AND CHURCH HEALTH SERVICES 341
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committed to PHC and have the expertise to supervise. Yet even where there are
agreements, the level of cooperation often depends on individuals. Mulanje Mission
Hospital (MMH), Malawi reports: ‘Especially in the PHC programmes MMH is ser-
ving its Health Delivery Area well . . . the governmental Mulanje District Hospital is
still responsible for all health centre supervision. Government is not ready to hand
over . . . Frequent changes of the post of District Health Officer lead to a decrease in
cooperation. It is hoped that this will improve soon’. (Mulanje Mission Hospital,
1998). In a recent study of 43 church hospitals in nine African and two Asian coun-
tries, 44% were functionally integrated or collaborating with government, and 56%
were working as private entrepreneurs (Asante, 1998).
To the external observer the CHA may present a strong and united front. Often,
however, a CHA’s policy is the result of complex negotiations between constituent
church members of the association, each with their own denominational ideology
and priorities, and each represented by a religious leader who may understand little
of the dynamics and dilemmas of health care. Indeed collaboration between different
denominations may be poor, with competition in some places for patients and poten-
tial converts. This has led to the anomaly still observable today in some places, of
similar facilities provided in the same location by different denominations. Different
denominations may also set up their own mechanisms for coordination and liaison
with government such as the Protestant and Catholic Bureaux in Uganda.
An association may also be weakened if not all members participate in a campaign
of action, as in Malawi in 1998 when most, but not all, church hospitals closed for a
period after Government failed to release staff salary payments. On balance, how-
ever, it seems likely that through the CHAs, church hospitals have consolidated their
position as national institutions and proper partners for Government.
Another potential mechanism for relations at the policy level is the wider NGO
coordinating bodies (both general and health specific) which exist in many countries.
These are often weak, however, and there is little history of significant involvement
by the church health sector in their activities.
Furthermore, such policy discussion with government as does take place has
focused on issues directly concerning the relationships between government and
church services, with fewer opportunities for discussion of specific health policy
issues on which churches may have particular views. Whilst one of the reasons
for this may be the lack of a more general mechanism for discussion of policies
between government and wider stakeholders, the lack of consensus between differ-
ent denominations on such matters as family planning, the use of condoms, and
abortion, may also hinder such discussion and indeed may be cited by government
as a reason for not working more closely with CHAs.
Irrespective of the national level, working relationships at the service level are
often good. Where the Health District or Health Service Area approach is in place,
as established for example in Lesotho, the contribution of each party may be opti-
mized. In a Health Service Area ‘each functioning hospital, regardless of affiliation,
is responsible for the technical organization and supervision of all the health activities
in its catchment areas’ (Fountain, 1990). Matomora, citing similar arrangements in
Zaire and Ghana, comments: ‘As a result of the cooperation and sharing achieved
in these countries, they can boast some of the most tenacious and resilient health
342 A. GREEN ET AL.
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districts reported in literature’ (Matomora, 1995). The Designated District Hospitals
in Tanzania (which include church hospitals) also have supervisory functions; while
relationships between government and other (non-designated) church health services
in Tanzania are less formal, the church health services are often involved in District
Health planning consultations. In Zimbabwe arrangements for formal contracting of
church hospitals worked effectively, although Mills et al. (1997) report concern ‘that
explicit contractual arrangements would damage the culture of missions that underlay
their good level of performance’. This concern may be overstated.
Elsewhere, as indicated above, collaboration seems to depend on the individuals
concerned rather than on structural arrangements. Relationships at an individual pro-
fessional level can be strong even in the absence of formal links. Competition,
despite the World Bank’s advocacy (World Bank, 1993), appears to be seldom a rea-
lity and, in circumstances where technical and professional resources are so scarce,
has few supporters, though as we have seen, there may be ‘competition’ between
different denominations for patients.
