Introduction

In February 2017, Dr. Matthew Opoku Prempeh was appointed Ghana’s Minister for Education. From the get-go, the President of Ghana, President Nana Akufo-Addo, tasked him with delivering Free Senior High School (Free SHS) in the country, a program that would provide free education, paying for a total of 41 items, including tuition, meals, textbooks, and boarding for Ghanaian children qualified for secondary education.

This task was challenging. More than 100,000 additional students, who should have been attending senior high school, needed to be absorbed into the system annually. Classrooms, dormitories, science labs, ICT labs, and workshops for technical and vocational education and training (TVET) were in short supply, in addition to teacher shortages and poor-quality teaching in the secondary education system. There was also political opposition. Many in the opposition cited infrastructure gaps and concerns over quality teaching as reasons why Free SHS should not be on the Ghanaian agenda at the time. Nonetheless, by September 2017, just seven months after his appointment, Dr. Matthew Opoku Prempeh launched Free SHS nationwide and, consequently, increased SHS attendance.

How did Ghana manage to deliver Free SHS nationwide so quickly? What lessons can other political ministers draw about leadership, resource mobilization, stakeholder engagement, and organizing for results? This case study, built from extensive conversations with Minister Prempeh and his collaborators, uses the Harvard Ministerial Leadership Program’s framework to unpack the strategies, challenges, and decisions behind the Free SHS program led by Minister Prempeh, while inviting ministers to reflect on how to apply these lessons in their own contexts.

Leading with Clarity

Minister Prempeh’s appointment was not a surprise; President Akufo-Addo pledged free secondary school in his manifesto. “In 2012, during the election petition, the President told me that if we won, he wanted me to be Minister for Education,” Minister Prempeh recalls. “When we finally won in 2016,” he said, “For you, I haven’t changed my mind.” Despite his background as a medical doctor, a path somewhat unconventional for leading a Ministry of Education, Minister Prempeh accepted the President’s challenge and the confidence placed in him to lead Ghana’s education sector and achieve the President’s vision.

President Nana Akufo-Addo’s mandate for Minister Prempeh was clear. “He had looked at his team and said I had the energy and intellectual depth to handle his most important legacy policy: free secondary education,” says Minister Prempeh. Thus, he went on to adopt the President’s goal as his own mission.

The following quote from President Akufo-Addo’s speech, when launching the free SHS program in September 2017, and as highlighted by Minister Prempeh, is what largely motivated him to ensure the success of free SHS:

“A government may not be able to make every citizen rich. But, with political will and responsible leadership, a government can help create a society of opportunities and empowerment for every citizen, and I know no better way to do so than through access to education.”

After his swearing-in to office, the first person Minister Prempeh spoke to about his role as a government leader was the President himself:

“I went to him for a series of engagements to help me get a deeper and better understanding of his vision for education in Ghana, in general, and the free SHS, in particular. I also had discussions with the Vice-President, Dr. Mahamudu Bawumia, who had been with and shared the President’s vision right from the onset in 2008. He indeed helped me reshape my thoughts and psych myself up for the task ahead.”

Moreover, Minister Prempeh immediately set expectations with the President. “I told him, ‘This is life-transforming. What I need most is your backing 24/7 until we get it done.’ He promised, and he delivered. The President was with me throughout, meeting frequently, even deciding what would go into the Free SHS package,” he says.

Minister Prempeh saw his role as Minister for Education as more than a job. “I was in politics for the long term. I could not fail. Failure would not only kill the policy but also destroy my career. I treated this as a mission, not just a position.”

Clarifying Priorities

Data available to the Ghana Education Service (GES) and the Ministry for Education, at the time, pointed to the fact that the biggest barrier to SHS (Secondary High School) enrolment in the country was financial. Many did not attend SHS because they could not afford its cost. This was evidenced by the enrolment rates analysis of pre-Free SHS data when disaggregated for learners benefiting from the Northern Scholarships, and learners in the Southern part of the country who were not beneficiaries of the scholarship or bursary.

TABLE 1: NORTHERN SCHOLARSHIPS ADMISSIONS AND PLACEMENT TRENDS

TABLE 2: SOUTHERN ADMISSIONS AND PLACEMENT TRENDS

Hence, “The free SHS was rolled out primarily to address inequality among students, through the removal of cost barriers whilst enhancing quality. We committed to creating a fair, safe and prosperous future for our citizens by providing equal opportunities for all,” Minister Matthew says. Moreover, to be effective in delivering free SHS, him and his team set four clear priorities and anchored them on four main pillars:

1. Removal of Cost Barriers: Remove cost barriers through the absorption of fees approved by the Ghana Education Service (GES) Council.
2. Access and Expansion of Infrastructure: Expand physical school infrastructure and facilities to accommodate the expected increase in enrolment.
3. Improvement in Quality and Equity: Improve quality through the provision of core textbooks and supplementary readers, teacher rationalization and deployment, etc.
4. Development of Employable Skills: Improve the competitiveness of Ghanaian Students to match the best in the World.

There is a reason why Minister Prempeh set priorities. From his perspective, priorities needed to be clear and set because “the goal was simple but massive”. This goal meant “full access to SHS up to age 18, at no cost, while maintaining quality. That meant new dormitories, classrooms, books, and teachers, all in months, not years.”

Moreover, these priorities drew on Ghana’s constitutional directive to expand free education as the economy allowed, and on global and continental targets, including SDG 4 (Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all) and the African Union’s Agenda 2063.

Defined Legacy Goal

Minister Prempeh and President Akufo-Addo did not just frame Free SHS as a policy. They framed it as a legacy that would shape their country. In Minister Prempeh’s words, “over 100,000 junior high graduates could not continue to SHS each year, primarily due to cost. In northern Ghana, where partial scholarships existed, only 11% of qualified students missed school. In the south, without scholarships, 35% could not attend.” Therefore, reducing cost and improving access to secondary education were a priority and the transformative legacy goal the minister wanted to achieve. His own experience growing up in Ghana motivated him to work on this goal. For him, “the shortest bridge [he] ever crossed was between poverty and prosperity, and that bridge was education. Without it, the gap is a gulf. With it, the bridge is short.” President Akufo-Addo said:

“By free SHS, we mean that in addition to tuition, which is already free, there will be no admission fees, no library fees, no science center fees, no computer laboratory fees, no examination fees, no utility fees. There will be free textbooks, free boarding, and free meals and day students will get a meal at school for free.” ¹

Defined Metrics and Delivery Unit

Minister Prempeh was appointed in February 2017, and Free SHS had to be launched in September 2017. With just seven months to launch, data monitoring and accountability were critical. Thus, Minister Prempeh constituted an advisory team, established a Free SHS Secretariat and a Delivery Unit, among other actions, to track every operational detail. He built these teams by closely collaborating with technical experts, such as Professor Kwasi Opoku-Amankwa, the Director-General of GES (Ghana Education Service), and indeed with heads of all the 26 agencies and their affiliates of the Ministry of Education. The GES is an agency under Ghana’s Ministry of Education that oversees the implementation of government policies to ensure that all Ghanaians receive formal education.

Together, “We built dashboards for each school,” Minister Prempeh explains. “We tracked classrooms, dormitories, textbooks, teachers, and feeding programs. We used a traffic-light system.”

Professor Opoku-Amankwa, who also acted as the technical advisor to the Minister for Education and the Government of Ghana on all matters relating to pre-tertiary education, explains how essential it was for the SHS Secretariat and delivery unit team to use data-driven tools to monitor free SHS outcomes and keep the program on track and accountable. He says:

“We put everything that we were doing into a table, and then we labeled them red, gold, and green. If it was green, it meant it was done. If it was red, it was outstanding. If it was gold, we were working on it, and we gave reasons for each status.”

This “traffic light” system created rapid feedback loops, with weekly updates to the Cabinet and, when necessary, escalations to the President’s office. It also created visibility across all program areas, from curriculum reforms and infrastructure development to teacher training and ICT rollout. By combining operational tracking (traffic light tables) with impact indicators (access, performance, and equity), the SHS program was able to identify gaps early, adjust quickly, and clearly communicate progress, setbacks, and program-related updates to stakeholders.

Cross-Collaboration & Stakeholders Mapping and Engagement

With a clear understanding of the President’s vision, and further details from the Vice President, Minister Prempeh’s next move was building a coalition across government and society to successfully implement free SHS. He says, “Ministers don’t connect to graphs; they connect to stories. So, we told a story about why Free SHS mattered, but we always backed it with hard data.” Therefore, he went on to have a series of engagements with virtually all colleague Cabinet ministers. He says:

“My view was that education affects and relates to all ministries. Every ministry has an input into education development. For example, I needed to secure the funds for free SHS from the Ministry of Finance. I had to talk to the Minister for Food and Agriculture on issues relating to food and manciple, while I talk to the Interior Minister on security and safety matters on our school campuses. There is a whole unit on school health programme in the Ghana Education Service. The unit works closely with a similar unit in the Ghana Health Service. I needed to talk to my colleague Health Minister, to ensure a seamless and collaborative work between the units.”

Professor Opoku-Amankwa added:

“The hon. minister used data and evidence-based research to effectively make a case for us all to participate fully in the President’s mission. Through a series of meetings and engagements, we developed a shared vision and implementation framework and communication plan to guide us. The hon. minister also communicated with us, the team, effectively the key objectives of the Free SHS and how free education has insured the success of many nations including the USA and most developed countries.”

Moreover, “The President himself met with the unions,” Minister Prempeh says. “We made sure everyone understood the vision, even if they didn’t fully agree.”

Minister Prempeh highlights the key stakeholders he included in this mission as follows:

1. “I also needed the buy-in of my caucus members of parliament and the leadership and communication team of the governing party – the New Patriotic Party (NPP).”
2. “I went beyond these internal party groups to engage the parliamentary committee on education.”
3. “I constituted an advisory team which included a group of eminent educationists, academists, technical experts and entrepreneurs, industrialists.”
4. “At the level of the ministry, I made sure we had a shared vision. I engaged and subsequently involved the leadership and management teams of all the twenty-six agencies under Ministry of Education. We worked together through a series of in house and out of office meetings to plan out the various reforms beyond the free SHS: curriculum reforms, teacher professionalization, infrastructure audit and upgrade, provision of logistics and equipment to support teaching and learning, enactment of enabling Acts of Parliament, etc.”
5. “The education sector unions and associations: GNAT, NAGRAT, CCT, CHASS, CODE, APTI, were all roped in.”
6. “The development partners – the World Bank, USAID, FCDO, (DfiD then), JAICA, etc., who are our key partners, were deeply involved right from the conception stage of our journey.”
7. “I equally engaged a good number of the civil society organizations in education, as well as those whose activities relate indirectly to education, were engaged.”
8. “As a strategy, I arranged for the leadership of the key stakeholders, such as the education unions, to meet and interact with the President on his vision for education and his national development agenda generally. These engagements helped a lot to ease the various agitations that were mounting.”
9. “Put the head of the union in the cabinet for them to understand that indeed this was government priority Number 1, and the whole cabinet was behind it, including the President, 100%.”
10. “The media was not left out. Beyond the periodic press conferences that were held to brief the media on the ministry’s activities. I tasked my deputies and agency heads to engage in frequent media programmes to inform and educate the public on the various reforms.”

A core reason Ghana’s Free SHS program succeeded was the deliberate strategy to map, engage, and coordinate stakeholders across every level of the education system.

This mapping was not just symbolic; each group was given a role in decision-making and communication. For example:

• Teachers’ unions brought representatives into program committees.
• School leaders (headmasters and headmistresses) participated through their associations.
• Parents and the media became partners in public updates.
• Retired educators and eminent experts formed advisory circles to shape vision and gather buy-in.

Professor Opoku-Amankwa added that “whatever vision was crafted became a shared vision. People were given various responsibilities, so it wasn’t just a government program, it became a national commitment.”

This approach also neutralized opposition and improved trust:

“We updated the public as frequently as we could. And with the unions involved, we had a seamless start.”

By mapping and activating 26 agencies under the Ministry of Education and multiple external groups, the GES and Ministry created a delivery network that could overcome skepticism, handle crises, and sustain the program beyond one government. Professor Opoku-Amankwa says:

“There wasn’t a single person who worked in the ministry who didn’t have something to contribute. Even the security person at the gate was expected to know the basics about the program.”

