GETTING RESEARCH INTO PRACTICE:THE EXPERIENCE OF THE ‘SAZA’ PROJECT

An opinion piece

by

Jane Doherty,1 Lucy Gilson1,2 and Di McIntyre3

1. Centre for Health Policy, University of the Witwatersrand, South Africa.2. Health Economics and Financing Programme, London School of Hygiene

and Tropical Medicine, United Kingdom.3. Health Economics Unit, University of Cape Town, South Africa.

June 2002

Prepared for:“Establishing and Reinforcing Links between EC-financed Health Systems Research and

Technical Assistance/Development Projects”24–26 June

Department of Tropical Hygiene and Public Health, University of Heidelberg, Germany

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1. Introduction

Between November 1997 and April 2001 the European Union funded a research project which evaluated health financing reform in South Africa (SA) and Zambia (ZA). The ‘SAZA’ Project, as it became known, was funded through the European Union’s DG XII International Co-operation Programme,1 and involved five research partners, three from Africa2 and two from European countries.3 The South African component of the project examined the evolution of three high-profile policies during the first term of the first democratic government (1994-1999). These were the removal of fees for certain health care services (including primary health care), social health insurance, and the geographic re-allocation of budgets according to a population-based formula.

This paper recounts the experience – from the South African research team’s point of view - of trying to ensure that the project’s findings influenced policy-making. In doing so, the paper draws heavily on the findings of the project which itself scrutinised the relationship between technical analysts and decision-making in government.4 The aim of the paper is to contribute to ideas on how to maximise the appropriateness and impact of research relating to government policy, without stifling the independence and creativity that allows academic institutions to initiate innovative projects. The paper concludes by reflecting on how these ideas might be applied to the activities of donor-funded research and development projects.

2. Background

In 1996, when the proposal for the SAZA Project was drafted, South Africa’s first democracy was only two years old. Government was still transforming itself into a non-racial, quasi-federal system with nine provinces. The new health ministry (known as the Department of Health or DOH) was restructuring along these lines, whilst at the same time introducing major reforms that included the development of a district health system based on the primary health care approach. In this climate of intense policy development and implementation, a long-term, academic evaluation of a subject as impenetrable as health financing reform may have seemed somewhat of a quirky choice of project, especially as the project’s emphasis was less on the economic analysis of the design of reforms than on understanding the process of change.

Nonetheless, by the time results began to emerge in 1999, the new government was reflecting more generally on the successes and limitations of its first term in office, and strategic difficulties in pushing through controversial reforms had sensitised many in government to the problems of change management. The project was able to provide a

1 The European Union INCO-DEV contract number was ERBIC18-CT97-0218. The project was co-funded by the USAID-funded Partnerships for Health Reform Project and the South African Medical Research Council (MRC) through its support to the Centre for Health Policy as the MRC Research Group on Health Policy. Lucy Gilson, through her membership of the Health Economics and Financing Programme in the London School of Hygiene and Tropical Medicine, also received financial support from the UK’s Department for International Development.2 These were: Centre for Health Policy, University of the Witwatersrand, South Africa; Department of Economics, University of Zambia; and Health Economics Unit, University of Cape Town, South Africa.3 These were: Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, United Kingdom; and Institute for Health Economics, Lund, Sweden.4 See, for example, Gilson et al. (1999) and Gilson et al. (2001).

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comprehensive analysis of the actual or likely impact of health financing policies, and explain why certain reforms had succeeded whilst others had failed, pointing sometimes to problems in the design of a reform and sometimes to problems in the way a policy was formulated or implemented. Feedback from the eleven reviewers of the project’s draft report, and from a much wider range of government officials and independent analysts who accessed the final report, has been that the findings and recommendations were credible and useful. In this sense, at least, the project could be labelled ‘a success story’. The following section assesses whether the research results have had a demonstrable impact on the approach to policy-making in South Africa.

3. The impact of the project

To date there has been no independent evaluation of the project.5 The points that follow have simply been generated by members of the research project through a process of reflection. The discussion divides impacts into two parts, the first relating to impacts on policy, the second to impacts on capacity development. It is by no means claimed that the project has been alone in generating these impacts. Rather, the project has clearly been one amongst a number of mutually reinforcing influences on a changing environment.

