HEALTH SECTOR REFORMS IN SUB-SAHARAN AFRICA - LESSONS OF THE LAST 10 YEARS

Over the past 10 years the poorest countries, especially in Africa, ha ve struggled with worsening economic conditions and reduced public fin ance for health services. Some governments have responded in a pieceme al fashion, reacting to internal and external pressures. Others have e mbarked on major reforms of various aspects of their health systems. T his paper reviews two specific types of strategy that have been initia ted by governments: reform of financing strategies, and reform of publ ic sector organization and procedures. Particular attention is paid to the experience of introducing user fees, community financing and dece ntralization since these have been some of the most popular strategies . The paper describes the nature, objectives and extent of reforms. It then presents an evaluation framework related to the criteria of effi ciency and equity, and evaluates current reform experience using this framework. It concludes that assessment of the potential impact of ref orms on efficiency and equity is undermined by the limited duration of many reforms and the limited nature of existing evaluations. It is cl ear, however, that a policy package is required rather than implementa tion of isolated reform strategies, and that in order to design an eff ective policy package, more needs to be known about the implementation and operation of reforms - particularly with respect to the influence of context, actors and processes.