FACTORS AFFECTING COLLABORATION BETWEEN CHURCH
AND GOVERNMENT HEALTH SERVICES
As we have seen, health sector reform policies in many countries clearly stress the
importance of developing a greater public/private mix. What is less clear, however,
is the exact meaning of the policy and the relationships that are desirable between
the two sectors. Indeed it is increasingly difficult (partly as a result of such policies)
to demarcate between the two sectors. Green and Matthias (1997) develop a frame-
work (see Figure 1) for analysing interagency relationships which sets out a conti-
nuum. In this section we examine three key factors that affect the position along this
continuum and which inhibit or encourage positive relationships between the State
and NGOs: the organizational objectives; types of service, and in particular the roles
and location; and lastly, organizational culture and management styles.
Objectives
The prime rationale for service provision may vary between providers. State services
are primarily provided as part of Government’s responsibility to promote the welfare
of its citizens. As we have seen the original objectives for church health service pro-
vision varied, with some coming close to the welfare/rights model and others seeing
it as a vehicle for evangelism. Where there is congruence between the objectives of
the State and church then there is clearly a genuine opportunity for collaboration.
However, where there is significant divergence of prime objective this may present
Figure 1. The competition–control continuum (Green and Matthias, 1997)
GOVERNMENT AND CHURCH HEALTH SERVICES 343
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a genuine obstacle to collaboration with mistrust on both sides. There may also be
differences between attitudes over specific health objectives. Church health services
may also have a commitment to a local area and its objectives.
Types of service
The second potential factor encouraging or inhibiting collaboration is the similarity
or difference between the type of service offered, including its location.
Government hospitals are usually located in centres of population such as the
main district town. Church hospitals, however, are often located in more remote rural
areas and are visibly the only health care providers in that locality. Where a govern-
ment hospital and church hospital are close enough to have overlapping catchment
areas, it has been observed that patients may bypass a poorly resourced Government
hospital to seek care at a church hospital (Airey, 1989). This may lead to resentment.
Similarities in the type of service offered may make it easier for government to
understand the service; paradoxically differences and the resultant potential for
complementarity may be attractive. Many church hospitals have perceived the need
for preventive programmes in the communities around them. One example is
Ekwendeni Hospital in Malawi with not only community-based health care and
preventive health programmes but shallow wells and sanitation, communal grain
banks, credit and savings schemes, a fertilizer revolving fund and nutrition pro-
grammes involving fortified flour and micronutrients (Ekwendeni Hospital, 1998).
Some hospitals, however, retain the more traditional vision of healing, regarding it
as essentially a curative model of care—the van Lerberghe and Lafort (1990) model
in which the hospital’s role is defined as complementary to community health ser-
vices, providing a referral service and concentrating on excellence and quality of
care within the hospital.
The range of services provided may be affected by the policies of the governing
church body (the most frequently cited example being family planning services
which are not usually offered by Roman Catholic health services) and this may be
a point of contention with Government.
Organizational culture and management styles
Although church and government health services may have a superficially similar
structure and function, the culture and management style may be very different.
Government health services are often still governed by the civil service culture, with
a strong sense of hierarchy and procedure, of the importance of good records and the
health services’ standing within the community. Jobs are valued for status, for ben-
efits such as uniform, housing and pension rights, and possibly, given low salaries,
for the opportunities of unofficial practice or income generation. The administra-
tion’s concern is to keep the service going and to ensure it works as smoothly as
possible with good relationships internally and externally. Staff management and
patient welfare may be less high priorities. Budget and staff appointments will be
a source of concern, but as they often both arrive unpredictably from headquarters
it is likely to be a passive concern. The health service, whether supervised by the
344 A. GREEN ET AL.
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District Health Officer (or equivalent) or managed directly by the Ministry of Health,
seldom enjoys proactive management (though, for hospitals, the shift towards semi-
autonomous status should change this). The curative work is perceived as a technical
function performed by professional staff, for which the organization provides an
administrative context.
The strength of the government health service is its undisputed location as part of
the public system and the status of its staff as government employees; access to the
resources of Government such as Central Medical Stores, legal and audit services;
and an assumption of full funding from the State. The weaknesses frequently obser-
vable are those shared by all Government services when revenue funding is uncer-
tain and supervisory capacity is limited—a shortage of funds and material resources,
lack of management support and training, and a sense of isolation.