3.1 The impact of the project on policy

It is relatively easy to point to the direct impact of research, that is, when it is instrumental in producing ‘changes in behaviour and practice.’6 However, research may also have a more conceptual use, contributing indirectly to policy by producing ‘changes in levels of knowledge, understanding or attitude.’Error: Reference source not found This sort of impact is harder to prove, because the role of research is only one amongst a number of influences. The SAZA Project has made both direct and indirect contributions, but the conceptual contributions may possibly have been the most important. As a whole, the project produced the first comprehensive analysis of financing reform. Apart from critiquing the content and impact of reforms, it demonstrated the key role played by contexts, actors and processes in shaping the particularities of health financing reform in South Africa. These features helped to capture the history of reform efforts, creating a rare form of ‘institutional memory’ in an environment where the mobility of skilled staff, both between sectors and within government, means that the lessons of the past are often forgotten. These features also provided frameworks for thinking about future reforms. If the SAZA Project had never happened, it is conceivable that the priority areas and mechanisms for intervention in health financing matters may have been far more difficult to identify.

In more specific terms, the project highlighted the fact that the actual or likely impact of certain reforms went contrary to stated government policy. Neither the resource allocation formula used by National Treasury to divide the government budget between provinces, nor the first official policy proposal on social health insurance (produced in 1997), did much for the reduction of inequity. In fact, the formula aggravated differences 5 However, Gilson (2002), as a key project member, speculates in some detail on the impact of the project, while an independent assessment of the project’s impact using interviews with key informants will be presented at this workshop.6 National Centre for Dissemination if Disability Research (1996), quoted in Gilson (2002).

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in government health care expenditure per capita between some groups. This information was presented directly to the Director General (Permanent Secretary) of the national Department of Health (DOH) and to his management team, clearly causing considerable concern and strengthening their resolve to review these areas of reform. The research team also made a submission on social health insurance to a commission of enquiry investigating issues related to social security. Indeed, the DOH has subsequently revised an aspect of the resource allocation mechanism (specifically the conditional grants that are top-sliced from the government budget before the application of the formula, which formerly led to the over-compensation of better-off provinces for their provision of highly specialised services and training). The social health insurance policy proposal has also emerged from the commission of enquiry in a different format. This may reflect some consideration of the critique developed by the SAZA Project, although certain important aspects of the critique have not been taken into account.

The SAZA Project also seems to have contributed to a growing appreciation by government of the need to prepare strategically for reform processes. This is reflected particularly in the current process to develop a comprehensive approach to interactions between the public and private sectors. The SAZA Project had identified the lack of a comprehensive policy on the private sector as a significant problem. It had also emphasised the need to prepare clear objectives for any reform process, to involve key stakeholders and to take a fairly long-term approach where large-scale reform is involved. These principles are certainly being applied in the case of the aforementioned process, and may also have influenced another current process reviewing the configuration and financing of highly specialised services. The commissioning of three stakeholder analyses relating to social health insurance and the re-regulation of the private health insurance industry is another example of how government has become more sensitive to the management of interest groups during the reform process.

Equally importantly, the lessons of the SAZA Project have had an enormous impact on the way members of the research team support current policy processes (such as the aforementioned policy framework guiding public-private interactions, which has seen direct involvement by SAZA researchers). Some of these researchers had been involved in past policy processes that were the subject of the SAZA critique. The project showed that the poor strategic and tactical skills of analysts working both inside and outside government had contributed to their inability to ensure that sophisticated technical analyses influenced policy makers.

A last, and smaller, intervention that the project has led to is the probable commissioning by government of new research into the levels of cross-subsidisation that exist within the health care system.