Political Navigation

Like in many countries, there was a strong political opposition in Ghana, and the opposition was intense. From Minister Prempeh’s perspective, “The opposition wanted to win the next election. They refused to support anything, held press conferences, and asked, ‘Where will students sleep? What will they eat? Where will you find the money?’ They even used my predecessor’s handover notes to highlight every gap.”

Infrastructure deficit was one of the pronounced challenges of the education sector in general, at the time the New Patriotic Party (NPP) took over the reins of government in January 2017. The opposition, then, the National Democratic Congress (NDC), argued that Ghana was not ready yet for the free SHS, insisting that free SHS could not be started because there was a huge infrastructure deficit that needed to be resolved first. But then, President Akufo-Addo and his government asked a simple question:

“Whose child should be left behind, while we build infrastructure to catch up?”

Minister Prempeh’s strategy was to out-communicate. “We met unions, parents, civil society, the press, anyone who would listen. We shared data, corrected misinformation, and gave regular updates. Because we had engaged early, people saw through the politics. By creating shared ownership, this goal gained legitimacy and avoided internal resistance.”

A key philosophy in Minister Prempeh’s leadership, according to Professor Opoku-Amankwa, was making sure every person in the ministry and every stakeholder could represent this program, even at the front gate of the Ministry. This ensured consistent messaging and built pride and ownership throughout the system.

In Minister Prempeh’s words:

“Criticisms were inevitable and were to be expected for such a grandiose pro-poor social intervention programme in a cash-strapped developing country such as Ghana. We were, however, resolved to execute the President’s vision of free SHS at all costs. We used the media more to educate and inform the general public on the importance of free secondary education. Perhaps we held more press briefings than any other ministry at the time.”

And delivery depended on trust and collaboration across diverse groups:

“Everybody who is a stakeholder was contacted, and they were represented in all the decisions that we made… teachers’ unions, heads of schools, parents’ associations, the media, and even retired professors and educators. Whatever vision was crafted became a shared vision,” Professor Opoku-Amankwa says.

By creating shared ownership, the program gained legitimacy and avoided internal and external resistance.

Delivering a nationwide program like Free SHS required more than plans, it demanded a mindset that treated every challenge as an opportunity to innovate, especially while dealing with multiple stakeholders. Professor Opoku-Amankwa described how a problem-solving culture, driven by the Minister and embraced by the entire team, became a cornerstone of their success:

“Anytime there was an issue, we discussed and found solutions. What he [minister Prempeh] was very much interested in was options… we would look at the strengths and limitations of each alternative before taking it to Cabinet for approval.”

This proactive, options-driven approach allowed the team to adapt quickly, whether it was managing unexpected over-enrollment through the double-track system or keeping education alive during the early months of the COVID-19 pandemic via Wi-Fi, remote teaching, and carefully managed schools reopening.

Ultimately, political leadership was decisive. “The President drove this himself. He didn’t just sign off; he chose the Free SHS package, defended it publicly, and ensured funding. Without that will, it would have failed,” Minister Prempeh recalls.

Key Levers: Infrastructure and Teachers’ Capacity

In Minister Prempeh’s words:

“The first thing I did was to put a team together to do a study to apprise me with the state of education in the country. This included a thorough infrastructure audit for the entire education sector, however, with emphasis on SHS. The handing over notes of the then outgoing Minister for Education, Professor Jane Naana Opoku Agyemang (current Vice President of Ghana), also listed a litany of infrastructure challenges.”

“On the basis of the audit report, I worked closely with the Ghana Education Trust Fund (GETFund) and other fund sources from our development partners, to construct over 800 senior high school infrastructural projects between 2017 and 2021, covering:”

1. 200 classroom blocks
2. 200 new dormitories
3. 350 science and computer laboratories were either newly built, retooled, reequipped or refurbished, and provided with requisite chemicals for practical work
4. Construction of TVET workshops and school administration blocks
5. 60 assembly halls, as well as dining halls, toilet facilities and teachers’ bungalows

“We equally provided furniture: bunk beds, classroom desks, laboratory equipment for all the newly constructed structures, as well as procured additional furniture for almost all the senior high schools. We also made provision in the free SHS budget for maintenance of buildings, furniture and equipment.”

“We also provided numerous resources and incentives to support teaching and learning:”

1. Math and Science training for SHS teachers
2. Core Textbooks: English language, mathematics, general science and social studies, for all SHS students
3. Special annual training for teachers in the four Core Subjects:
1. English
2. Mathematics
3. Science
4. Social Studies
4. Paid Teacher Motivation/Academic Intervention allowance to teachers
5. Remedial packages delivered to all students
6. Support for low-performing schools
7. On-time payment of subventions

“Our strategy was not on rural schools per se; the strategy was to look up for underperforming schools. The MOE, GES, and the development partners – the World Bank, under the ‘secondary education improvement project’ (SEIP) had identified about 30% of our secondary schools across the country as underperforming. The SEIP supported the schools with infrastructure, grants, and training in accountability for heads and programmes for teachers to improve teaching and learning.”

Resource Mobilization

The cost of Free SHS was around 450–500 million US dollars annually for subsidies, textbooks, feeding, and teacher incentives, plus hundreds of millions more for infrastructure.

Funding strategies included:

• Allocating 9% of Ghana’s oil revenues to education.
• Securitizing the GETFund, Ghana’s education fund, for infrastructure.
• Leveraging World Bank and development partner support.

These resources funded 200 dormitories, 200 classroom blocks, 350 science labs, 600 assembly halls, new furniture, textbooks, and teacher pay raises of up to 80%, alongside extra allowances for tutoring students who needed tutoring. Minister Prempeh explains that:

“The government made funding available from the oil proceeds. About 9 percent of the country’s oil proceeds were earmarked for free SHS and the education sector. However, to secure funds upfront, the Ministry of Finance accepted my proposal to securitize the Ghana Education Trust Fund (GETFUND) receivables to secure the Ghana cedi equivalent of USD 1,500,000,000. This move helped to raise funds to support infrastructure development and the provision of tools and equipment for the sector.”

Moreover, implementing Free SHS required significant financial, human, and institutional resources, often in the face of skepticism, even within government. In Professor Opoku-Amankwa’s words:

“Even within the Government, we had initial challenges. There were ministers, including the finance minister at that time, who thought that we were probably rushing. There were times that we had a feeling we were being denied the resources to run the place.”

Despite this, the Minister for Education found ways to secure the necessary support, Professor Opoku-Amankwa shared. “He found a way of going around to get the right resources to move the entire programme.”

Resource mobilization went beyond just budget allocations. The team activated multiple ministries and agencies to contribute:

• Ministry of Health for school health programs and food safety.
• Ministry of Agriculture to secure food supplies.
• Engineers and infrastructure teams to expand school capacity.
• ICT investments, including Wi-Fi installations, to sustain learning during COVID-19.

This whole-of-government and whole-of-society approach ensured the Free SHS program had the financial backing, facilities, human capital, and technical support it needed, even when resources were scarce or contested.

Organizing for Effective Delivery

As Director General of the Ghana Education Service (GES), overseeing over 350,000 teachers and staff and more than 6 million students, Professor Opoku-Amankwa described how effective organization was central to the success of Ghana’s Free SHS. “My duty was to ensure the seamless and successful implementation of any program or policy that the Minister and the Government put in place. I was almost like a co-pilot to the Minister as far as the implementation of the free SHS was concerned,” he says.

Professor Opoku-Amankwa coordinated a vast network of Regional Directorates, Directors, District officials, and School heads. He emphasized the importance of clear roles and communication. “We had about 700 secondary schools across the country. Regional Directorates, Regional directors, District directors, and then the Heads of the schools. All that structure had to be aligned.”

This structure allowed the GES to act as the implementing engine for policies, while the Ministry handled strategy and policymaking.

Minister Prempeh also credits the Harvard Ministerial Leadership Program for sharpening his approach to his role. After his appointment in February 2017, he was invited to the Harvard Ministerial Leadership Program in June 2017, where he participated in the Sectoral Ministers Forum to go through the Program curriculum and access its resources. Minister Prempeh took full advantage of the opportunity, and as he put it:

“Harvard opened my eyes to delivery units, stakeholder mapping, and rapid implementation. It showed me how to track every detail, so nothing slipped through. That’s how we launched Free SHS in just seven months. My participation in the Harvard Ministerial Leadership Program gave me top notched knowledge and skills in leadership, governance and management. I got the opportunity to hear and learn at first hand the success stories and the pitfalls to avoid from a wide range of current and former ministers from across the globe. The Program also provided a network and a pool of experts to contact in times of need. Overall, the Program gave me the needed confidence to execute my mandate as Minister for Education successfully.”

Moreover, Minister Prempeh credits his knowledge in project management for leading with clarity and organizing for effective delivery. He says:

“Planning, preparation, communication and teamwork, and various leadership principles and stories, and case studies from my Harvard Ministerial programme, came in handy. The ‘traffic light system’ helped me a lot to monitor and track progress of work.”

Results: Launched Free SHS

Free SHS outcomes validated the effort. Impact was measured not only by implementation milestones, but also by student outcomes:

“When the first Free SHS cohort wrote their exams in 2020, 411 of our students scored top ‘A’ grade in all 8 subjects, out of 465 in all of West Africa. Ghana won all top three positions of the 2020 and 2023, won second and third positions in 2021, and in 2022, won the first and second positions of the West African Examinations Council’s International Excellence Awards.”

The positive outcomes have also reflected in the academic performance of the first four cohorts of the Free SHS who completed in 2020, 2021, 2022 and 2023. Analyses conducted on performance trends in the core subject areas over a nine-year period, shown that the WASSCE results of the Free SHS 2020, 2021 and 2023 cohorts, scored above 50% in all four core subject areas, making their prospects for enrolment into tertiary institutions higher than in previous years.

TABLE 4: PERCENTAGE OF CANDIDATES OBTAINING A1 – C6 IN THE CORE SUBJECTS

Specific to the implementation of the Free SHS and the passage of the following two Acts were very significant: the Education Regulatory Bodies Act, 2020 (Act 1023) strengthened and enhanced the regulatory roles of the National Teaching Council, the National Council for Curriculum and Assessment, and the National Schools Inspectorate Agency. The Pre-Tertiary Education Act, 2020 (Act 1049), on the other hand, established the Ghana TVET service as a new agency to cater for the TVET sector. The Act also defined FSHS to include TVET.

In Professor Opoku-Amankwa’s words:

“Dr. Matthew Opoku Prempeh provided what I will call results-oriented leadership. He ensured that every team member had the resources required to enable them to deliver. He delegated effectively, monitored and did formative and summative evaluation of the programme. He devised what he called the traffic light system to effectively track implementation and the performance of each team member. Chaired meetings and gave support and guidance to the team.”

And because of the focus on this transformative goal and the strategic approach, Minister Prempeh says, “In the first year of Free SHS, dropout rates in the South fell to match the North. Over 100,000 students each year, who would have been on the streets were now in school.”

References

¹ Borgen Project. “Ghanaian Government Supports Free Education Program – the Borgen Project.” The Borgen Project, 5 Oct. 2017, borgenproject.org/free-education-program/.

Background

Over several decades, Nigeria has confronted major health crises characterized by a double burden of disease — preventable infectious diseases and a rising prevalence of non-communicable diseases (Li et al., 2022). Vaccine-preventable diseases, in particular, have contributed to the country’s high child and maternal mortality rates (Ophori et al., 2014).

Minister Muhammad Ali Pate was appointed Nigeria’s Minister of State for Health in June 2011. Before he was appointed Minister of Health, he served as the Chief Executive Officer of the National Primary Healthcare Development Agency (NPHCDA) for three years, made significant progress in improving Nigeria’s primary healthcare system, and initiated crucial health sector reforms during his tenure.

President Goodluck Jonathan appointed Dr. Pate Minister of Health to continue his previous work at NPHCDA. His mandate included improving efforts to eradicate polio and enhancing routine immunization. Initially focusing on polio, his goal as Minister of Health expanded to encompass child and maternal health through the Saving One Million Lives campaign. The Saving One Million Lives campaign by Minister Pate was developed to ensure that efforts to improve health in Nigeria also addressed other urgent health issues such as measles and malaria.

This case study explores how Minister Pate was able to navigate the fraught politics of Nigeria and win the support of the President, key Cabinet allies, and 36 state governors for a country-wide transformative health initiative.