The church health service is likely to have a distinctive culture derived from the
religious organization of which it is part, and this will inform staff relationships,
the pattern of the day, planning priorities and charging policies—every aspect of
the organization. Management may be more proactive in directing activity, and in
obtaining external funding. It is noticeable that those health services with expatriates
on the staff seem to be more successful in attracting outside funding; the ‘sending
churches’ overseas often continue to assist the hospital even after former mission-
aries have returned home (Asante, 1998). In many health services there is a culture
of positive striving after high standards of care and concern for the patient’s well-
being; staff may perceive the hospital as a ‘therapeutic community’ in which all
members of the organization contribute to the supportive environment which facil-
itates healing. This is sometimes matched by a critical attitude towards neighbouring
health institutions which do not share the same perspective. The health services
might cover local costs from user charges, in urban areas especially, but it is more
likely to have several sources of income apart from user charges. Sources may
include government grant, government support in kind such as secondment/posting
of staff or provision of fuel, drugs, tax exemptions; gifts from donors in or out of
country; payments under pre-payment or community insurance schemes; funds from
income generation schemes, ranging from poultry and cattle-keeping to petrol sta-
tions, restaurants, office blocks. This diversity may be considered a weakness and
certainly challenges administrative capacity, but may also be seen as a strength in
that it spreads the funding risk over many areas.
Amone et al. (2000) reporting on a study of 10 Catholic mission hospitals in
Uganda, record that for all hospitals together the sources of revenue were: user fees
40%, delegated funds 10%, external aid 28% and other sources 22%.
The strengths of the church health services are perceived, especially by donors, as
being a capacity for efficient and ethical use of resources; a commitment to quality
of care even with limited resources; access to external funds and a diversity of
income sources; a sympathy with, and support from, the local community. These
are, however, only perceived as such; there is little hard evidence that church health
services are more efficient, and quality differences may be the result of higher
resource levels, including subsidized staff.
Church health service weaknesses are seen as their potential isolation from
national health policy and planning mainstream; subordination to an independent
GOVERNMENT AND CHURCH HEALTH SERVICES 345
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religious body with its own agenda; and dependence on Government for qualified
staff, for subsidy and sometimes other resources as well. Such organizational cul-
tural differences can lead to mistrust between government and church organizations.
One factor that may mitigate this (or in some circumstances heighten it) is the fact
that many civil servants have been educated in church schools.
KEY ISSUES AFFECTING THE FUTURE PATTERNS OF RELATIONSHIP
The final section looks to the future. It starts by examining the key changes likely to
be experienced by the health sector. It then outlines possible models for relationships
between the church and government sectors and ends by examining the implications
for the three key players—government, church providers and coordinating bodies.
The changing scene
It is observable in many countries that government/church health service relation-
ships are changing. At national level, relations, even where previously good, have
often become more difficult. A lack of trust, complaints about ‘lack of transparency’,
demands for more information as a condition of agreement often characterize cur-
rent relations. Finance is more difficult as Structural Adjustment programmes mean
governments have less money for subsidies or grants, while patients are less able to
pay for care. Government officials may complain that church health services do not
fully report donor funding when asking for Government grants and the suspicion of
double-funding or shadow accounting is raised. Church health services may com-
plain that agreed levels of grant subsidy are not paid, causing difficulties with pay-
ment of staff and suppliers. Where a formal agreement has never been signed, there
are calls for one as a demonstration of goodwill; where a Memorandum of Under-
standing has been signed, there are complaints that it is not being observed. Mechan-
isms such as regular joint meetings, a liaison officer in the Ministry, Government
representatives on the coordinating body, are effective when there are committed
individuals and high level support, but these are often lacking. From our experience,
the involvement of CHAs in national health planning and policy discussions is better
in some countries than others. For example they are closely involved in Uganda but
hardly at all in Malawi. In Nigeria, there is no relationship at all, either in funding or
in policy.
At individual health institution level conditions are also challenging. External
donor funds are harder to raise, and user fee income, especially in the rural areas,
is low; professional staff are hard to attract to rural areas, and costs, especially of
supplies, continue to rise. Meanwhile patient demand continues to rise reflecting
in part the growing needs of long-term conditions such as AIDS and TB.
