international journal of health planning and management Int J Health Plann Mgmt 2002; 17: 333353.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hpm.685

A shared mission? Changing relationships between government and church health services in Africa
A. Green1*, J. Shaw1, F. Dimmock2 and Cath Conn1
1 2

Nufeld Institute for Health, University of Leeds, Leeds LS2 9PL, UK Regional Health Consultant, East and Southern Africa, Presbyterian Church, USA

SUMMARY
This article reviews the relationships between government and church health providers within sub-Saharan Africa with a particular focus on East and Southern Africa. This is of particular interest at this time, given the changing conguration of the health sector in many countries as a result of health sector reform policies. The article provides a historical overview of the development and emerging role of the church health services within this changing environment. The factors affecting the relationship between the government and church sector are identied. These include differences in objectives, types of service provided, and the organizational culture and management styles. The paper then explores key issues seen to affect the future pattern of relationships including the changing scene, and identies different models for relationships and implications for key actors including the Ministry of Health, church health agencies and coordinating bodies. The article concludes that church health services will continue to play a key role in health care in sub-Saharan Africa; however, there are challenges facing them and both parties need to develop a response to these. Copyright # 2002 John Wiley & Sons, Ltd. key words: 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 potential contribution of the non-State sector and the need to develop clear roles for, and relationships between, the different health care actors.

* Correspondence to: Prof. A. Green, Nuffield Institute for Health, University of Leeds, 7175 Clarendon Road, Leeds LS2 9PL, UK. E-mail: a.t.green@leeds.ac.uk

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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 signicant 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 signicant proportion of the overall health care. This paper focuses on this group of providers. It aims to explore their current contribution 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 conguration 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 publicprivate mix. However, though the analysis in the paper is illuminated by this particular experience, it is not conned 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 contribution of the church sector and its historical development. Against this background the paper analyses issues affecting collaboration between church and government services 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 environment within which the church is operatinghealth sector reform policies and funding 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 product of church experiences with community outreach programmesand 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.
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Both of these shifts led in the 1980s to greater policy interest in NGOs, in part related to their greater institutional exibility and their ability to cross sectoral boundaries. The nancial strains on the public sector faced by most African countries not only led the State to seek other sources of funding (World Bank, 1987) but also forced more active engagement with the non-State sectors 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 reconguration of relations between the church and public sector. The initial impetus for health sector reform as a specic named policy initiative can be traced back to the World Bank Development Report of 1993 (World Bank, 1993). During the rest of the past decade, a number 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 nancing 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 signicance concerns external funding ows. For the majority of church health services that originated as part of a wider missionary movement, there has always been a signicant level of external support whether in the form of direct grants or as contributions in kind, and in particular funded technical staff or equipment and drugs. Many churches found that indigenization led to a reduction in external supportas Hastings observed As the number of African bishops multiplied in the 1970s, the practicability of a successful appeal for funds from abroad greatly diminished (Hastings, 1979). This has caused signicant resource shortages for many church health services at a time when they face both demands for increased services and rising costs. It has also encouraged them to explore alternative sources of income generation which, when successful, has strengthened their nancial 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 provide 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
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Table 1. Links between elements of health sector reform and church health services experiences Health sector reform element Contracting Linkage with church sector Church hospitals in a number of countries have a history of subventions from government sometimes formalized into a service agreement (see for example the district designated hospital model in Tanzania) or contract The church health sector is already one of the largest single providers outside the public sector in many countries with potential for further growth, and free of the political constraints of government services This will lead to the need for new local mechanisms for collaboration between the public sector and church organizations including opportunities for the church organizations to be more involved in planning. Church health services are used to autonomous working and have experience to share. It also requires new resource allocative mechanisms to levels such as districts and from there to subvented organizations Church health services have many years experience of user charges as a form of revenue and this experience can be invaluable to the public sector. Furthermore there is an increasing number of community based prepayment schemes operated by church health facilities which provide a rich source of experience for the wider health sector Within the church sector there is wider experience of a variety of different management. There may also be greater exibility to introduce different management approaches potentially of use to the private sector Church health services priorities will be related to their mission statement and their community rather than national policies. The State may both draw on NGO experience of different packages and potentially enforce their usage Experiences within the church sector of community participation and governance by local church body or ofcials may be of interest to public sector Some Christian Health Associations (e.g. in Ghana) have been developing quality frameworks and accreditation systems and have experience to share