Building a Guiding Coalition

When Minister Pate took office, there were rumblings of discontent regarding Nigeria’s health system, but health issues were not high on the national political agenda. Plus, given the decentralized nature of the health system, the Minister had limited control over how each of the 36 states spent their federal budget allocation. Although a significant part of the state budget came through federal allocations by a constitutionally determined formula, the fiscally decentralized federal system of government allowed states fiscal autonomy. The result was limited federal oversight or accountability regarding how much states allocated to health and how such resources were allocated. National Health Account data showed that most health resources were spent on politically popular curative facilities. These were often geared to the health needs of wealthy citizens. Even though the federal government had conceptually sound health policies, execution and enforcement at the state level were difficult.

Developing a Legacy Goal

Soon after taking office, Minister Pate assembled a core leadership team, led by a long-time trusted colleague, Dr. Kelechi Ohiri. With the support of his core team, Minister Pate reflected on the healthcare landscape in Nigeria to determine what he wanted to accomplish during his limited term of a maximum of four years. He said:

“I built a very strong team, including some I had mentored before, like Dr. Kelechi Ohiri. I chose people who were not only competent but had the right mindset and character attributes to help me deliver on our goals. As a Minister, very early on, you need to know what you want to accomplish. Build a good team, mobilize resources, and ensure everyone is accountable, including yourself. Focus on execution, or you will not achieve much.”

Minister Pate wanted to focus his agenda on something that would help Nigeria achieve something tangible, particularly given the multiplicity of problems within his main portfolio of primary healthcare. As he reflected, he realized that all around him was a culture of input-based thinking. Healthcare policy was made based on what else could be put ‘in’ to the health system. He wanted to shift the conversation to what was coming ‘out’ of the system, i.e., an outcomes-based approach. To drive this mindset, Minister Pate asked his ministry:

“What are we here for?”

When they thought about primary healthcare, saving lives was the most concrete outcome. The next step was to define ‘saving lives’ in a way that was easy to communicate. From this discussion, Minister Pate’s signature program, “Saving One Million Lives (SOML),” was born.

SOML was an aspirational target that was big enough but also tangible enough to focus people on the outcomes that matter and to work backward toward the inputs. SOML aimed to strengthen primary healthcare and prioritize interventions that could save lives, such as improving maternal and child health, eliminating mother-to-child transmission of HIV, strengthening immunization, scaling up access to essential medicines, controlling malaria, and improving child nutrition.

SOML built on existing policies outlined by the National Strategic Health Development Plan and the President’s Transformation Agenda rather than introducing new ones by way of strengthening existing delivery channels.

Minister Pate also used the Lives Saved (LiST) tool to prioritize the critical intervention areas that would contribute the most to lives saved. Based on this analysis, the six key priorities of SOML were improving maternal and newborn child health, eliminating mother-to-child transmission of HIV, strengthening routine immunization and achieving polio eradication, scaling up access to essential medicines, malaria control, and improving child nutrition. The underlying idea was that to save one million lives; the primary healthcare system would have to be strengthened by increasing health personnel, introducing performance management systems to increase health worker productivity, improving quality of care, and using information and communication technology for the supply chain management. By linking health systems strengthening to concrete outcomes, Minister Pate hoped that beyond saving one million lives, the benefits of these systemic changes would continue. Nonetheless, Dr. Pate realized that SOML’s success depended on the political will that supported it. This began with the President.

Working with the President

According to Minister Pate:

“When I started in 2008 as CEO of the Primary Healthcare Development Agency, it was polio that led the previous President to appoint me. To deal with polio and immunization, I had to build a primary healthcare system. By 2011, when the new President was elected, he asked me to join his government to build on the work I had started.”

Soon after his appointment as Minister of Health, Dr. Pate made sure to meet with President Goodluck Jonathan to thank him for the honor of appointing him to serve. In that meeting, he promised to serve the President with his very best and asked him for one thing in return:

“If I make any mistakes or if I am not doing something you really want, I want you to call me directly. And if I have a similar issue with you, I want to be able to come to you directly.”

This conversation formed the foundation for an effective working relationship and proved useful for the duration of Pate’s term.

To communicate SOML to the President, Minister Pate recollected what he knew about the President. Two key factors proved important. Firstly, President Jonathan had lost several siblings to preventable diseases at a very young age. Secondly, President Goodluck’s term had begun with a deeply unpopular move – the cancellation of longstanding subsidies to Nigerians on oil and petroleum gas.

Saving children from death and disease was something the President had a connection to, and the public was concerned about it, so it made for a compelling goal.

After the President’s support for the SOML campaign, Minister Pate provided monthly written updates to the President to regularly reinvigorate his political will and to maintain their connection. The President wanted to say that he had eradicated polio and ‘saved one million lives’ as part of his Transformation Agenda. His and Minister Pate’s legacies were aligned. Minister Pate said:

“Polio and immunization were embedded within the context of primary healthcare revitalization. We reframed the polio fight to include vaccines and saving the lives of children and mothers, rather than isolating it as a separate issue.”

Minister Pate gained this high-level backing by aligning SOML with the President’s personal experiences and the public’s needs.

Finance Minister

After the President, Minister Pate set his sights on bringing the Minister of Finance, Ngozi Okonjo-Iweala, on board with SOML. He knew Minister Okonjo-Iweala as a senior colleague from their time together at the World Bank, where she remained until her cabinet appointment. He had built on this pre-existing relationship with her by visiting her in Washington, DC, after her appointment but before her taking office. He also knew that during her previous tenure as Minister of Finance, she had been frustrated with the health sector because she did not have a clear sense of what had been accomplished with the funds she had allocated.

To get Okonjo-Iweala on board, Minister Pate had to stress the outcomes-based approach to SOML. Okonjo-Iweala was swayed by SOML’s clear definition of goals and deliverables because she could easily see and understand it as Minister of Finance. Thus, she was willing to support it. She asked Minister Pate to serve on the Economic Management Team and the Economic Management Implementation Team – two intersectoral working groups housed within her ministry. This was the first time the health sector was fully represented in such a body.

As part of the Minister of Finance’s Economic Management Team, Minister Pate gained a higher-level understanding of government priorities and connected with his colleagues on the team – including the Minister of Planning, the Director General of the Budget Office, and the Chief Economic Advisor to the President. He made SOML one of the key deliverables of the Economic Management Team, which further solidified their buy-in to its success.

Consequently, Minister Pate convinced both the President and the Minister of Finance to invest part of the money recouped from the cancellation of oil subsidies in maternal and child health to deliver results for the public. In September 2011, with President Jonathan’s and Minister Okonjo-Iweala’s support, Dr. Pate made a public announcement about defining his term with the goal of Saving One Million Lives in Nigeria.

Managing Stakeholders with Influence

With the support of the President, the Minister of Finance, and high-level officials from the Ministry of Health, Minister Pate moved to identify other key stakeholders that needed to be managed. Later in his career, he would learn more about using stakeholder analysis to explicitly map supporters and opponents against their level of influence. Still, at this time, he took a more intuitive approach. He maintained an internal inventory of the relationships he had cultivated and leveraged his social networks to forge connections with those who were truly influential, regardless of their positional authority.

Within his own ministry, Minister Pate had traditional authority by virtue of his position as Minister of State for Health, but this was supplemented by good relationships with the Federal Minister of Health (whose primary focus was on tertiary care and health insurance, among other areas), the Permanent Secretary, key directors, and the Primary Health Care Agency.

Nonetheless, within his own health ministry, Minister Pate sensed a feeling of “passive resistance.” The Health Ministry had traditionally taken responsibility only for the allocation of the federal health budget to states without monitoring the use of the state health budgets, with minimal state accountability and little regard for impact. At the outset, senior officials in the health ministry thought they could ignore Minister Pate’s SOML initiatives and “let it die on its own.” Nonetheless, Minister Pate persisted onwards with the higher-level health officials who formed his guiding coalition to prove to these opponents that SOML was not going away.

As SOML gained traction in the form of support from the President, the Finance Minister, and more state entities, and by raising substantial funds, the naysayers not only came on board but also began to be champions of the initiative.

As Minister Pate continued to work to achieve his mandate, he had a secret weapon on his side: the initiative’s name – “Saving One Million Lives.” By framing the program this way, opposing stakeholders, particularly those in the political sphere, had a challenging time voicing their opposition to “Saving One Million Lives.”

Engaging Governors and Community Leaders

Minister Pate leveraged his previous relationships with governors and community leaders to understand the importance of state-level cooperation, especially when it came to vaccinating citizens. He organized forums and secured commitments from state governors to support primary healthcare improvements. Additionally, he established the Northern Traditional Leaders Committee on Primary Healthcare to engage trusted community leaders in vaccination and health campaigns. He explained:

“When it came to vaccination hesitancy, we worked to earn the trust of communities and community leaders. We created the Northern Traditional Leaders Committee on Primary Healthcare, which engaged religious and community leaders across Northern Nigeria. This network became crucial in planning and implementing vaccination campaigns. To select the Northern Traditional Leaders, we went to the Sultan and asked him to convene a group of representatives from each of the 19 states in the North. The Sultan and a committee selected leaders who were relatively younger, stronger, respected, and trusted. We then organized them into a committee and enabled them to act effectively. To engage communities, we provided them with information and involved them in planning, which built legitimacy in the eyes of the people.”

As he had anticipated, Nigeria’s 36 state governors were key stakeholders whose support Minister Pate needed to save one million lives. Fortunately, Minister Pate had existing relationships with several governors and with the Director General of Nigeria’s Governors’ Forum. The Governors’ Forum had preexisting goals to eradicate polio and implement effective routine immunization programs as part of Nigeria’s 2009 Abuja Commitments to Polio Eradication. Minister Pate said:

“When I became Minister, it was easier for me to build on the relationships I had already established with the governors. As CEO of the Primary Healthcare Development Agency, I had worked closely with the Governor’s Forum, helping to organize their secretariat and getting them to sign the Abuja Commitment Declaration in 2009. This previous work allowed me to leverage those relationships when I became Minister.”

While this was helpful in aligning them with SOML, convincing them to relinquish their budget autonomy was still a challenge. Ultimately, the President had to play a significant role in bringing the governors on board.

The President asked the Governors to be accountable for progress in their states. Minister Pate’s team provided each state with a ‘Countdown to 2015’ one-page document summarizing how many lives the state could save by expanding specific services relevant to its context. This provided each state with its own baseline and endline target.

Once the states had pledged their commitment to their targets, Minister Pate’s team set up a scorecard system tracking progress state-by-state. The data comparing state performance was presented at the quarterly meeting of the Presidential Task Force on polio eradication, with the governors in attendance, presided over by the President, and quickly became a major incentive for the states to improve performance. Initially, some governors were uncomfortable with the pressure to be accountable and pushed back. However, according to Minister Pate, the measurement of performance became:

“An inflection point shifting the dialogue to focus on the data to its use in decision-making and results.”

Furthermore, the scorecards on state performance were published in newspapers. This decision was made to ensure that data collected from the public was ‘given back’ to the public and to further motivate state progress.

Finally, there were donors. Minister Pate needed donor support to generate more innovative ideas for technical assistance and strategy for the maternal and child health programs associated with SOML. Traditional and particularly non-traditional donors were eager to fund the initiative, and he was able to work with philanthropic foundations with flexible sources of funding to recruit world-class experts to help with ideation and design. He explained:

“As Minister, I was very active in mobilizing resources. I leveraged traditional domestic financing, multinational financing, and other sources to move the agenda quickly. We raised resources through innovative financing, which helped draw states in the direction we wanted.”

Implementing Strategically

As he worked to bring stakeholders on board, Minister Pate was invited to attend the Harvard Ministerial Leadership Forum in June 2012. This gave him the opportunity to learn about tactics for effective policy implementation and organization. In his own words:

“I was internally strengthening my hand while externally learning and strengthening relationships to succeed.”

The President officially launched SOML in Nigeria on October 16, 2012. The idea behind this campaign was a national rallying cry to end preventable infectious diseases and curtail infant and early childhood mortality. SOML had a strong brand identity (including a logo) and a deliberate communications strategy.

Minister Pate created a culture of collaboration and a sense of obligation amongst public and private sectors to do their part by positioning the campaign as a collective social movement across the nation. The communications strategy allowed key actors to pledge how many lives they would save – the private sector initially pledged to save 30,000, which later increased. Finally, and perhaps most importantly, SOML’s multichannel messaging plan created a sense of accountability to the people. This made it more difficult for state governments to allocate resources away from the program’s initiatives.

Once launched, Dr. Pate had to ensure implementation success. He needed some control over state-level health spending to ensure compliance with the national goals.