3.2 The contribution of the project to capacity-building

As will be discussed in more detail later, the SAZA Project was one activity amongst several that helped to improve the networking between the research units and the Directorate of Health Financing and Economics (DHFE) in the DOH. This had the end result of strengthening the capabilities of all three partners. Hopefully, the lessons – and even the methodologies used by the project (such as stakeholder analyses) – have improved the skill with which all three partners deal with new challenges. One of the researchers now heads the DHFE, while others of the original research team have

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begun to apply the lessons of the project to the development of a policy framework for interactions with the private sector. The SAZA Project has also proved a rich source of material for training materials for courses for post-graduates and senior managers. These are impacts on the local front, but materials summarising the findings of the SAZA Project as a whole have also been circulated quite extensively internationally with the aid of one of the co-funders of the project, the Partnerships for Health Reform initiative of USAID.

4. Factors facilitating the project’s positive impact

The factors that facilitated the project’s success, both in terms of the credibility of its findings and in terms of the diffuse impact that these findings seem to have had, can be grouped into those relating to the way the project was designed and staffed, and those relating to the evolving receptiveness of government to the information generated by the research institutions involved in the project. Some of these factors are presented below, together with recommendations for applying these lessons to other projects.

4.1 Features of the project itself

4.1.1 Timeliness of the project

Government’s attention is often focused on dealing with day-to-day management of services, or developing policies in response to immediately critical issues. Government often finds it difficult to engage in processes with a longer-term agenda, or to commission other groups to do so on its behalf. As an independently initiated effort, the SAZA Project was able, by being proactive, to ensure that highly relevant information could be generated by the time it was needed by government. This included an explanation of why the resource re-allocation process was not having its desired effects, and the critique of the 1997 social health insurance policy just as it was coming up for review. This feature of the project was largely dependent upon it’s location within academic institutions which are more generally able to conduct long-term analysis than government or, for that matter, consultancy agencies. In addition, these institutions had a long history of applied research and, indeed, involvement in policy development. This allowed them to ‘read’ the policy environment and identify key gaps in information appropriately. Lastly, substantial funding was made available to these institutions by an international funding community alert to the potential local and international contribution of this sort of research.

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Recommendations

There is a danger that, in seeking to make research relevant to policy, governments endorse only projects responding to immediate concerns and crises. Academic institutions have an important role to play in initiating more forward-looking research. Governments need to remain open to endorsing a wide range of research, including research that has a longer-term perspective, tests new approaches, and has less predictable outcomes. Donors have an important role to play in funding such research – and funding it adequately - as government sources are often focused on more immediate needs.

4.1.2 The creation of a sustainable and successful mechanism for consultation with government

The progress of the project was communicated to government throughout its lifespan, from the initial conceptualisation of the project, through to its closing stages. The initial channel of communication was through ad hoc meetings or telephonic and e-mail discussions with the leader of the DHFE.7 A second channel, which was eventually discontinued, was the creation of a ‘reference group’ involving the leader of the DHFE as well as another key person in government. It proved difficult to get these people to meetings because of constraints on their time.

A third channel that proved very successful, and has continued beyond the lifespan of the project, was the holding of regular meetings between the two research units involved in the project and several members of the DHFE, which grew steadily over the years. The first of these meetings was held to discuss the project formally once the methods had been developed in some detail (hence, there were concrete issues to review, such as the details of what to raise with key informants). The discussion proved fruitful and it was decided to continue with these formal meetings on a quarterly basis. Importantly, it was decided to expand the scope of the meeting to include a more general discussion of the work of the three units, as the need for this sort of liaison had frequently been raised in the past. The purpose of these more broadly defined discussions was to exchange information on what research was being done. It was hoped this would encourage research findings to be used more widely, avoid the duplication of research, exploit the synergies between the work of different units, and identify important gaps in the current portfolio of research.

This new format for the meetings improved communication between the three units dramatically. It created a sense that the range of health economics research in the country was becoming better understood8 and it allowed participants to get to know one another. Importantly, it promoted the exchange of ideas in a collegial atmosphere. Hitherto, researchers had tended to come into contact with the DHFE in contexts either of negotiating the terms of commissioned work, or of lobbying for certain policy options. The quarterly meetings allowed participants to put aside their respective ‘positions’ and institutional affiliations, at least to some extent.