Use of non-public sector Decentralization and greater autonomy

New forms of nancing and in particular user charges Greater use of private sector management styles New prioritizing approaches linked to minimum clinical packages Orientation towards users Stronger, regulatory and policy frameworks

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 signicant role in the development and provision of health care in many African countries. Although
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church health services may be overlooked by health policy makers and indeed often may seem to t 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 population, 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 African countries, particularly in rural areas. Church-based medical care developed as part of the Christian mission to proclaim the Kingdom of God and to heal, (Luke 9:2) and the traditional mission station 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 difcult 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 Gods presence. as a source of income to nance 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 specic 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 medicine 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 development work today, considered it a social duty to meet medical or social needs, viewing health as a human right. Irrespective of their motivation, important and often pioneering work was done by medical missionaries such as Stanley Brownes work on leprosy and Chestermans
y See Brown (1992, pp. 233239) for discussion of the difficulties encountered by those first wishing to include medical activities in Baptist Missionary Society work. z While these are mostly understandable, the last one may seem surprising in view of the financial difficulties faced by most church hospitals now. But it remains the case that some church leaders still expect the hospital to be a source of income for other church activities; this may partially explain why some church hospitals are so discreet about their external donor funding.

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on sleeping sickness (Brown, 1992). Innovative practice was not restricted to clinical medicine. Morleys work on child growth monitoring was developed at the Wesley Guild Hospital, Ilesha in Nigeria from 1956, but the hospital had developed a network of village dispensaries from 1934 onwards (Pearson, 1996). Mengo Hospital in Kampala developed, from 1919, a total of 23 rural maternity and child welfare centres (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 signicantly during the early part of the twentieth century and by the time of independence were a signicant 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 paralleled 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 development 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 condence supported by the owering 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 ofcials 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 signicant changes from their original foundation. First, they are part of a more complex array of health care providers including central government, local authorities, private-for-prot providers, secular NGOs and traditional practitioners. This has implications for their role both as providers and as policy inuencers 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 indigenous 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 promote 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 themselves with government. This may be for a variety of reasons including a mistrust of
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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 stakeholders outside the traditional government mechanisms, including NGOs of which church providers are, as we have seen, a signicant 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 development 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 services at a policy level has been assisted by the establishment of such coordinating bodies. They can engage in policy dialogue and funding negotiations with government 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 agreement or memorandum of understanding (e.g. Ghana, Kenya). In Lesotho, for example, 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 hospital to supervise all the community health services in its area, regardless of ownership. 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 lead UN agency, was developed. One product of this intercourse was the formulation of the principles of PHC in 1975, which was warmly welcomed by many mission organisations, perhaps more than by governments (Paterson, 1998). Copyright # 2002 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2002; 17: 333353.

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Table 2. Key indicators of selected Church Health Associations

Membership No of health units % of national health Agreement or service provided Memorandum of (gures are Understanding approximate) 40 Yes Liaison ofcer or committee

Organization

Year founded

Number of secretariat staff

Christian Health Association of Ghana 16 Protestant churches 14 Hospitals; 20 HCs; 180 dispensaries 40 35 40 Yes

1967

19

Catholic and Protestant churches

49 Hospitals; 79 HCs; 5 training schools

Christian Health Association of Kenya 17 27

Copyright # 2002 John Wiley & Sons, Ltd. Catholic and Protestant churches Catholic and Protestant churches 48 50 9 Hospitals; 75 HCs; 4 training schools 18 Hospitals; 10 Rural Hospitals; 120 HCs 6 training schools Under revision In preparation Yes, consultative committee No 35 Catholic and Protestant churches under (CMBT) Protestant churches 17 Hospitals; 115 HCs and dispensaries 17 Designated District Hospital with contracts Yes, general Yes, health policy MoU and A implementation nnual Servicecommittee level agreements Catholic churches 32 Catholic and Protestant churches Catholic and Protestant churches 9 27 Hospitals 193 HCs and dispensaries 30 Hospitals; 66 rural 30 Under revision HCs; 17 other programmes 79 Hospitals; 46 HCs 45 Informal mutual agreement Yes, working group committee

1946 (PCMA) 1982 (CHAK) 1974

Yes, Ministry of Health/ Private sector Steering committee Yes, liaison ofcer in Ministry of Health

Christian Health Association of Lesotho Christian Health Association of Malawi

1966

A. GREEN ET AL.

1992

Approx 27

Christian Social Services Commission of Tanzania Uganda Protestant Medical Bureau

1957

1957

Uganda Catholic Medical Bureau Churches Health Association of Zambia

1970

Yes, regular consultative meetings

Zimbabwe Association of Church-related Hospitals

1974

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HC, Health Centre; MoU, Memorandum of Understanding.