To this end, he introduced three key nationally managed elements to the program. The first was developing a robust data management system to monitor and evaluate performance. Historically, data had been collected independently at the state level, but in order to improve its reliability and comparability across states, he implemented a centralized data management system to enable the tracking of outcomes for the nationally outlined priorities. Furthermore, this data would be used for decision-making purposes regarding future state health budget allocations.

The second element was stewardship and stakeholder engagement. It involved introducing a steering committee housed within his ministry comprising representatives from federal and state government, professional associations, civil society associations, and donor groups. The goal of this committee was to enhance coordination through increased transparency and mutual accountability for the outcomes determined by the data collection. Pate chaired meetings with the steering committee every three months to review progress and ensure stakeholder alignment.

The final element introduced by Minister Pate was a program delivery unit, jointly accountable to the health and finance ministries, to support execution and ensure effective, high-quality delivery. This was led by competent professionals with a focus on results.

After Strategic Implementation

Minister Pate resigned in July 2013, confident that SOML was institutionally secure and embraced by his successors. By 2018, one million lives had been saved, and SOML had raised over US$1 billion in investments. The initiative had survived three Ministers of Health and fundamentally shifted the mindset towards primary healthcare. SOML’s principles were further institutionalized through a partnership with the World Bank, rewarding federal and state governments based on performance.

Looking back, Minister Pate was gratified by the adoption of outcomes-based thinking within the ministry and state governments. However, he reflects on areas for improvement, such as spending more time with state governors, consolidating information management systems, focusing on public sector supply chains, and integrating health insurance into SOML plans. His final reflection underscores the importance of strategic decision-making in complex systems:

“In a complex system, you cannot always fight in all directions. You have to choose which battles to fight and when.”

In 2020, “Nigeria was declared free of wild polio in 2020” (The WHO, 2023).

2023 Reappointment

In 2023, Minister Pate was again appointed Coordinating Minister of Health & Social Welfare, Federal Republic of Nigeria. He said:

“I’m refreshing and learning from every experience I have had. When I enter a new role, I treat it as a fresh start and apply the lessons learned from previous experiences, ensuring we build strong teams, mobilize resources, and maintain a clear focus on execution. In my current role, I quickly did a stock take together with my colleague the Honorable Minister of State, engaged with the ministry bureaucracy and agencies, and developed an agenda and blueprint. We are focused on saving lives, reducing pain, and producing health for all Nigerians. I brought in capable hands, the best I could find, to ensure we could deliver on our objectives.”

References

Li, Z., Shi, J., Li, N., Wang, M., Jin, Y., & Zheng, Z. (2022). Temporal trends in the burden of non-communicable diseases in countries with the highest malaria burden, 1990–2019: Evaluating the double burden of non-communicable and communicable diseases in epidemiological transition. Globalization and Health, 18(1). https://doi.org/10.1186/s12992-022-00882-w

Ophori, E. A., Tula, M. Y., Azih, A. V., Okojie, R., & Ikpo, P. E. (2014). Current Trends of Immunization in Nigeria: Prospect and Challenges. Tropical Medicine and Health, 42(2), 67–75. https://doi.org/10.2149/tmh.2013-13

The WHO. (2023, August 24). Protecting every child in Nigeria from poliovirus. WHO | Regional Office for Africa. https://www.afro.who.int/countries/nigeria/news/protecting-every-child-nigeria-poliovirus#:~:text=Nigeria%20was%20declared%20free%20of

Introduction

From 2002 to 2010, Colombia underwent an Educational Reform under the leadership of Minister of Education Cecilia María Vélez White, which strived to develop a more efficient system to ensure education access for all through tackling local union power and interests with firm and decisive actions (MinEducación, 2010).¹¹ This set the foundation for profound changes that to date have resulted in increased access to educational services from early childhood (reaching 646,188 children with comprehensive attention by 2009) to higher education (63% increase from 2002 to 2009). The number of students in pre-school, primary, and middle school rose from 9,994,404 in 2002 to 11,241,474 in 2009; quality improved in K-12 where dropout rates decreased from 8% in 2002 to 5.4% in 2008 and tertiary education certification increased with the number of graduate students graduating with masters degrees growing (6,776 in 2002 to 16,317 in 2008). In addition, the reform almost tripled the number of doctorate students from 350 to 1,532 in the same period; and led to the creation of information systems for improved data collection and problem solving. As with any large-scale transformation, a number of factors had to align to create a conducive environment.

Such was the case of Colombia during the two-term presidency of Álvaro Uribe Vélez, where the intentional political and operational strategy of the administration involved many confluent stakeholders aiming together for the same objectives. It is through this lens that this case study will examine Colombia’s education revolution with the ultimate goal of highlighting actionable strategies that current ministers can employ to facilitate their own institutional change.

Legislative Environment: Tools for a Reform

To understand the success of the Educational Revolution in Colombia, one first needs to analyze the process that began a few years prior to actual policy implementation. In the early 2000s, Colombia was living through a period of great instability caused on the one hand, by an ongoing armed conflict that had eroded its social tissue and blurred the lines of the State, and on the other hand of the biggest financial crises in its recent history. With a rapidly increasing deficit, Colombia had to commit to more efficient use of the nation’s budget. As a result of these contextual factors, President Andrés Pastrana introduced two key pieces of legislation in 2002, the last year of his administration, that laid the groundwork for Colombia’s Educational Revolution.

The first piece of legislation (Law 715) modified a previously instated decentralization process that changed the way resources were allocated. It “unified the budgetary allocation and the contributions to the national government’s revenue in a General Contribution System (SGP)” (MinEduación, 2010)¹¹ and shifted many attributions that had previously been conferred to the territories back to the national government. One of the consequences of these decentralization laws was that the implementation of educational policies was now the mandate of local Secretaries of Education. In cities where the population was greater than 100,000 citizens, new administrations were created with more ascriptions. The administration of education in rural areas also shifted from the national government and became the responsibility of the now enhanced local Secretaries of Education.

To help the President tackle the surrounding crisis, Congress authorized for extraordinary legislative powers to be attributed to the President to transform the educator’s career path. This led to the second big legislative change which had to do with the teachers’ promotion system. Previously, teacher salary raises were determined only by seniority (rather than by merit) and with increasing seniority each year, the system had become unpayable and urgent change was needed. Two different options were considered to deal with the salary situation: (1) the possibility of reforming a teaching statute seemed unlikely to find consensus among the union leaders, educator, education specialists, and the government due to the short time available, or (2) the introduction of a statute that would only be applied to new teachers entering the workforce with entrance exams and evaluation for promotion. A fast negotiation with a fragmented Teacher Union, which had internal problems due to unstable leadership and to the fact that many of its representatives in Congress were not grouped in a single front, but rather in several political parties, that doubted that the government would be able to move forward with a new proposal concluded with the introduction of a new and controversial teaching statute, the 1278 Presidential Decree (MinEducación, 2010).¹¹

Political Context: 2002 Presidential Campaign & Selection of Minister of Education

Concurrent with these legislative changes, Colombia was in the midst of a presidential campaign. At the time, both the business community and civil society were strong proponents of the idea that education should be a central piece of a Colombia that was forward looking. Colombia’s constitution mandated that the political platform and proposal of any presidential candidate that was elected became the basis for the national strategic plan. Knowing this, some representatives of the business community and civil society organized a series of dialogues and encounters with all presidential candidates in which they talked about their vision for the education sector moving forward. It was clear that stability was crucial, since the average term in office of a Minister of Education in Colombia had historically been only seven months. During these encounters, representatives from the sectors conveyed to all candidates that for a meaningful change in the education sector to take place, it was necessary for them to name a Minister that would stay in their position for the full length of the administration.

The presidential campaign saw the rise of a local politician whom many perceived as an outsider: Álvaro Uribe Vélez. He had won his nomination as an independent candidate without the formal support of a political party, and a strong stance against the FARC (Colombian Revolutionary Armed Forces). Uribe promised the business community and civil society that if he won, he would only name one Minister of Education for the full length of his administration. He ultimately won the presidency with over 53% of the vote and his allies won Congress in a landslide.

With presidential victory in hand, Uribe began his search for the ideal person to become the next Minister of Education. Cecilia María Vélez White emerged as the natural candidate. Minister Vélez had majored in Economics at the Louvain University in Belgium and pursued graduate studies in urbanization at Massachusetts Institute of Technology. Her experience at the Central Bank, the Ministry of Foreign Affairs, and the National Planning Department provided her with insights into both public administration and finances.

Vélez was a well-respected name in the sector due to the profound change she had achieved as Secretary of Education in Bogotá (1998 – 2002) during the government of Mayor Enrique Peñalosa, which continued with Mayor Antanas Mockus. During her time as Secretary, her team had been at the forefront of the decentralization process from a local administration perspective and had the opportunity to “pilot” some of the changes she would later implement at a national scale. She was able to create information systems to more accurately collect data on student enrollment, teacher attendance, and infrastructure tracking. She used this data to track school performance, identify infrastructure needs, and adjust teacher pay based on absenteeism. The results of her ministry’s interventions could be clearly seen in non-profit public education providers that operated in highly marginalized neighborhoods, known as Concession Schools. These schools saw improvements not only in standardized test scores but also in process indicators such as parent participation and school punctuality, which could be easily contrasted with those of nearby public schools who did not receive the same interventions.

In her role as Secretary, Vélez acquired an insightful perspective into the education sector and learned some of the strategies to negotiate with different stakeholders. Her management style and professionalism helped her consolidate a high-quality technical team that would continue with her throughout the years as Minister.

Given her track record of success in both leadership and implementation, President Uribe invited Vélez to become Minister of Education. While the emphasis of President Uribe’s administration was security and stabilizing the country, he was still a strong proponent of Minister Vélez and her education reform efforts for two reasons. Firstly, he was trying to regain spaces where the presence of the State had been lost and basic services had been impossible to provide due to the armed conflict. Secondly, his own management style was similar to that of Minister Vélez and thus they were able to work together easily. Thus, Minister Vélez began her term backed by a President with a very high approval rating who also had the cooperation of the majority of local authorities. This gave her significant political capital which eased the future implementation of the reform.

Leadership: Decisive Actions to Set Course

Minister Vélez came into her position with clear knowledge of the education sector and a vision to transform it. She knew she had to aspire to an ambitious set of goals that comprehensively shifted every aspect of the sector so she created a strategic plan with three main goals: to increase access, to improve quality, and to modernize institutions with the use of information systems. These goals were chosen to promote a robust system with higher standards to ensure a developed, egalitarian, and peaceful Colombia. The first period’s goal was to emphasize education as a social government policy with a strong focus on equality, and the second period would set the education policy as a cornerstone of competitiveness for the country (MinEducación, 2010).¹¹ But to start, she first needed to “put the house in order” in her ministry.

Minister Vélez and her team started doing this by reorganizing the structure of the ministry (Annex 1). The new organizational structure was based on functions and was meant to be supported by reliable information systems. To uplift morale and generate buy-in to this change, Minister Vélez focused on tangible, physical changes to the ministry as well. First, she turned a dated, bare-bones office environment with minimal technology into an open co-working space with more furniture and better use of space. Second, she instituted a “customer service system” [Sistema de Atención al Ciudadano – (SAC)] on the first floor of the ministry, which consisted of a one-stop shop for citizens to get help with accessing any Ministry services and provide feedback.

As the space changed physically, so did the culture of the Ministry. First, Minister Vélez recruited a strong technical team with significant expertise. She led by example to demonstrate the kind of work ethic she expected of her team. She was a strict leader who always came in at 7 a.m. and stayed in the office until the job of the day was done but she also wanted to show investment in her employees so she supported workforce training programs to improve capacity in digital literacy, results-based management, and other technical functions that could foster effectiveness and efficiency. Minister Vélez and her team were able to promote buy-in from all ministry employees through open and transparent communication and by creating channels and routines for direct communication with her. The first Monday of every month, she held a planning meeting with the most senior ministry officials: vice ministers, the secretary general, and ICFES¹ and ICETEX² directors. Every subsequent Monday of the month, she would open the meeting to first include directors from different areas for budgeting and planning; then to include deputy directors to follow up on project implementation; and finally the last Monday of each month would be an open conversation conference for all employees to share and discuss policy ideas.

Finally, Minister Vélez prioritized improved organization of data and use of information systems within the ministry. This started with better organizing archived information and ensuring systems were in place to appropriately store and use routinely collected data (Annex 2). It also included making sure this data was publicly available to ensure accountability to all stakeholders.