Soon, additional meetings were being placed back-to-back to the more general meeting. As one of the research units was geographically distant from the other two units, and as generally participants had very full diaries, this improved the logistics and reduced the cost of getting together. One of the additional meetings became the quarterly review of what was known as the ‘capacity-building project’. This important project was commissioned by the DHFE and funded by the EU through a direct grant to government. The project required the two research units to conduct research that had the dual purpose of training young researchers in health economics and providing expert support to the DHFE. Work undertaken under this project had to respond to priorities identified jointly by the DHFE and the units, but specifically excluded brief and hurried pieces of 7 There were three different leaders during the lifespan of the project. 8 Historically, the bulk of health economics research in South Africa (particularly relating to national financing policy) has been conducted by the two research units involved in the SAZA Project. It is only in more recent years that substantial work has begun to be produced by other institutions and individuals, including government.

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work responding to crises in government. The project provided a direct mechanism for the research units to support government policy needs, and allowed the immediate implementation of some of the recommendations of the SAZA Project with respect to strengthening the working relationships between technical analysts working inside and outside government. A number of other directorates and senior officials in the Department have pointed to the emerging relationship between the three units as a ‘success story’ and have sought to establish their own links with academic institutions in order to reap similar benefits. Thus, the SAZA project acted as a spur to a more ‘institutionalised’ relationship between research units and government, although it was not the only factor responsible for sustaining this relationship over time.

4.1.3 The creation of a trusted team of researchers

One of the reasons why the quarterly meetings worked successfully was because the research team was trusted by government. The researchers had a long history of working towards reform, either in South Africa (in the apartheid era and subsequently) or in other developing countries. Their track record combined a tradition of good quality, applied research with trustworthiness in dealing with confidential issues, and a fairness in reflecting different points of view. This facilitated not only the quarterly meetings but also meant that easy access was granted to senior key informants, whether inside or outside government, even when their policy positions were known to be at odds with those of the researchers. The manner in which the interviews were conducted was important in maintaining the relationship of trust. Interviewers were courteous, and made it clear that they were genuinely interested in hearing ‘the story’ that the interviewee had to tell about his or her part in the policy process. Interviewees seemed interested in the project and appeared to enjoy the interview experience. The key informant interviews were a vital component of the research, as was the review of the first draft of the project’s report by a number of key informants and other individuals. Whilst the researchers reserved the right to make a final judgement on the interpretation of information, these inclusive techniques allowed the triangulation of ideas and undoubtedly added to the depth and specificity of the findings. The use of important

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Recommendations

One of the most important mechanisms for ensuring that research is appropriately tuned to government needs, and thus has a better chance of implementation, is the development of a good working relationship with government. While informal links are useful, a formal mechanism - such as a quarterly meeting which deals with a substantive agenda - provides weight and depth to such interactions, especially when a large and ongoing portfolio of work involves all the participants (given the limited number of health economists in developing countries, this is often the case). If these meetings are held in the spirit of collegial debate, they can be very successful. There are dangers inherent in such mechanisms, however. Working relationships that become exclusive could lead to unfair patronage by government of certain institutions and stifle the work of other institutions. If government becomes prescriptive in such meetings, the independence and objectivity of academic institutions could be compromised. Government and academics therefore need to make the objectives and limits of such meetings clear at the outset.

policy-makers as reviewers was also a successful mode of disseminating findings ahead of the project’s completion.

The fact that the researchers were trusted also meant that, once the research had been completed, they were granted easy access to senior policy-makers in order to make face-to-face presentations. Thus it was that the SAZA Project was able to present its findings in a personal meeting with the Director General (Permanent Secretary) of the DOH, to the management team of the DOH, and to the parliamentary committee tasked with scrutinising health care issues. These direct presentations were vitally important, but were supplemented with a range of other dissemination activities that targeted South African policy-makers, planners and providers, international policy-makers and funders, and members of the public (details are provided in the attached Annex).