Table 3. Key features of relations between Church Health Associations and Government in selected countries

Features of the current relationship

Christian Health Association of Ghana (CHAG)

Block contracts of 2 years provide funding support for staff and other expenses. Budget allocation is formula-based considering population, workload and stafng levels and is reviewed annually and awarded at the beginning of each quarter. Annual District-level planning and budgeting sessions include CHAG and other stakeholders. Standardized annual reports, QA plans and surveys, equal staff training opportunities, community advisory committees, fee waivers, and service exclusions are included in contracts. Clinical and management assessments are conducted annually

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Christian Health Association of Kenya (CHAK)

CHAK was restructured in 1997. Area Coordinating Committees are given a greater role in the planning, and monitoring and evaluation of regional health programmes. The secretariat is refocused on advocacy and technical assistance. No government grants have been received since 1996. MoH set up joint committee in 1959 to document relationship. A report published in Nov 1960 provides guidelines in standardizing fees, reporting, government grants and support to training facilities. The Health Policy Framework states that incentives (e.g. tax exemption, land) will be offered to church and private providers who serve rural areas. Contracting is also being piloted. A Liaison Ofcer is newly appointed in MoH to relate with church/NGO providers

Christian Health Association of Lesotho (CHAL)

Government salary grant to missions began in 1984 (though inconsistent until 1989). A formal agreement (MoU) was signed in 1991 and has been revised 3 times since. CHAL facilities enjoy tax exemption, staff salaries and equal benets with government in exchange for management of 50% of Lesothos Health Service Areas (HSAs) and regular reports and budgets. A new MoU excludes certain cadres from government salary subvention

Christian Health Association of Malawi (CHAM)

CHAM and Ministry of Health/Ministry of Finance have circulated draft agreements since 1992, but nothing has been nalized. For a period of 3 years there was a Health Sector Coordinating Committee (until 12/95). Government reimburses salaries of Malawian staff of CHAM units. Duty exemption is case-by-case, limited staff secondments and medical donations shared

Uganda Catholic Medical Bureau (UCMB)

Two UCMB hospitals serve as District hospitals, others as sub-district hospitals. They receive government support for this function. Government seconds staff (medical ofcers, medical assistants and tutors) and pays their salaries. Delegated grants are given to missions by government which cover only 5%10% of running costs. Conditional grants are given for specic PHC projects. Collaboration between UCMB and government at central level is very good, at district level the relationship is variable

GOVERNMENT AND CHURCH HEALTH SERVICES

Churches Medical Association of Zambia

MoU was signed in May, 1996 (in accordance with National Health Services Act of 1995). Hospitals administered by the churches are given 75% of the budget allocated to MoH hospitals of the same category. Annual reports of external donations are sent with statistical reports to government. District Health Boards are responsible for planning and implementing PHC activities within the district. Staff establishments of all (Government and mission) units shall be based on nature of services provided and workload. Conditions of service and promotional criteria are equal. Planning is done jointly through District Health Boards. District-level contracts are developed for each institution detailing budget, services to be provided and audit procedures

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Zimbabwe Association of Church-related Hospitals (ZACH)

Government pays 100% of staff salaries and recurrent expenditure. Government seconds some staff and provides medicine and medical supplies to all hospitals. Government supports training schools. Church proprietors are responsible for accounting audits. Church health units are tax exempt. Eight ZACH hospitals are designated as district hospitals (DDH) and receive additional government support. Zimbabwe health system is integrated, fee charges are controlled by government for all public (government and NGO/church) units. Separate grants for approved investment projects. Government grant is reduced by amount of revenue generated