While many of these moves consolidated the efforts of previous administrations to modernize the sector, they also caused tension between the educators in the ministry who called for pedagogical accompaniment and felt that the focus on modernization was overlooking other critical areas in need of reform.

1 The ICFES underwent also an important change from being the “Colombian Institute for the Promotion of Higher Education” to becoming the Institute in charge of Assessing and Evaluating all levels of Colombia’s education.

2 Colombian Institute for Educational Loans and Technical Studies Abroad (Instituto Colombiano de Crédito Educativo y Estudios Técnicos en el Exterior, “ICETEX”).

Implementation: Collaboration, Data, & Communication as Tools for Success

When leading an institution such as the Ministry of Education one has to manage a number of different stakeholders both internally (e.g. ministry, Cabinet, President) and externally (e.g. local secretaries of education, teachers, unions, the business community, parents, students, etc.). Thus, a Minister’s scope of action to implement change is heavily impacted by her ability to dialogue and negotiate with different stakeholders and to convey well-tailored messages to address their varied concerns.

A key factor contributing to Minister Vélez’s success was her ability to coordinate and collaborate with the wide range of interests that surrounded the education sector. She was able to do this well because she ensured that she had access to timely data on which to support her decision making and communication. This evidence-based strategy allowed her to more effectively disprove misconceptions and provide accurate information where needed. In addition, and perhaps more importantly, it allowed her to acknowledge accurate faults identified by any of the stakeholders, so that she could also set a timeframe to respond to them and show indicators of progress.

Local Secretaries of Education

One of the most difficult challenges to overcome when working at the federal level was coordination with local entities. The decentralization process that Colombia was undergoing exacerbated some of these difficulties as local authorities had varying levels of capacity to deal with the new mandates for which they were now responsible. The Ministry of Education had to work closely with local authorities to make sure that education policies designed at the federal level could be implemented effectively. There were several mechanisms for this cooperation. The first one echoed the way in which the Ministry had achieved internal buy-in: communication. Every three months, summits were introduced and almost all the newly appointed education secretaries convened to discuss and learn about the changes that were being promoted at the Ministry. These summits also gave them the opportunity to share best practices from the federal level and across local levels, and to ask for the institutional help they needed in order to transform local capacity.

Even though the success with which the local authorities were able to implement the educational revolution was uneven (mainly because it also depended on the size and wealth of each of the departments and municipalities), there were incentives promoted by the ministry that supported a good degree of implementation. For instance, Law 715 not only changed the formula for the distribution of resources to the regions, but it also attached them to the number of students enrolled in each school. This was a fundamental transformation of the incentives and logic with which local authorities functioned; now they were forced to increase enrollment to get more resources. This policy of “money following the students”, plus a policy designed by Minister Vélez and her team to distribute additional resources to areas where the vulnerable populations were, helped promote the access in an unforeseen manner. It also created a new problem: “phantom students,” which gave the ministry additional incentives to create, promote and audit accurate information systems. To address this unintended consequence, the ministry had to confront the data systems it had with data from other governmental agencies and an auditing system implemented with the ICFES.

Higher Education Institutions

Legislation preceding Minister Vélez’s term had near autonomy of higher education institutions. This had led to a large increase in access to higher education (from 22% of the total students who graduated from high schools enrolling into tertiary education in 1992 to 46% in 2002) but was not accompanied by any oversight to ensure quality. To satisfy the need for more regulatory control and standardization, one component of Minister Vélez’s reorganization of the Ministry of Education was the introduction of the Vice Ministry for Higher Education.

This change was important because it elevated the importance of higher education to the vice-ministry level and institutionalized a state policy process into the creation of a National Accreditation Board composed of universities representatives. This allowed for important and constant dialogue coordinated by the Ministry between the presidents of private and public universities, professors, the business community, and student unions to co-create and define the standards and certifications that would govern them. Stakeholders felt heard in this process, and their feedback was documented in the ECAES3 series, where both positive, those who view it as an opportunity to add structure and to redesign their programs, and negative reviews, especially regarding fear of losing autonomy and more government incidence, from university presidents can be read. Universities were incentivized to participate in this change from a low regulatory environment to a strict, but voluntary, accreditation process because of the appeal and prestige associated with the government certification that would be granted to programs that were deemed to be high quality. The certification process sparked competition among public and private institutions, thereby creating a higher quality and better-regulated system in a short period of time.

3 Examen de Estado de la Calidad de la Educación Superior (State Exam for Higher Education Quality), which was later renamed SABER – PRO and is administered by the ICFES.

Colombian Educators Foundation (FECODE) Union

FECODE is Colombia’s largest teachers’ union and it has traditionally served not only to protect the labor rights of teachers in the country but also to contribute to education policy. Minister Vélez’s administration is still the only that can claim that during her eight years in office there was not a single general strike. Alongside a mutual understanding to place teachers’ wellbeing at the heart of policies that govern them, four main reasons contributed to such an atypical relationship between Vélez’s ministry and FECODE.

Firstly, as with other stakeholders, Minister Vélez ensured open and regular communication routines with FECODE with a clearly defined agenda centered on teachers’ wellbeing and working conditions. She instituted monthly meetings between herself, her senior ministry team, and the leaders of FECODE. In this meeting, she would share updates from the ministry on policy and implementation progress and listen to suggestions and complaints from the union. The Minister appointed her General Secretary to monitor the agreements that were reached in these meetings and to keep all parties updated on progress. This process allowed for constant advancement in the union’s efforts to protect teacher rights and was seen as a win for both sides.

Secondly, before taking office Minister Vélez negotiated with President Uribe that one of the requirements for her to become Minister was that the teacher payroll had to be up to date and disbursed on time. Since FECODE’s main goal is to ensure the labor security of its members, the fact that the Ministry was delivering salaries on schedule created a strong foundation for a fruitful and stable relationship.

Thirdly, Minister Vélez was in a politically fortunate situation. Her predecessors had recently passed laws instituting an admissions process to become a teacher and a merit-based teacher evaluation system. Despite regional resistance to some of these laws, Minister Vélez was legally mandated to implement them and she was able to communicate these constraints effectively to justify her actions. Building on this, while it was often customary for politicians to ally themselves with FECODE during elections and then remain indebted during their administrations, Minister Vélez and President Uribe were not constrained as such. Thus, they could always remain firm and maintain their independence when dealing with FECODE. However, this never translated into active opposition because Minister Vélez and her team understood that teachers’ wellbeing is a critical element of a successful education sector.

Business Community

The business community played a prominent role in the reform by serving as key allies throughout the process. Building on President Uribe’s initial promise to protect the Minister of Education protection during his term, the business community had created a key source of stability for Minister Vélez which gave her the opportunity to promote large scale changes. During her time in office, local chambers of commerce and regional companies provided significant donations which suggested that the government was working alongside the business community, something that was unusual in Colombia at the time. To the general population, this was perceived as an endorsement of the ministry from a serious enterprise.

To maintain this support, Minister Vélez arranged monthly meetings with some of Colombia’s most important industry leaders and “Empresarios por la Educación” [Businesspeople for Education]. These meetings provided a space for accountability and an opportunity to solicit advice regarding the professionalization of a sector badly in need of capacity development among its workforce. The advice from these meetings ultimately led to the ministry obtaining technical support from a firm that specialized in organizational change and helped reinforce the actions pursued by the ministry.

Media

As she demonstrated with all stakeholders, Minister Vélez’ ministry was one that was open for dialogue and the profound transformations made the education sector a newsworthy topic that the media was eager to cover. The ministry was willing to communicate with the media and used it as an avenue to showcase its progress since this was the first time that the Ministry of Education had quality, publicly available data. The increased accessibility of information about the education sector meant that public interest increased. The Ministry faced a more informed population which scrutinized their actions and ultimately, created a higher level of accountability in the public sphere.

Outcomes: Successes and Outstanding Challenges

As a result of the changes implemented in Colombia’s Education Reform, there were significant improvements in access, quality, and information systems as mentioned earlier. Below are some additional highlights achieved during this period:

• Literacy: Between 2002 and 2008, 1,017,934 adults learned how to read and write.
• Higher Education: The number of instructors increased by 32.6% between 2002 and 2008, and their professionalization can be measured thanks to an increase in instructors with graduate degrees of 46% and those with doctorate degrees grew 87.2% in the same period. Dropout was also considerably reduced from 16.5% in 2002 to 12.1% in 2008.
• Infrastructure: To control and improve the education inventory funds were tied to the improvement and regularization of the infrastructure. As a result, between 2003 and 2008 1,760 educational institutions had projects approved, which meant an increase in project approval from only 7% in 2002 to 27.2% in 2008.
• Private education: Thanks to efforts in certifying and assessing the private institutions, the number of schools that were labeled as Regulated Freedom (i.e. certified, accredited or high-performing schools) rose from 33% in 2006 to 42% in 2009, and those labeled as Controlled Operation (i.e. sanctioned or low-performing schools) decreased from 31% in 2006 to 20% in 2009
• Teacher Training: For the first time in Colombia’s history, teachers were able to enter the workforce after passing an evaluation. Between 2002 and 2008, 49,727 teachers and teacher directors were hired through competition (16%) and 14,265 teachers and teacher directors took the promotion evaluation.

Despite the significant progress Minister Vélez was able to accomplish, certain challenges persist in the education sector. Firstly, even though the center of her quality strategy was to set standards and implement student evaluations, some actors claim that pedagogy has not changed at the classroom level and that memorization and rote learning is still a common pedagogical method at the school level. Even though some teacher training programs were implemented to improve instruction, limited federal and local resources prevented the distribution of textbooks to all schools, forcing learners to rely on public libraries. Such an example highlights the stark inequalities that remain between the private and public schools.

Another ongoing challenge is the proposed transformation of the teacher admission process. Even teachers who went through this process (i.e. passed an entrance exam and underwent one year of training) were not necessarily appropriately trained to teach. Teaching manuals were provided to all teachers but workshop training to supplement them did not occur. As such, the admissions process did not improve teaching quality and demand for teachers meant that schools were not able to be as selective as they would like in their hiring.

Lessons Learned: Recommendations for a Minister of Education

Colombia’s experience during the Educational Revolution helps to highlight the importance of a strong Minister of Education in creating a clear vision and taking decisive actions. The ambitious goals that were outlined since the presidential campaign thanks to dialogue with key stakeholders were constantly co-constructed at different levels. The public had access to this progress thanks to transparency in the education indicators and the promotion of public discussions.

Transformation of a sector cannot be a one-person job, so the importance of working alongside a strong team is vital for any leader’s success. In Minister Vélez’s case, she was able to summon a team of well-respected professionals in the education sector, who were themselves insiders with technical knowledge. Their competence was found not only in the highest offices, but also at middle management levels to lead each of the workstreams. The leaders of Colombia’s educational policy today emanated from this time. Perhaps, the inclusion of more geographically diverse team could have helped to point out solutions to some of the problems the implementation encountered.

Another important factor was that as a coordinating agent of the educational sector, Minister Vélez invited local authorities to assess the policies and their implementation. Their presence and participation helped tailored the national policies to local realities that they knew from first-hand experience. This two-way communication was possible because of the ability to listen, learn, and act with humility when people perceived certain actions as mistakes. The fact that Minister Vélez was also willing to walk alongside her teams in the territories also created a sense of proximity that allowed her to put a face to the stories she was telling with precise data and accurate information systems. She was able to steer the public conversation away from general strikes and into more constructive nuances, which created a better-informed society that held the ministry, local authorities, and school staff accountable. The alliances formed with civil society, the media, and the business community were also a central factor for the buy-in the Educational Revolution had from the public.

Her ability to align herself with the agenda of the President, and to count on his support, gave Minister Vélez the stability that was needed in the sector to stay on as minister for eight years, making her the second longest-lasting minister in the recent history of Latin America. Education policy is a long-term project, so being able to think and implement policies throughout two administrations allowed the sector to understand and cope with the changes gradually, but most importantly, to see the results of each of the actions that were being put into place.

Another fundamental lesson was that, thanks to her prior knowledge of the sector acquired while serving as Secretary of Education in Bogota, she was able to think about the sector comprehensively. This also allowed her to come up with a National Strategic Plan that shaped the guidelines and goals of her administration since the very first days. Instead of promoting incremental changes in small areas, she pursued an ambitious transformation of the sector as a whole.