One of the major factors affecting change is that of funding flows, sources and
levels. The future of the churches’ diverse and fragile funding seems uncertain. In
poor countries user fees are likely to continue to bring in limited income. Donors
may withdraw funds from individual church organizations or services in favour of
funding SWAps. Governments may reduce or remove subsidies. On the other hand,
346 A. GREEN ET AL.
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church providers may actually attract more funds in future because of their positive
reputation and the desire of the international community to fund institutions other
than public services. They may become recipients of decentralized SWAps budgets
(although perhaps with limited independence and subject to conditionality). They
may benefit from a possible global upswing in resources for health partly manifested
in the increase in private (both local and international) sources of charitable funding.
For countries benefiting from debt relief initiatives, additional finance may be avail-
able through government. There seems no reason why funding contributions from
church organizations and individuals overseas should not continue.
Even if more funding is available for church organizations to continue and even
expand their operations they are likely to face additional pressures. They may need
to conform to the priorities of government and the standards and norms including
accreditation and licensing set out by contracting authorities. There may be only
limited funds for being innovative, for example for controversial work, such as facil-
itating community ownership, which might not have clear health outcomes. They
may not be able to support and represent the poor if they have limited financial inde-
pendence and lack of commitment from the church hierarchy. They are also likely to
continue to find it difficult to recruit staff to rural areas. They may find difficulties in
harmonizing fee levels with government health services.
As well as changes in the health sector, future opportunities will also be very much
shaped by the particular nature of church organizations as religious entities. ‘Today
the Christian church is probably the most powerful institution in sub-Saharan Africa’
(Lamb, 1985). This position is not only due to historical influence but also to the
churches’ capacity for growth and change: ‘Christianity is assuming an increasing
significance in the creation of a modern, pluralistic African society’ (Gifford,
1998). The willingness of church leaders to act politically; the education of many
of the ruling classes at church schools, the international links between churches—
all these contribute to the regard in which many church organizations are held. But
this does not guarantee special status, much less secure funding, to church health ser-
vices. Indeed, increasing collaboration with government on a contractual basis may
further diminish their special position. Within the church, too, senior church leaders
may continue to lack understanding and knowledge of the key concerns and
dynamics of health policy and management; especially as health care becomes more
complex. This may explain a continuing traditional preference for hospitals rather
than primary health care. However, greater involvement in decentralized services
may offer church staff the opportunity to innovate and modernize, addressing local
needs—without opposition from a remote church hierarchy—so as to meet contrac-
tual or partnership obligations.
The role of the church hierarchy in overseeing health activities is also likely to
change. In some countries an active church leadership is mobilizing overseas
resources, initiating developments, linking health issues into wider development
concerns and taking a high profile in national negotiations. In others, church leaders
have little interest in health activities (except as a source of revenue) and seem to
resist change. In such cases the local church health services leadership will struggle
to respond to changing needs, and to develop partnerships across and outside the
health sector.
GOVERNMENT AND CHURCH HEALTH SERVICES 347
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The growth of other providers including other religions (Islam particularly) and
private for profit sector may add to a competitive environment for the churches;
again, one where they no longer are seen as special. Church providers, as a result
of adopting new models of health care, may become more business-oriented in a
competitive market and therefore it could be increasingly difficult to distinguish
them from the private for profit sector (Tibandebage and Mackintosh, 1999). Again,
this endangers the churches’ special status because they may be less value driven. In
such a situation, the poor are likely to suffer because of reduced access to more
costly, less appropriate services.
Models for relationships
The changes in the structure of health systems that was outlined at the beginning of
the article suggest various possible future models including the following which
move through a spectrum from minimal collaboration through a variety of models
of collaboration:
* Continued independence of church services with no formal relationship other
than NGO registration with government
* Continued independence but with a grant-in-aid from Government, either central
or local
* Collaboration between Government services and church services on the lines of
Health Delivery areas with shared supervision, shared responsibility for service
delivery and quality
* Collaboration in a formal partnership to provide comprehensive coverage across
the district
* A contractual relationship, either competitive or (more probably) negotiated, with
funding provided by Government for specific services and even specific levels of
service to be delivered by church health services
* Merger between government and church health services to integrate services for a
district population
* Nationalization by government of non-government hospitals (as in Nigeria in
1975).