4.2 The receptiveness of government to the project

4.2.1 Openness of government to constructive critique

Health economists in the DHFE were very open to discussing the limitations of government health financing policy. Initially this may have been due to the unusual circumstance that the leaders of the unit had each been trained at some stage in one of the research units (one of the leaders had even been an integral part of the SAZA Project), combined with the fact that they were themselves concerned about the limited ways in which health economics skills were being deployed within government. This openness remains, however, despite the growing size and influence of the DHFE, and the increasing diversity of past employment histories of its staff members. This reflects an ethos created by DHFE staff members themselves, as well as the leadership style of the DOH’s second Director General. This Director General has a particular bent towards critical self-reflection, and is unusually sensitive to health financing issues, having championed some major controversial reforms in the past. These traits within government are commendable given that the SAZA project – alongside a national health accounts exercise performed by the same research units – identified considerable shortfalls in the development and implementation of government policy.

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Recommendations

The usefulness and impact of research findings can be enhanced when researchers are trusted by government and other stakeholders. Trust is built up through a demonstrably sound track record and, on a current project, through research techniques that preserve the objectivity of the research whilst dealing sensitively with controversial issues and allowing the appropriate scrutiny of findings by stakeholders. Whilst foreign researchers bring invaluable insights to local projects, in some instances the location of local researchers – or of foreign researchers who have had long-term experience of local issues – in key positions in a research project may increase the acceptability of findings for local audiences. In their activities in recipient countries, donors should attempt to strengthen and extend local networks, as it is these networks that have a long-term presence in the country. Conversely, donors should guard against activities that contribute to breaking down the trust formed between local institutions and individuals.

4.2.2 The growing stature of the DHFE

When it was first set up, the DHFE did not have a major part to play in policy-making. The Directorate came into being a year after the new DOH was restructured, almost as an after-thought. This reflected the over-riding concern in government at the time with restructuring services on the ground as quickly as possible, with only a limited appreciation of the key part financing mechanisms play in achieving change. The Directorate was perceived to simply offer ‘accounting services’ and, with a shortage of skilled staff, was unable to undertake major pieces of analysis. The unit was also hampered by its position being relatively low down in the departmental organogramme, which isolated it from senior-level discussions and influence. To aggravate matters, the unit had few horizontal links to other DOH units working on related issues, such as hospital reform. As a consequence, most health economics advice during this period was channelled through expert committees set up by government (mainly to consider the issue of social health insurance) or through influential individuals who had the ear of certain policy-makers. The former mechanism offered only ad hoc opportunities to influence policy (and, as it turned out, the committees often held contrary opinions to the then Director General and Minister). The latter mechanism was even more unsatisfactory, as it side-stepped open debate.

With time, however, the DHFE strengthened its position within the department. This was partly due to the growing experience of the unit and the acquisition of a few more skilled staff members. The successful passing of a new and highly controversial Medical Schemes Act, which re-regulated the large private insurance industry, required the deployment of considerable technical and strategic skills and was important in raising the profile of the unit. Shortly thereafter, the assignment to the Directorate, for the first time, of an EU technical analyst had a further positive impact. This helped the unit to respond to day to day requirements whilst also taking on longer-term initiatives. The particular individual’s loyalty to the interests of the unit (and government more generally), and his openness to dialogue with outsiders, helped to strengthen the unit’s identity.

The growing ability and profile of the unit was mirrored by a growing appreciation within the rest of government of the centrality of health financing issues to the achievement of key societal goals. The DOH began to look more and more to the DHFE for advice, and to draw it more regularly into discussions on linked issues such as hospital reform. Despite its lowly position in the department, the unit began to have direct links with

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Recommendations

Openness in government to constructive critique is an attribute that can advance reform. The risks to government of openness - such as the political repercussions of admitting to failure - are less within an environment of trust. In a trusting environment, constructive debate tends to replace confrontation. Long-term working relationships between technicians based inside and outside government help to preserve openness, especially when both groups espouse common social objectives. The disadvantage of like-mindedness is, however, that alternative viewpoints might be neglected.

senior policy-makers. More than ever, the DHFE had become a functional route through which to channel ideas generated by activities such as the SAZA Project.

5. Limitations

Despite these positive developments during the life-time of the SAZA Project – which made it easier for the research team to access and influence government than it had been for other health economists in the past – there were a number of limitations on the project’s impact. Two of the factors more amenable to intervention are discussed below.