The above was only possible because of the information systems that were installed. Up to date information was able to be conveyed from the territories to the ministry and back to detect problems and to act upon them. The coordination mechanisms that supervised and audited the information served to decide on agreements and to fix short- and long-term measurable goals that were monitored by dash-boards. This allowed for a periodic assessment of progress that disentangled the complexities of tackling the system as a whole.

At the time, two issues in Colombia had been spared from the ideological struggles between the left and the right: urban policy and education. Both were areas where a consensus was possible and where “soft reformism” was given fertile ground to promote better services for the overall population resembling an effective social democracy. Although many of the actions performed by Minister Vélez and her team were well known around the world, the way in which she implemented them made a big difference in the outcomes when compared to other cases in the region. Her example shows that with an understanding the importance of the human factor combined with data-based decisions, real change is possible, even in a context as challenging as the education systems in Latin America.

This report was made possible by the Harvard Ministerial Leadership Program. None of the conclusions, recommendations, and/or opinions expressed in this report necessarily reflect those of the Harvard Ministerial Leadership Program or Harvard University and its affiliates. © 2019 Harvard Ministerial Leadership Program.

References

1. Bolman, L. G., & Deal, T. (1997). Reframing Organizations, Artistry, Choice, and Leadership, 6th Edition, San Francisco: Jossey-Bass Publishers, Inc.
2. Davis, I. (2010). “Letter to a newly appointed CEO,” in McKinsey Quarterly, McKinsey Company.
3. Deal, T. (1985), “Cultural Change: Opportunity, Silent Killer; or Metamorphosis?” in R. Kilmann, M. Saxton, R. Serpa, Gaining Control of the Corporate Culture, San Francisco: Jossey- Bass. pp. 292-331.
4. Delors, J. (1998). Learning: The treasure within. Unesco.
5. Reimers, F. (2019). Cartas para un Ministro de Educación. Cambridge.
6. Hauser, C. B. (2015). A Communication Strategy for the First Six Months in “Opportunity Knocking.”, Council for Advancement and Support of Education
7. Hackman, J. R. (1998) “Why Teams Don’t Work,” Leader to Leader, Winter. P. 24-31.
8. Kingdon, J. W., & Thurber, J. A. (1984). Agendas, alternatives, and public policies (Vol. 45, pp. 165-169). Boston: Little, Brown.
9. Kline, H. F. (1999). State building and conflict resolution in Colombia, 1986-1994. University Alabama Press.
10. McLaughlin, J. (1993) “Leadership Transitions: A Wide-Angle Lens,” in Harvard Institutes for Higher Education. Cambridge, MA: Harvard Graduate School of Education, vol. 2, no. 2.
11. Ministry of Education (MinEducación) of Colombia. (2010) “Colombian Educational Revolution 2002-2010. Action and lessons”.
Ministerio de Educación de Colombia 2010.
12. Mintzberg, Henry, and Frances Westley. (1992). “Cycles of organizational change.” Strategic management journal 13, no. S2: 39-59.
13. Orlando Melo, J. (2017). Historia mínima de Colombia. El Colegio de Mexico AC.
14. Vélez, C. (2019). Building Institutional Capacity for Large Scale Educational Reform [ppt Slides]. Shared from lecture on March 2019 at the Harvard Graduate School of Education.

Annex 1: Re-Engineering of the Ministry

Source: Vélez, C. (2019). Building Institutional Capacity for Large Scale Educational Reform [ppt Slides]. Shared from lecture on March 2019 at the Harvard Graduate School of Education.

Annex 2: Information Systems

Source: Vélez, C. (2019). Building Institutional Capacity for Large Scale Educational Reform [ppt Slides]. Shared from lecture on March 2019 at the Harvard Graduate School of Education.

Methodology: Interviews

The interviews were conducted in person or virtually and consisted of 20-minute to two-hour in-depth conversations about the role and perceptions of these stakeholders who played a central role in Colombia’s Education Reform.

Executive Summary

A high-quality health system should support the physical, mental, and social wellbeing of the people it serves and a high-quality education system should help students reach their full potential as productive members of society. The likelihood of achieving improvements in the health, education, and economic development of a population hinges on the quality of the underlying and interrelated health and education delivery systems.

This policy brief provides an overview of three key areas in health and education: human resource motivation and performance; procurement, supply delivery and management; and data for decision-making. It reviews challenges and potential policy options to guide quality improvement efforts in those areas. A summary table is included in Annex 1.

Human resource motivation and performance are fundamental to equitable service provision and effective achievement of health and education outcomes. Key challenges include absenteeism; professional attrition (either to urban areas or high-income countries); and low technical competence. Root causes of these challenges include inadequate professional training; stressful working conditions; scarcity of essential supplies and materials; heavy and increasing workloads; low and unreliable remuneration; and lack of opportunities for growth and professional development.

Policy options to tackle these challenges could include reforming remuneration schemes to create a stronger link between payment and performance indicators. Changes could also be made to the recruitment and deployment strategies for health and education workforces, including setting higher admissions standards into the profession, diversifying the workforce and putting in place measures to attract and retain staff in underserved areas. Policies could also include enhanced professional development programs, either in-service or using technology to facilitate remote learning and supervision. Finally, technology could also be integrated into monitoring and service delivery systems to make them more accountable and responsive.

Procurement, supply delivery, and management systems critically affect efficient resource utilization and effective achievement of health and education outcomes. In education, the provision of textbooks is a challenging area for supply chain and procurement, but one which yields excellent returns on investment. Across both the health and education sectors, weaknesses in national procurement and supply chain systems are leading to stockouts and waste of essential supplies, inflated prices, and poor quality of products (including counterfeit or ineffective medicines). The causes of these issues range from high production and import costs, difficulties with making accurate forecasting and requisition estimates, inadequate storage and transportation conditions (which can lead to theft or damage), as well as diffused responsibility in the underlying accountability structure and unpredictable financing.

Effective policies to strengthen these systems should be carefully adapted to the local context and capacity but could include seeking procurement agreements with national or regional producers, the private sector, or through a pooled funding arrangement. Policies could also aim to centralize procurement or streamline the distribution of essential goods, while also potentially reducing the number of wholesalers and intermediaries to drive down costs. Distribution processes could be improved through investments in strengthening the stock-management and requisition systems at local levels (potentially enabled by technology), shortening the lag between replenishment cycles, and integrating systems for improved product traceability and efficient transportation. Finally, focusing on developing and retaining a qualified procurement and supply chain workforce is an important area to consider.

Data-driven decision making is a fundamental delivery tool that impacts the equity, efficiency, resilience, and effectiveness of a delivery system. The availability of quality data is often inadequate in many low- and middle-income countries (LMICs) as well as underutilized when available. Data from health and education systems are often managed in a fragmented system with little capacity for rapid and digestible analysis and dissemination. At the root of this situation is a history of underfunding national statistics offices, an over-emphasis on donor-driven aggregated surveys for cross-national comparisons over disaggregated and actionable national-level data, as well as weak demand for data from users (from government decision makers to citizens).

To enact the “data revolution” called for by the UN, initiatives should be put into place to improve the quality of data, through financing more robust national statistical offices, performing enhanced data audits and better aligning donor and local data streams. The key indicators for each sector should be chosen to reflect the desired outcomes (quality) and not just quantity and should include regularly administered internationally recognized standard measures. Policies should also be enacted to create a culture of “demand for data” at every level, as well as working with data producers to create user-friendly products that meet the needs and are easily actionable for decision makers.

Introduction

There has been increased attention in recent years on moving beyond accessing services to focusing on the quality of service delivery across health and education. High-quality delivery systems are effective at achieving outcomes, efficient at utilizing resources, equitable at providing services, and resilient in the face of challenges. Thus, a high-quality health system should support physical, mental, and social wellbeing of the people it serves and a high-quality education system should help students reach their full potential as productive members of society. The likelihood of achieving improvements in the health, education, and economic development of a population hinges on the quality of the underlying and interrelated health and education delivery systems.

Strategies to improve quality must include policies to improve resource utilization and service delivery in three key areas: human resource motivation and performance; procurement, supply delivery and management; and data for decision-making. This brief will seek to provide context, as well as possible policy options and combinations, to guide quality improvement efforts.

Quality in health systems

A recent Lancet Global Health Commission on High Quality Health Systems in the SDG Era¹ has called for “a revolution” in health care quality. Despite gains in health outcomes globally, the commission points to the often poor quality of care provided across LMIC, which leads to nearly eight million avoidable deaths each year. As countries strive to provide universal health coverage (UHC), an integral part of achieving SDG 3 “Good health and well-being,”² they must also make improving quality a core component of these efforts, together with expanded coverage and financial protection. The Commission’s report includes among the foundational elements of high-quality health systems: workforce numbers and skills, tools and resources from drugs to data, as well as the capacity to analyze and learn from data.¹

Quality in education

Since 2000, there has been enormous progress around the world toward achieving Millennium Development Goal (MDG) 2: universal primary education. Total enrollment rates reached 91% in 2015 in developing regions, and the number of children out of school was halved.³ However, these efforts have often eclipsed concerns around the quality of education, a concept which encompasses the learners’ cognitive development and the “promotion of values and attitudes of responsible citizenship and in nurturing creative and emotional development.”⁴ The 2018 World Development Report has called the current situation a “learning crisis,” with hundreds of millions of children worldwide failing to learn basic arithmetic and reading skills. To address this, SDG 4 is concerned explicitly with “quality education.”

Within UNESCO’s framework for understanding education quality,⁴ “enabling inputs for quality education” include teaching and learning materials, physical infrastructure and facilities, human resources (teachers, principals, inspectors, supervisors, and administrators), as well as school governance.

Human Resource Motivation and Performance Overview

Worker performance is highly linked to worker motivation due to the labor-intensive and interpersonal nature of the services being provided. The performance of health professionals (though relevant to education professionals as well) has been defined as being available – retained and present – competent, productive, and responsive.⁵ A WHO framework for health worker performance and its link to motivation is in Annex 2.

Motivation has been defined as “an individual’s degree of willingness to exert and maintain an effort towards organizational goals.”⁶ This definition also frames motivation as being composed of two components: “the extent to which workers adopt organizational goals (‘will do’) and the extent to which workers effectively mobilize their personal resources to achieve joint goals (‘can do’).”

Herzberg⁷ provides a theoretical foundation for the determinants of motivation that is grounded in two types of factors:

While financial incentive levels and schemes may be important determinants of worker motivation, they alone have been found to be insufficient to keep health professionals motivated. A motivated worker must also have the right competencies, work environment, and resources to be high performing.⁵

Challenges in Human Resource Motivation and Performance

The challenges relating to human resource motivation and performance in health and education systems are considerable.

• Absenteeism: Many countries have epidemic levels of teacher and health worker absenteeism, particularly in rural and remote areas. A study in six developing countries found an average of 19% of teachers and 35% of health workers were absent during regular working hours.⁸ In India, more than 23% of teachers were absent during unannounced school visits, which was associated with an annual cost of $1.5 billion for services that were not delivered.⁹
• Professional attrition and “brain drain”: Teacher attrition rates in sub-Saharan Africa are variable but high—between 5-30%,¹⁰ and yet demand for teachers in low-resource countries is expected to grow dramatically in the years ahead, nearly doubling by 2030.¹¹ Similarly, for health professionals in LMICs, migration to urban areas or higher-resource countries is mostly unplanned, leading to a “brain drain” of talented professionals and exacerbating shortages in resources in health. Despite efforts by the WHO to curb this trend, physician density is still declining in the majority of African countries and physician migration is on the rise.¹²
• Low technical competences in teaching and care: A study of nine sub-Saharan African countries using Service Delivery Indicators (SDI) found very weak rates of adherence to clinical guidelines. Less than a third of providers adhered to guidelines for neonatal and maternal health complications, and 35.9% adhered to guidelines for diarrhea, pneumonia, and malaria, with a diagnostic accuracy for these conditions of only 50%. Similarly poor guideline adherence was found in studies in health centers in India.¹³ Concerns also exist with the quality of teaching. The Learning Barometer survey of student performance, carried out in 28 African countries with primary school-age learners (Grades 4 and 5), identifies the proportion of children who meet a minimum learning threshold. It found that over a third of students—23 million children—fell below the minimum learning threshold, meaning most will be “unable to read or write with any fluency, or to successfully complete basic numeracy tasks.”¹⁴

Root Causes of These Challenges

Several of the root causes of the aforementioned challenges are described below.