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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 serving 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 Ofcer 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 countries, 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 CHAs 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 potential 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, however, 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 specic) which exist in many countries. These are often weak, however, and there is little history of signicant 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 specic 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 different 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 optimized. In a Health Service Area each functioning hospital, regardless of afliation, 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
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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 professional level can be strong even in the absence of formal links. Competition, despite the World Banks advocacy (World Bank, 1993), appears to be seldom a reality 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 difcult (partly as a result of such policies) to demarcate between the two sectors. Green and Matthias (1997) develop a framework (see Figure 1) for analysing interagency relationships which sets out a continuum. 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 Governments responsibility to promote the welfare of its citizens. As we have seen the original objectives for church health service provision 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 signicant divergence of prime objective this may present

Figure 1. The competitioncontrol continuum (Green and Matthias, 1997)

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a genuine obstacle to collaboration with mistrust on both sides. There may also be differences between attitudes over specic 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 government 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 programmes involving fortied our and micronutrients (Ekwendeni Hospital, 1998). Some hospitals, however, retain the more traditional vision of healing, regarding it as essentially a curative model of carethe van Lerberghe and Lafort (1990) model in which the hospitals role is dened as complementary to community health services, 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 supercially 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 benets such as uniform, housing and pension rights, and possibly, given low salaries, for the opportunities of unofcial practice or income generation. The administrations 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
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District Health Ofcer (or equivalent) or managed directly by the Ministry of Health, seldom enjoys proactive management (though, for hospitals, the shift towards semiautonomous 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 observable are those shared by all Government services when revenue funding is uncertain and supervisory capacity is limiteda 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 policiesevery 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 missionaries 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 patients wellbeing; staff may perceive the hospital as a therapeutic community in which all members of the organization contribute to the supportive environment which facilitates 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 stations, restaurants, ofce 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 efcient 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 efcient, 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
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religious body with its own agenda; and dependence on Government for qualied staff, for subsidy and sometimes other resources as well. Such organizational cultural 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 nal 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 playersgovernment, church providers and coordinating bodies. The changing scene It is observable in many countries that government/church health service relationships are changing. At national level, relations, even where previously good, have often become more difcult. A lack of trust, complaints about lack of transparency, demands for more information as a condition of agreement often characterize current relations. Finance is more difcult as Structural Adjustment programmes mean governments have less money for subsidies or grants, while patients are less able to pay for care. Government ofcials 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 complain that agreed levels of grant subsidy are not paid, causing difculties with payment 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 Understanding has been signed, there are complaints that it is not being observed. Mechanisms such as regular joint meetings, a liaison ofcer 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 reecting 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 ows, 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,
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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 benet 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 beneting from debt relief initiatives, additional nance may be available 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 facilitating community ownership, which might not have clear health outcomes. They may not be able to support and represent the poor if they have limited nancial independence and lack of commitment from the church hierarchy. They are also likely to continue to nd it difcult to recruit staff to rural areas. They may nd difculties 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 inuence but also to the churches capacity for growth and change: Christianity is assuming an increasing signicance 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 services. 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 needswithout opposition from a remote church hierarchyso as to meet contractual 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 prole 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.
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The growth of other providers including other religions (Islam particularly) and private for prot 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 difcult to distinguish them from the private for prot 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:
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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 specic services and even specic 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 signicant 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 allocation. In terms of organizational survival, they may nd opportunities for increased and more secure funding. Also, they offer possibilities for diversication 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
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alliances and relationships. In terms of benets to users, these models offer opportunities 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 accountability 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 nancing and systems to such an extent that they are unable to function without government. They may lose the benets 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 designated 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 innovative 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 rst 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 government 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 provided 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 beneting 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 stafng difculties 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 government pay levels). There may be scope to share good human resource management and development practicesuch 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 systems. 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 alleviating 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 improvements 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 nd it easier to secure donor support 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 government and NGO health units, and also incorporate clearly dened 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 ingredients 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 ofcer at the Ministry. Competent negotiators (with the necessary authority to commit their organizations) need to be supported by good information systems, both to provide detailed gures on human resources, patient activity and nance, and also to communicate with constituent members who need to be party to evolving agreements. At a more general level, a culture of partnership 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 signicant 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 unied policy front to government on common issues.

COORDINATING BODIES The prevailing trend for devolution of health care services to district-level management (whether by a District Health Team or an elected District Assembly), in laying new responsibilities on the health services management, to work with Government ofcers 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 opportunities. Individual church health providers will be in need of specialist advice and support, on information systems, nancial management, quality systems; they will still benet 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 interest of either party. Government has a responsibility to maximize the effectiveness of all available health resources in the country. The signicant 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 objectives of universally available and affordable health care, which both public and church health sectors would acknowledge as their ultimate goal.