5.1 Weaknesses in the long-term strategy for dissemination of the project’s findings

Although the SAZA Project’s dissemination strategy was fairly exhaustive as far as research projects go (see the attached Annex), it was dwarfed by the extent and complexity of the findings. The project identified weaknesses in the design of two key reforms, both of which affected a number of stakeholders and at least one of which required action outside the DOH altogether.9 Further, the project identified major weaknesses in the processes through which financing policy had been formulated and implemented, and developed numerous recommendations – none of them simple – on how to remedy these problems.

Putting aside the issue of whether policy research can expect to have an immediate effect on policy, it would certainly have been beneficial to continue re-packaging the outputs of the SAZA Project in ways increasingly well-tailored to the needs of emerging

9 This was the resource allocation formula used by National Treasury to divide the government budget between provinces on an equitable basis.

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Recommendations

It is important to have appropriate channels for communicating research findings to influential policy-makers. At times these include expert committees. Expert committees have the advantage of allowing in-depth discussion of key issues which are difficult to address through the day-to-day workings of government, or which require the substantial involvement of people outside government. A limitation of these committees is, however, that they are ad hoc events and, unless supported by a policy champion within government, have no institutionalised mechanism for taking forward their findings. A more constant channel – and one that allows research to influence the daily evolution of policy - is communication of findings to an influential structure, such as a unit, within government. However, for research to be used effectively, it is important that this unit has sufficient skills, stature within government, and direct links to influential policy-makers. EU technical assistants can play a useful role in building the capacity of internal government units more generally, but specifically in bolstering their ability to take on long-term initiatives. This is dependent, however, on the way in which these technical assistants work, which is itself dependent on their personal motivations and attitudes.

policy processes, different levels of government (right down to health workers active on the ground) and the general public. This was not achieved, partly because of the capacity constraints of the research units involved (the project had a relatively small staff complement that was already over-stretched by other commitments) and partly because of the time and cost implications of disseminating information in a sophisticated manner throughout a complex health system. The development of training materials for post-graduate students and senior managers has gone some way, however, in providing a continuous mechanism for disseminating the ideas generated by the project.

5.2 Continuing problems with the profile of the DHFE

Whilst the DHFE has developed its profile within the DOH considerably, it is still hamstrung by its relatively low position in the departmental organogramme and the lack of structural linkages to other policy development and planning units. Due to changes in the Deputy Director General positions, until recently the only senior person with a knowledge of health financing policy issues was the Director General himself who, despite being highly appreciative of the importance of financing policy, is far too busy to provide sufficient time to engage with the issues in a sustained manner. For a while this led to a failure of confidence in the health economics skills and leadership within the department, particularly from the direction of the National Treasury. In dealing with the public health sector, Treasury needs to engage with high-level units that have the specific mandate of a senior policy-maker. As several of the SAZA project findings challenge the policy position of National Treasury, the lack of a powerful figurehead who can negotiate with Treasury may have been a major obstacle to taking the SAZA critique forward.

Linked to this problem is the fact that the DHFE has shifted its focus from broad financing policy to the more restrained environment of budget and expenditure analysis. This was partly a response to the more bread-and-butter issues facing the provincial level of government which is largely responsible for implementation. It was also a result of the flight of more controversial issues – such as medical schemes reform and social health insurance – into parastatal or supra-departmental structures. While more recently a new directorate has been created with a prime focus on social health insurance issues, this directorate is on a par with the DHFE in the departmental organogramme and also suffers from staffing limitations. The recent entry of the DHFE into the highly politicised arena of restructuring highly specialised services and academic medicine will

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Recommendations

It is often difficult for a research project to move beyond the initial dissemination of research findings to a more comprehensive strategy that borders on advocacy. This is usually due to resource constraints – such as lack of time and funding – but may also be because this does not usually fall within the role and capabilities of academic units. Donors could play an important role in finding mechanisms for extending the dissemination of ideas beyond the life of a project, and providing not only funds but also technical skills to support this process. These could include the development of more (and more accessible) written materials, the setting up of workshops and training opportunities, and the routing of research ideas into pertinent development projects, either locally or in other countries.

undoubtedly raise the profile of the unit again, as well as require it to move from the domain of technical analysis back into strategic policy formulation and implementation. As with the recent process initiated by the Director General to develop a comprehensive policy on the private sector, this may usher in greater opportunities for making use of the ideas generated by the SAZA Project.