• Inadequate initial professional training: Many teachers graduate from their training lacking information on what their pupils are supposed to learn and basic teaching and curricular management skills.¹⁴ Training programs for health care professions also suffer from chronic under-investment.¹⁵ A survey of medical schools across Africa found “ubiquitous faculty shortages in basic and clinical sciences, weak physical infrastructure, and little use of external accreditation.”¹⁶
• Difficult working conditions, including insufficient physical and supportive infrastructure: Schools and health centers, particularly in rural areas, can lack the very basics such as running water, consistent electricity, and adequate sanitation facilities.^17,18 Access to decent housing and family-centered services (schools, daycare) outside of urban areas is also a major challenge for many professionals in education¹⁹ and health,²⁰ particularly for women.
• Lack of work materials and essential supplies: (discussed in the following section)
• Increasing workloads: Pupil to Teacher Ratios (PTR) have increased dramatically following the roll-out of Universal Primary Education policies. This has meant overcrowded classrooms, more teaching periods, and more non-teaching activities.¹⁷ The global needs-based shortage of health-care workers is projected to be 14 million by 2010. When taking into account population size, the most severe challenges are in sub-Saharan Africa, where ratios of health professionals to patients are predicted to worsen between 2013 and 2030.¹⁵
• Low and unreliable remuneration: In many countries, teachers and health care providers do not earn enough to live above the poverty line, requiring many to turn to other part-time work to supplement their income.^5,19 They may also experience delays in receiving their salary and be required to travel long distances to receive it.¹⁷
• Lack of constructive supervision, professional recognition or professional development opportunities: Education systems in many countries report having infrequent or ineffective supervisory visits. Teachers also generally receive very little feedback, support, or advice from more senior teachers or school administrators on how to improve.¹⁴ Similarly, health professionals have often limited access to professional development opportunities, which tend to be unevenly distributed despite high demand.¹⁷

Policy Options to Improve the Motivation and Performance of Human Resources

Below is an overview of policy options that could be considered to improve the motivation and performance of health and education professionals.

It must be noted that worker motivation is sensitive to system-wide or facility reform processes which can affect organizational dynamics, reporting, accountability and incentive structures. These changes may elicit a range of responses from professionals as they often require the development of new workforce capabilities and can affect different health system cadres differently.⁶ The involvement of health workers in the design and implementation of reforms has been found to be an effective way to manage these concerns.⁵

Policies to improve motivation and performance can be undertaken at the macro-system level or at the micro-facility level and can be designed to address performance issues by tackling “can do” or the “will do” gaps. They can also address the living conditions of health workers in ways that are adapted to the context, including rural location, age and gender considerations.⁵

Option 1. Changes to Payment and Reward Systems

Creating stronger linkages between payment and performance indicators can be an important way to improve the quality of professional work. The implementation of reforms to payment schemes requires careful consideration of bureaucratic and political economy considerations, such as resistance from unions, and the required data collection infrastructure.²¹

• Health worker performance-based financing (PBF or P4P) schemes: PBF is a contracting mechanism designed to increase the performance and quality of service providers by offering financial incentives to health facilities for the provision of a defined set of services, with adjustments based on measures of quality. These vary considerably in their format (payment structure, target services, etc.) and effect on employee performance and health outcomes.²² In the past decades, PBF schemes have generated substantial interest among policy-makers, donors and international organizations; as of 2015 a dedicated trust fund at the World Bank alone supported 36 PBF programs.²³ Conditional cash transfers, modified by quality measurements, were found to be particularly effective in Rwanda – where P4P was found to have a positive effect on health care utilization, quality of care and outcomes, as well as on lowering worker absenteeism.^24-27
• Teacher performance pay schemes: Numerous schemes exist to reward teachers based on specific measures of performance and outputs. Studies in Tanzania, India and China generally found these approaches to be effective when combined with providing resources such as unconditional grants or textbooks.^25,28,29 However, several other evaluations showed either no or marginally positive gains from such measures, especially for low-performing schools. It was also found that rewards may have detrimental effects, such as diminishing peer collaboration, narrowing the curriculum, and over-emphasis of teaching to the test. Generally, these schemes remain relatively rare at scale – a review found that only 17 of 101 education systems used test scores to formally sanction or reward schools or educators.³⁰
  • Benchmarking: Payments are based on the number of students that reach specific proficiency levels. This was found to be easier to communicate and implement,³¹ but difficult to sustain.³²
  • Pay for Percentile: Payments are based on students’ test scores relative to other students at the same starting level or similar students in other schools. This is harder to implement but incentivizes teachers to improve learning across the entire student distribution.³³
  • Special awards for teaching quality: Particularly when recognizing collaborative work among teachers, as research has found that monetary incentives are more effective when awarded to teaching teams compared to individual teachers.³⁴

Option 2. Changes to Recruitment and Deployment

Macro-level policies can aim to improve education and health workforces by targeting who is recruited into key professions, how they are trained, and where they are deployed to work.

• Higher standards for recruitment: Setting higher minimum qualifications to enter the teaching or nursing profession, such as an undergraduate degree, could be an effective way to improve the status of the profession as well as to attract high-performing individuals. A merit-based appointment system, such as one implemented in Pakistan for teacher recruitment, included a test administered by a third-party National Testing Service to protect the system from political influence.³⁵
• Measures to attract and retain professionals in understaffed rural areas: Several initiatives have been found to be effective for health care workers, including providing preferential admissions to students from rural areas, designing a “rurally oriented curricula” with a focus on rural health issues, imposing compulsory training rotations in rural settings, as well as providing scholarships, financial incentives, professional advancement, support networks, and help with setting up medical practices in rural areas.²⁰ In education, other non-monetary incentives have been used, such as offering bicycles, housing, and preferential access to resources and training. “In the short term, the provision of good quality housing with running water and electricity for teachers is probably the most cost-effective way of attracting and retaining teachers at hard-to-staff rural schools.”¹⁹
• Diversification of the health and education workforce: To minimize the time spent by teachers on non-teaching activities, it is possible to include pedagogic assistants, health practitioners, and administrative support.¹¹ Similarly in health care, shifting tasks between health care workers (“task sharing”) and expanding the clinical team, particularly to include community health workers, can relieve short-term human resource limitations.¹⁸

Option 3. Enhanced Professional Development Programs

Opportunities to improve existing or develop new technical skills are often a major source of motivation for professionals in health and education, and they also directly address the “can do” gap that inhibits performance.

• In-service or facility-based skills-development programs: Training is best when done close to practice where learners can immediately apply concepts and receive feedback. Meta-analyses show that successful in-service teacher training, coupled with ongoing monitoring, mentoring, and coaching, is a proven way to improve primary school teachers’ instructional practice in LMICs.^36,37 Such approaches are generally more expensive but preferable to external continuing education programs or training-of-trainers cascade models, which have the disadvantage of being expended on a small minority of professionals who are withdrawn from their work.³⁸
• Training and skills-building programs specific to management professionals: In addition to frontline workers, initiatives to develop the skills of managers are an important part of improving overall system quality. Health facility management training and supervision were found to be effective at improving organizational practices and health outcomes but needed to be ongoing.³⁹ Training programs for headmasters in school management and leadership were also found to be effective across 13 countries at improving teacher motivation and performance.^19,34
• Technology-enabled training and support: Some initiatives, such as technology-assisted professional development and text-message support, have been used to effectively reach teachers in remote areas.^40,41

Option 4. Integration of Technology into the Classroom or the Clinic

Technological innovations, from apps to integrated teaching and learning systems, are multiplying in health and education spaces. These present great opportunities for improved performance, but also require significant investments and infrastructure. Across many developing countries, the rate of internet connectivity in schools is less than 10%. There is some concern that uneven access to these resources could exacerbate existing learning inequalities between rural/urban or affluent/resource-constrained areas.¹¹ Nevertheless, technological innovations have been deployed to achieve a number of goals.

• “Blended-learning classrooms”: This format combines learning using technology with face-to-face teaching and was found to be effective in several case studies.⁴¹
• Technology for improved attendance monitoring: Different approaches have been tried to reduce absenteeism, including using sophisticated surveillance technology or simple mobile phone text systems. Biometric attendance monitors in primary health centers or cameras in schools in India were only found to be effective when attendance was linked to rewards or penalties and there was sufficient buy-in from the stakeholders involved in these processes.⁴² Other simple phone-based platforms to send daily data on teacher attendance were found to be effective in the Gambia and Zimbabwe.⁴³

Procurement, Supply Delivery and Management Overview

Functioning procurement, supply delivery, and management systems are essential for quality health and education service delivery. A supply chain encompasses an “ecosystem of interlinked organizations, people, technology, activities, information, and resources” that is required to get products from manufacturers to users in the most cost-effective way possible. This includes inventory management, storage, distribution, and inventory control, and requires a large, competent, and properly trained workforce. Supply chains do more than simply delivering products, they also produce critical information related to the need, demand, and consumption to national and regional level planners.⁴⁴

Procurement and Supply Chains in Health

The structure of supply chains for health varies greatly depending on national health system characteristics, such as the different sources of financing, risk pooling and purchasing, as well as national pharmaceutical regulations and treatment-seeking behaviors of patients. Supply chains play a role in many dimensions of health system performance: payment, organization, regulation, and also behavioral aspects of the health system.⁴⁴ In the coming decades, as many global health initiatives such as GAVI, the Global Fund, and PEPFAR roll back their support, many LMICs will need to play a larger role in the procurement of health products.⁴⁵

Procurement and Supply Chains in Education

Access to appropriate learning materials is listed as a key strategy for achieving SDG4 – particularly the dimension related to providing inclusive and effective learning environments for all.³ Textbooks are a particularly important input for improving learning outcomes in contexts with large class sizes, under-qualified teachers, and shortened instructional time. They have been found to be, when they are in the appropriate language and level of difficulty, a particularly cost-effective input with high returns in student achievement.³⁰ A multi-country study of 22 sub-Saharan African countries found that providing one textbook to every student in a classroom increased literacy scores by 5–20%.⁴⁶

Challenges in Procurement, Supply Delivery and Management

Supply chains can significantly affect the availability, price, and quality of strategic inputs. However, many national procurement and supply chain systems remain ineffective and poorly managed.

• Lack of availability of working materials and supplies: Key health system inputs, such as medicines, are not consistently available in many low-resource settings. According to an analysis of WHO data, the average availability of generic medicines in the public sector ranges between 29% to 54% across WHO regions.⁴⁷ Interruptions in the access of medications are an important threat to public health, as they interfere with treatment initiation or continuity and increase the likelihood of ill health and antimicrobial resistance.⁴⁵ Similarly, the procurement and supply of essential learning materials, particularly quality textbooks, remains a challenge in many LMICs. Between 2000 and 2007, rapid enrollment increases were experienced across several LMICs; however, textbook availability could not keep up. For example, in Malawi, “the percentage of students who either had no textbook or had to share with at least two other pupils increased from 28% in 2000 to 63% in 2007.”⁴⁶ Gaps in essential school supplies are even more pronounced in rural or underserved areas.
• Inflated prices: Across LMICs, the prices of many vital inputs for health and education systems can be variable and disproportionately high. According to an analysis of WHO data, median government procurement prices for 15 generic medicines are 1-11 times international reference prices, and procurement prices that were low did not always translate to lower patient prices. This created a situation in which “treatments for acute and chronic illness were largely unaffordable in many countries.”⁴⁷ The cost of textbooks varies greatly by country and region. In sub-Saharan Africa, the unit cost of a primary school textbook is between US$2 and US$4 compared to Vietnam, which produces books domestically, where the cost is between US$0.33 and US$0.66.⁴⁶
• Poor quality of products delivered to end-users: Dysfunctional health product procurement and supply chain systems are associated with an increased risk of substandard quality or counterfeit drugs, which can lead to poisoning, ineffective treatments, and anti-microbial resistance.⁴⁸ It is estimated that 1 in 10 medical products in low- and middle-income countries is substandard or falsified.⁴⁵ In education, some national regulatory bodies lack a reliable process to evaluate the quality of textbooks, resulting in the use of substandard materials and production and errors in the content.⁴⁹ The provision of quality textbooks in the correct language should be prioritized in early grades as this is when they have the largest impact on learning. However, in Chad, a 2010 survey found that only 20% of students had a textbook in the correct language of instruction (French) in grade two, and 40% of students in grade five.⁴⁶

Root Causes of These Challenges

Weaknesses in national supply chain and procurement systems in health and education have several root causes.