While these two last options may seem less likely in the 2000s, it is significant that
a mission doctor, was quoted at a Medicus Mundi conference in 1999 as saying that
‘the choice for becoming part of the public health system [rather than privatization]
will probably mean, in the long term, that the distinctions between governmental and
church institutions may fade away’ (Verhallen, 1999).
The new models of collaboration outlined above offer a number of potential
opportunities for church health services but also potential threats.
As part of a decentralized system they can be included as active partners in local
level planning with the potential for greater involvement in policy and resource allo-
cation. In terms of organizational survival, they may find opportunities for increased
and more secure funding. Also, they offer possibilities for diversification into new
activities, exploiting the traditional role of the NGO in pioneering innovation in
service delivery, and thus generating new skills as well as scope for building new
348 A. GREEN ET AL.
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alliances and relationships. In terms of benefits to users, these models offer oppor-
tunities for more effective existing services as well as access to new services.
Increased effectiveness may result from better collaboration between health service
providers and the additional demands made of church providers in terms of account-
ability and quality assurance.
However, these potential gains are unlikely to be without a price. There is the risk
that too rapid or badly planned change may weaken the provider and damage the
quality of service. A contractual or integrated health delivery area relationship
may compromise the independence of the churches to implement their own policy,
by tying them to government financing and systems to such an extent that they are
unable to function without government. They may lose the benefits of their unique
style, becoming one of a number of homogeneous provider organizations.
If the preferred new model of health care is to identify church providers as desig-
nated health services and contractees for existing services there is a danger that there
will be reduced incentives for church providers to develop new PHC or other inno-
vative activities. On the other hand, it may be that models such as the integrated
health delivery area will offer incentives to churches to provide the most appropriate
services (i.e. combination of first and second level services) for the population they
have agreed to cover.
There may also be an opportunity for increased effectiveness as a result of the
SWAp model of donor support leading to closer integration of the church and gov-
ernment sectors. Increased access to donor funds through SWAps to fund activities,
joint planning, sharing experiences and resources may all lead to improved services
for users.
However, the channelling of funds through a central ‘basket’ may actually reduce
funding to churches rather than increase it. Donor funds, which were previously pro-
vided directly to churches may instead be channelled to the central basket and
decentralized government may choose not to fund churches. Where churches are
actively involved in planning and allocation of the ‘basket’ they may have a better
chance of benefiting from funds. However, a recent report (Foster et al., 2000) noted
that there has been limited participation of NGOs in the development of SWAps.
Reform may also offer opportunities to address the staffing difficulties faced by
many church providers. Higher government salaries and bonus systems may attract
staff to rural facilities (especially if church providers are currently pegged to govern-
ment pay levels). There may be scope to share good human resource management
and development practice—such as recruitment standards, performance systems,
human resource planning and training.
Churches may, however, need to look at ways of providing increased incentives to
meet the standards expected from contracts, regulation and quality assurance sys-
tems. Also, churches will need additional skills (in management) for implementing
new models of health care and for inputting into government policy mechanisms.
Lastly, some church providers have demonstrated a particular concern for the
poor. It is possible that the current interest amongst international donors in alleviat-
ing poverty will offer opportunities for new sources of funding though such funding
may have limitations. Funders may want to see results in the form of direct improve-
ments in health outcomes. However, church health staff working with communities
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may believe that more controversial empowering and enabling outcomes are key for
giving the poor a voice as a way of securing longer term gains in health (Edwards
and Hulme, 1995). Increasing donor awareness concerning participation and
empowerment of communities and the poor in health may offer opportunities for
churches to fund such projects. Already churches find it easier to secure donor sup-
port for PHC programmes such as nutrition support, than for curative care.
Implications for key actors
The above potential changes in the nature of the relationships between church and
state health services have implications for the various key actors which are outlined
below. For all the actors there needs to be a recognition that the past situation is no
longer tenable and that change is inevitable. What is then critical is the degree to
which each of the actors is prepared to shape future relationships in a pro-active
fashion, or is likely to adopt a policy of reactivism, or resistance to all change.