6. Conclusions

Previous sections have reflected on the ability of the SAZA project to influence policy-makers, especially those within government. What has this to do with the development of mechanisms to improve links between EU-funded research into health systems, and the work of EU-funded development projects and technical assistants? First, this paper has shown that the development of clear channels for communication – and the formalisation of these channels – was a successful strategy employed by the project to improve the transfer of ideas. This must surely be an issue to consider when looking at the basket of EU-funded activities within a country. While the EU could itself actively build bridges between its different initiatives, the most appropriate point of contact might be through government structures. After all, it is government policy that EU-funded intitiatives are most often seeking to influence. In addition, linkages between EU-funded projects should not be the over-riding concern, but rather the creation of linkages between all research and development projects in the interests of a country’s development.

The effectiveness of channels of communication depends, however, in large measure on the credibility of the people who utilise these channels. Technical credibility is important, and a long track record helps in this regard. Equally important, however, is the level of trust built up between analysts working inside and outside government. This trust cannot be immediately conjured, and is dependent both on the passage of time as well as the dynamic interactions between personality types, perceived personal and institutional objectives, and the relative power and influence of different players. Donors, and the foreign technical assistants or consultants that they fund, have immensely important roles to play in supporting the evolution of policy in developing countries, but are faced with the tricky challenge of building trust in environments where – at least as individuals – they are largely unknown entities. Donor-funded projects and technical

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Recommendations

Health financing policy is one of the broadest policy domains, touching on many aspects of the health system and challenging the interests of numerous stakeholders. As such, government analysts need to be technically skilled and strategically astute, and wield considerable power, either directly or through a policy champion. Research, and donor-funded development projects and technical assistants, can help to strengthen government units, but are also dependent of these unit’s inherent power for the implementation of their recommendations. The continuing demands placed on governments’ analytic capacity also speak to the need to preserve the long-term capabilities of units working outside government. Academic units often have a stable, long-term presence in a country and are able to ensure that important issues do not slip off the policy agenda.

assistants come and go, hence the importance of using donor-funded activities to strengthen local skills and networking capabilities.

Whereas communication could and should certainly be improved, it is seldom possible to achieve a complete alignment of interests. Indeed, it is the differences in style and opinion – and the fluidity of relationships over time – that may produce opportunities for ideas to coalesce around initiatives that bring about real change. These opportunities are notoriously slow in coming in the policy field, and sometimes the impact of research can be more readily identified as a gradual change in the mood and orientation of the policy environment. Even when the immediate policy environment remains refractory to change, ideas may be taken up in other contexts in unexpected ways. Thus, while every effort should be made to increase the direct use of research findings by governments, donors and other stakeholders, the subtle ways in which research may already have influenced ideas should not be under-estimated.

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ANNEX:THE DISTRIBUTION STRATEGY FOR THE SOUTH AFRICAN COMPONENT

OF THE SAZA PROJECT

Extensive distribution of the country report

The draft report was reviewed by 11 reviewers drawn from government and the local and international policy community.

The final report was sent, along with a separate executive summary, to carefully selected individuals in government and academia. A large number of reports were subsequently requested by a variety of people and organisations.

Lessons from the resource allocation and budgeting experience of the project were developed into a guide for legislators.

A report which extracted the information on social health insurance for a more targeted audience was published.

Negotiations are afoot with a British publisher to publish the report in book form. The cross-country report was published in a full version and a summary format, and

distributed widely to an international audience.

Presentation and discussion of findings with key interest groups

A draft of the country report was given to the government’s Directorate of Health Financing and Economics. A presentation of the findings was also made and verbal feedback was received on it.

The above process led to the setting up of quarterly meetings between the Directorate and the two South African research units which deal with the identification of key areas of research.

The findings of the report were presented to the Director General for Health (the equivalent of the Permanent Secretary). He arranged subsequently for the findings to be presented to the Senior Management Team of the Department of Health.