REFERENCES
Airey T. 1969. The impact of road construction on hospital inpatient catchments in Meru. Social Sci Med 29: 95106. Amone J, Asio S, Cattaneo A, et al. 2000. Report of a research: user fees in private not-forprot hospitals in Uganda. Development and Health Supplement to 2, Padua Italy, CUAMM. Asante KO. 1998. Sustainability of Church Hospitals in Developing Countries. World Council of Churches: Geneva. Bennett S, Dakpallah G, Garner P, et al. 1994. Carrot and stick: state mechanisms to inuence private provider behaviour. Health Policy Planning 9: 113. Bennett S, McPake B, Mills A (eds). 1997. Private Providers in Developing Countries: Serving the Public Interest? Zed Books: London. Billington R. 1993. A Tune on Black and White KeysPartnership in Healing: The Story of Mengo Hospital. Janus: London. Brown SB. 1992. The History of the Baptist Missionary Society 17921992. Edinburgh: Clark. Cassels A. 1997. A Guide to Sector-Wide Approaches to Health Development: Concepts, Issues and Working Arrangements. WHO: Geneva. Edwards M, Hulme D. 1995. NGO Performance and accountability. In Non-Governmental OrganisationsPerformance and Accountability, Edwards M, Hulme D (eds). Earthscan: London. Ekwendeni Hospital. 1998. Annual Report. Ekwendeni Hospital: Ekwendeni, Malawi. Foster M, Brown A, Norton A, Naschold F. 2000. The Status of Sector Wide Approaches Centre for Aid and Public Expenditure. Overseas Development Institute: London. Fountain DE. 1990. In A New Agenda for Medical Missions, Ewert D, Merrill A (eds). International Monograph, 53. MAP International: Brunswick, GA. Gifford P. 1998. African Christianity: Its Public Role. Hurst and Co: London. Gilson L, Mills A. 1995. Management and health care reform in sub-Saharan Africa: lessons of the last 10 years. Health Policy 32: 215243. Green A, Matthias A. 1997. NGOs and Health in Developing Countries. MacMillan: London. Hastings A. 1979. A History of African Christianity 19501975. Cambridge University Press: Cambridge, 239. Lamb D. 1985. The Africans. Methuen: London. Luke 9:2. 1991. Holy Bible (New Revised Standard Version). Oxford University Press: New York. Matomora KSM. 1995. The district health systems approach. Contact 143: 714. Mills A, Hongoro C, Broomberg J. 1997. Improving the efciency of district hospitals: is contracting an option? Trop Med Int Health 2: 116126. Mulanje Mission Hospital. 1998. Annual Report. Mulanje Mission Hospital: Mulanje, Malawi. Paterson G. 1998. The CMC story. Contact 161/162: 4048. Pearson CA. 1996. Front-Line Hospital: The Story of Wesley Guild Hospital Ilesha, Nigeria. FSG Communications: Cambridge.
Copyright # 2002 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2002; 17: 333353.

GOVERNMENT AND CHURCH HEALTH SERVICES

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Schulpen TWJ. 1975. Integration of Church and Government Medical Services in Tanzania: Effects at District Level. AMREF: Nairobi. Tibandebage P, Mackintosh M. 1999. Managing and Regulating Mixed Health Care Systems: A Tanzanian Case Study in Comparative Perspective. Collaborative Approaches to Health Care Regulation: A Consultative Paper Based on Recent Fieldwork in Dar Es Salaam, Mbeya and Coast Region. Economic and Social Research Foundation. Group Behaviour and Development Workshop, Helsinki, 1999. Uka EM. 1989. Missionaries Go Home? Peter Lang: Berne. van Lerberghe W, Lafort Y. 1990. The Role of the Hospital in the District. WHO: Geneva. Verhallen M. 1999. MMI Partner Consultation Report on Updating Health Care Development Cooperation. Medicus Mundi International: WHO; 6. WHO. 1978. Primary Healthcare: report of the International Conference on Primary Health Care, Alma-Ata, USSR. World Health Organisation, Geneva. World Bank. 1987. An Agenda for Reform. World Bank: Washington, DC. World Bank. 1993. World Development Report 1993: Investing in Health. World Bank: Washington, DC.

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