MINISTRIES OF HEALTH
For Ministries of Health, there needs to be broadening of the perception of the health
sector away from a focus on those public sector elements that were previously
directly managed. Strategic plans and policies on, for example, quality assurance,
or medical staff deployment need to foster consistent standards across both govern-
ment and NGO health units, and also incorporate clearly defined roles for NGOs
including church organizations. As such new tools, including both carrots and sticks
(Bennett et al., 1994) are needed. Changing attitudes towards the NGO sector are also
required. The development of policies and plans at all levels in the health sector need
also to be opened up to allow the views of key stakeholders such as church health
agencies to be heard. Ministries need to consider how to incorporate the key ingre-
dients to better relationships. Written formal agreements such as a Memorandum of
Understanding may be helpful. Top level political support from within the Ministry of
Health (or above) seems to be a deciding factor, and is linked to the need for mutual
respect (with or without formal agreements). Helpful mechanisms include a regular
liaison meeting and a designated liaison officer at the Ministry. Competent negotia-
tors (with the necessary authority to commit their organizations) need to be supported
by good information systems, both to provide detailed figures on human resources,
patient activity and finance, and also to communicate with constituent members who
need to be party to evolving agreements. At a more general level, a culture of partner-
ship rather than either a narrow public service focus or policing-style regulation needs
to be fostered.
CHURCH HEALTH AGENCIES
We have argued earlier that the churches in many countries are also facing signifi-
cant change. It is important that in the light of these changes, churches come to a
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considered understanding of their desired role in health, and communicate this to
government, entering into dialogue concerning relative roles and relationships. This
will inevitably mean compromising the independence of such agencies and opening
up their often closed decision and budget processes, but this is essential if churches
are to continue to provide a key role. Furthermore different denominations need to
develop greater cooperation despite differences of dogma if they are to present a uni-
fied policy front to government on common issues.
COORDINATING BODIES
The prevailing trend for devolution of health care services to district-level manage-
ment (whether by a District Health Team or an elected District Assembly), in laying
new responsibilities on the health services management, to work with Government
officers within the District, now calls into question the role of the national church
health coordinating body (CHA). It may no longer have a quasi-managerial role
in passing on policy directives and distributing money from central government
nor be the national voice and representative for all constituent units.
But in fact, especially for those CHAs who have always perceived their role as a
service to members rather than a management role, the new situation offers oppor-
tunities. Individual church health providers will be in need of specialist advice and
support, on information systems, financial management, quality systems; they will
still benefit from joint purchasing and procurement, for drugs and medical supplies;
and from central negotiation of tax exemptions and handling of paperwork; they
will still need advocacy with the policy community, a ‘presence at court’; they will
need an intelligence network, inter-district meetings, a forum for sharing of good
practice and good experience with government colleagues.
CONCLUSION
A number of aspects of church health services, including their relationship with
the public sector, are under-researched. Nevertheless, it is clear that church health
services, though neglected in policy analysis and research, have had and continue
to have a major role to play in health care delivery in sub-Saharan Africa. However,
there are challenges facing them, one of which relates to the relationships between
them and government, within a changing and uncertain external environment. Under
such circumstances it would be easy for governments and church health services to
follow their separate agendas. We would suggest, however, that this is not in the inter-
est of either party. Government has a responsibility to maximize the effectiveness of
all available health resources in the country. The significant role of the church health
services, which have a long history, is needed as much now as ever. Although funding
is perceived as a challenge, the mix of funding which most church health services
have evolved is actually more robust than a reliance on government funding as a
single source. Furthermore, the strong service ethos, concern for quality and good
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staff/staff and staff/patient relationships are critically important assets. The church
health services have much to offer and are essential to the future of health care.
Each party therefore, while developing its response to its immediate challenges,
needs to be actively exploring new means of partnership and fruitful collaboration.
The combined forces of the two sectors can go further towards achieving the objec-
tives of universally available and affordable health care, which both public and
church health sectors would acknowledge as their ultimate goal.
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