Key findings were presented to the Portfolio Committee for Health of the national parliament (the Chair of this Committee was also the guest speaker at the launch of the report).

Key findings were presented to two Provincial Department’s of Health. The executive summary of the project, together with an explanatory letter, were sent to the

Minister of Health. On request of the national Department of Health, a paper was prepared on the extent to

which present utilisation data informs the development of social health insurance. This request grew partly out of the project’s work.

Presentation of methodology and findings to the local and international academic community

For the overall study, which included the South African component:

A brief article on evaluating health financing reform appeared in the newsletter of the International Clearinghouse for Health Systems Reform Initiative.

A paper on the same topic was published by Partnerships for Health Reform. A brief presentation was made to the EU’s contract-holders’ meeting in 1998. A paper was delivered to the Third National Health Accounts Regional Workshop for the East

and Southern Africa Region. A special session on the project was presented to the International Health Economists’

Association in York (UK) in July 2001 (this included three papers on the project plus comments from a panelist and a discussion: two of the papers included aspects of the South African study).

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One article has been submitted to an international journal.

For the South African study:

A paper was delivered to the 1999 conference of the International Health Economics Association.

A paper has been accepted by the journal Social Science and Medicine. Two papers were presented in consecutive years to the main epidemiological and public

health conference in the region. Two papers were presented to Provincial Health Department workshops, and one to a

national department meeting. Articles on the project appeared in the newsletters of the South African Medical Research

Council, the University of the Witwatersrand and the University of Cape Town. Three academic seminars were held, two with the Department of Community Health of the

University of the Witwatersrand, and one with the Health Policy Unit of the London School of Hygiene and Tropical Medicine.

Three papers were presented at international conferences (the CERDI conference in November 2000 in France, the Asia-Pacific Health Economics Network conference in June 2000 in Bangladesh, and the American Public Health Association conference in 2000).

Five articles are in draft or outline form and are being submitted to international journals. The study was reported on in the newsletter of the London School of Hygiene and Tropical

Medicine’s Health Financing and Economic Programme, and also appeared as a policy briefing inserted into this newsletter.

Distribution of findings to the broader public

The retrospective country report was launched at a public event attended by approximatley 80 guests drawn from government and the academic community.

The executive summary of the country report was placed on the Website of the Centre for Health Policy.

A press release was sent to all radio, television and newspaper reporters interested in health issues.

An article on the findings was published in a widely read Sunday newspaper. The results were presented to the Parliamentary Portfolio Committee on Health. An article on Social Health Insurance was published as a chapter in the annual South African

Health Review 2000, which is widely read by health workers, managers, policy-makers, academics, donors and the private sector.

Use of methodology and findings in the development of teaching materials for post-graduate students and senior policy-makers

The study is being used in the development of teaching materials for the Masters in Health Economics of the University of Cape Town.

The experience gained in the study was used to develop case study materials and teaching sessions for the three-week regional course, “Health Sector Reform and Sustainable Financing: Challenges for Managers in African Countries”, and the ten-day regional course, “Senior Health Policy Seminar on Social Health Insurance”, mounted by the Health Economics Unit and Centre for Health Policy, and funded by the World Bank Institute.

The report is being used as the basis of some teaching for the Masters in Public Health of the University of the Witwatersrand.

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REFERENCES

Gilson L. 2002. Confronting equity in South Africa: the interface between research and policy. Keynote speech delivered to the second International Society of Equity in Health conference, Toronto, June 2002.

Gilson L, Doherty J, McIntyre D, Thomas S, Brijlal V, Bowa C, Mbatsha S. 1999. The dynamics of policy change: health care financing in South Africa, 1994-1999. Johannesburg: Centre for Health Policy, for the Centre for Health Policy (University of the Witwatersrand) and the Health Economics Unit (University of Cape Town)

Gilson L, Thomas S, Lake S, Mwikisa C. 2001. How can health exonomists influence health care financing policy debates? Poster presented to the International Health Economics Association Conference in York, United Kingdom, July 2001.

National Centre for Dissemination of Disability Research. 1996. Review of international literature on dissemination and knowledge utilisation. NCDDR: USA. (see http://www.ncddr.org)

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