• High production and import costs: The reasons for variations in the cost of textbooks across country and region include “fluctuating prices for raw materials, manufacturing, procurement, publishing overheads, distribution and storage, importation, and shipping.”⁴⁶ In the health systems of many countries, depending on the size of the market and regulatory environment, importers and wholesalers of health products are numerous and fragmented, which significantly drives up prices. For example, there are 292 licensed medicine importers in Nigeria and 166 national wholesalers in Ghana.⁴⁴
• Inability to correctly predict needs: The capacity to effectively forecast procurement or requisition materials is often deficient, particularly at decentralized levels. Accurate data estimating needs and consumption rates are fundamental to the effective management of procurement and distribution processes, and yet they are often unavailable or unreliable, resulting in stock-outs or waste.^44,46 In most national health systems in LMICs “there are no processes by which information about consumption is systematically captured” – with many systems relying instead on “ad hoc surveys.”⁴⁴
• Poor storage conditions and theft: Inappropriate distribution, storage, and usage conditions have been found in some cases to lead to an annual loss rate of 50% for textbooks. Moreover, poor security during transport and storage allows school supplies, particularly books, to be stolen and resold in the black market. A 2010 survey in Ghana found that 29% of English textbooks went missing during this process.⁴⁶ Similarly, product diversion is a major driver of drug stock-outs in LMICs. The complexity of drug distribution systems can create many opportunities for diversion; in Kenya, for example, “medicines can change hands ‘five to seven times’ before reaching local clinics.”⁴⁵
• Inefficient transportation: The lack of a well-functioning and managed government transportation fleet is a major barrier to effective supply chains in health. Vehicles for medication distribution are often unavailable due to lack of appropriate planning, poor maintenance, and inappropriate use.⁴⁴
• Underlying weakness of the accountability structure: These weaknesses may be a result of fragmented responsibility and governance at different levels. Furthermore, the enforcement of supply chain and distribution regulations may be hampered by underfunding and limited human resource and organizational capacity, as well as inadequate supervision and corruption.⁴⁴
• Unpredictable financing: The predictability of financing for the procurement of textbooks is very important because their development, production, procurement, and distribution is a long process. However, this is the case in only a few LMICs.⁴⁶ In health systems, delays in the disbursement of funds from national finance bodies or international donor agencies often result in disruptions that ripple down the supply chain.⁴⁴

Policy Options for Improved Supply Chain and Procurement

There is no ‘one-size-fits-all’ approach to improving the performance of procurement and supply chain systems. There are only a few well-designed randomized or quasi-randomized studies that demonstrate effective reforms to improve health system supply chain performance. The external validity of what evidence exists is reduced by the context-specific and complex features of national supply chain systems across countries.⁵⁰ Nevertheless, some promising policy avenues exist and are described below.

Option 1. Procurement from Different Actors

Working with different actors for the procurement of key inputs in health and education systems may provide opportunities to improve the performance of procurement and supply chain systems. In health systems, however, the flexibility to work across different producers may be more limited.

• Regional or national production: Depending on the context and the product being procured, these may provide cost savings compared to international producers in relation to competition, taxes, import duties, and transportation. In Viet Nam, for example, the unit price for books is much lower than in many sub-Saharan African countries because it prints books domestically and fosters competition among publishers to drive down prices.⁴⁶
• Procurement from the private sector: Turning to the private sector for textbook procurement is something some countries have done to try to drive down costs. For example, in 2002 Uganda began working with a private publisher through a competitive process and “saw the cost of textbooks fall by two-thirds and their quality increase.”⁴⁶ However, other studies in Ghana, Tanzania, and Kenya suggest that there is little effect on the inefficiency, corruption, and lack of transparency from changing from state-controlled to private sector textbook provision.⁵¹
• Pooled funding mechanisms for improved predictability: These kinds of systems could provide more and predictable funding for textbooks; however, the current pooled funding mechanism for education, the Global Partnership for Education (GPE), has not had the same success as pooled funds in other sectors, such as GAVI health, in attracting more and predictable funding.⁴⁶

Option 2. Re-Design the Procurement and Supply Systems

There are several potential ways to restructure these processes to make the best possible use of limited resources.

• Centralized procurement and tendering processes: This can help to create economies of scale and improved purchasing power. Such reforms were found to produce cost savings in a number of case studies from different regions, including the Middle East, Brazil, Mexico, and several countries in Asia and Africa.⁵⁰
• Streamlined tiers of the supply chain system: Some countries have sought to decentralize procurement and supply processes to lower levels of the system, to provide additional flexibility, autonomy, and speed for purchasing at local facilities. However, in some cases, this has led to worse outcomes.⁴⁴ In contrast, a quasi-randomized study in Zambia resulted in large improvements in medical product availability by cutting out the regional distribution step. Multiple modeling studies have also confirmed the benefits of reducing tiers in the supply chains for vaccines and immunization supplies.⁵² The decentralization of the supply of textbooks has also had mixed success with some countries, like Uganda, preferring instead to centralize procurement to combat corruption and mismanagement at the school and district levels.³⁰
• Reduced number of wholesalers or middle-men: A smaller number of wholesalers is generally preferable for optimal supply chain performance, since fewer larger wholesalers gain economies of scale in their distribution efficiency and have improved access to capital for infrastructural investments. The creation and enforcement of regulations around quality standards and distribution practices can lead to the consolidation of smaller players, although the resistance from smaller actors who stand to lose from this type of reform may be prohibitive.⁴⁴ The cost of distributing textbooks can contribute to high variations in price, as seen when comparing Kenya and Rwanda. Although both countries use a commercial distribution system to deliver books, the unit textbook cost in Kenya is nearly double that of Rwanda, partly because Kenya delivers books through a bookseller middleman rather than having publishers deliver directly to schools.⁴⁶
• Public-private partnerships: Several effective partnerships have been established, particularly those which involve the contracting of private operators for the last-mile delivery of products. Large multinational companies partnering to improve the effectiveness and efficiency of supply chains in LMICs include Coca-Cola and the UPS Foundation.^49,53

Option 3. Improved Distribution Processes

At different points in the supply chain process, improvements can be made to improve forecasting capacity, replenishment systems, as well as product transportation and traceability.

• Improved stock-management and procurement request practices: Simple technology and software can be used to track consumption and demand—to know when stocks are running short and to update them faster. If such systems are not able to be put in place, particularly in areas with poor technology infrastructure or IT connectivity to carry out stock requisitioning, it is possible to combine information collection with product distribution. Such systems were found to be effective in Zimbabwe and Mozambique.⁴⁴
• Reduced lead-times from suppliers and increased frequency of replenishment: Increasing replenishment frequency “increases the speed and velocity of the supply chain and decreases the reliance on long-term forecasts,” approaching actual levels of demand. However, this can lead to higher transport costs, and therefore statistical modeling should be used to determine the best balance between transport costs and benefits from forecast improvement.⁴⁴
• Digital technologies that help “track and trace” the movement of products: In addition to improved security throughout the storage and transportation process, unique serial numbers at the package level can be a good defense against theft during the distribution chain.⁴⁸ “Track and trace initiatives allow actors on a supply chain to determine where a product is at any given time (tracking) and where it came from (tracing). The approach starts with the process of serialization, in which a manufacturer assigns a unique identifier to each product that it ships using a two-dimensional (2-D) barcode that other supply chain actors can scan to obtain information about the product and record when it changes hands.” This creates a digital trail of information linking each package along its path through the supply chain for increased accountability.⁴⁵
• New or outsourced delivery methods: “Depending on the geography, overall economic situation, maturity of the transport market and structuring of the price and service level contracts, a third-party logistics provider can offer better service at rates comparable to the fully loaded cost of owning and operating a government fleet.” In the case of Kenya, this approach helped to address problems with transport planning, vehicle maintenance, and inappropriate use.⁴⁴ Leapfrogging using novel delivery technology is also possible, such as using drone delivery for emergency supplies or deliveries in hard-to-reach areas in Rwanda.⁵⁴

Option 4. Invest in Human Resources and Management Tools

Recruiting talented supply chain experts into the public sector is important for high levels of financial and operational performance. Management and leadership roles in this sector should not only be restricted to civil servants but also include individuals with strong commercial sector experience.

• Professional development for procurement and supply chain professionals: Several countries have successfully implemented comprehensive short-term training programs aimed at procurement practitioners, members of tender committees, tender review boards, and oversight institutions. As procurement and supply chain processes become increasingly technology-driven, it is equally important for practitioners to also expand their expertise in business engineering and design and information technology.⁵⁵ Other effective quality improvement interventions focused on improving teamwork and the human elements of supply chain management.⁵⁰
• Benchmarking tools to improve performance: These tools can also help to standardize supply chain performance metrics such as Data Envelopment Analysis (DEA).

Data for Decision Making Overview

Data is a fundamental part of strategic, goal-oriented, and effective systems. “Data-informed decision making” is a process that is proactive and interactive, and that “consider[s] data during program monitoring, review, planning, and improvement; advocacy; and policy development and review.”⁵⁶

For data to be used for decision making, it should be accurate, timely, disaggregated, and widely available, as well as made actionable through analysis.⁵⁷ Given the ambitious vision of the SDGs—with 17 goals, 169 targets, and 232 indicators to be achieved by 2030—there is a great need for quality data for monitoring and measuring progress.⁵⁸

Challenges with Using Data for Decision Making

There have been gains in the frequency and quality of censuses and household surveys, however, many of the “building blocks” of national statistical systems remain weak. Importantly, this gap includes data that is central to estimating “almost any major economic or social welfare indicator—[such as] data on births and deaths; growth and poverty; taxes and trade; sickness, schooling, and safety; and land and the environment.”⁵⁷ The inadequacy and unreliability of official statistics in many Sub-Saharan African countries have led to the U.N. High-Level Panel on post-2015 development goals calling for a “data revolution” to improve tracking of economic and social indicators across the developing world.⁵⁹

Data in Education

Behind the learning crisis in much of the developing world is a huge data gap. Only a few middle-income developing countries have the political incentives and technical capacity to develop and sustain national data systems for education. Countries in the developing world rarely have the infrastructure of data collection in place, nor the capacity to analyze and feed information back to educators, parents, and communities. International assessments and regional initiatives cover relatively few developing countries; the majority of school children in the developing world are not tested at all. Moreover, while there is a range of data sources on education systems, services, and outcomes, these are not always translated into user-friendly formats for decision making.⁶⁰

School-level enrollment statistics are necessary to make efficient staffing decisions, however, in some countries, like Kenya, this information is only available from the country’s Education Management Information System (EMIS) three times a year.⁵⁹

Data in Health

Quality and timely data from health information systems are the foundation of the health system and inform decision making in each of the other five building blocks of the health system. Recent years have witnessed significant commitments to and investments in the strengthening of information systems.⁵⁶ However, data quality and the availability and demand for timely analysis for decision making remain problematic.

• Poor quality data: Many LMICs continue to face challenges related to the poor quality of routinely collected data. Comparing administrative and survey data of primary school enrollment in 46 surveys across 21 African countries found a bias toward over-reporting enrollment growth in administrative data—with an average change in enrollment nearly one-third higher in administrative data. “Many countries’ health management information systems (HMIS) databases rely on self-reported information from clinic and hospital staff, which aggregated up by district and regional health officers, each with potentially perverse incentives.”⁵⁹
• Under-resourced and under-staffed national statistical agencies: The high turnover of qualified EMIS staff, particularly in Ministries of Health, is a recurring challenge in LMICs, largely due to the low and relatively unattractive salaries.⁵⁸ These agencies have also failed to improve significantly over time due to a lack of functional independence, as well as being reliant on volatile donor funding.⁵⁹
• Fragmented and inadequate information systems: Electronic Medical Information Systems (EMIS) in many sub-Saharan African countries are “chronically weak,” with problematic or at times absent key functions such as data entry control, import-export, data consolidation, consistency checks, and data extraction, estimation and imputations, projections, or archiving facilities.⁵⁸
• Limited capacity for analysis and use of data at local levels: All too often, data remains unutilized, sitting in reports, on shelves, or in databases and not being used in program development, quality improvement, policymaking, or strategic planning.⁵⁶ In a survey of several tiers of Ethiopian government officials, only about 12% of officials stated that they used national information management systems as their primary source of information, preferring instead “formal field visits” (63%) or informal informational interactions such as discussions with frontline colleagues (51%) or colleagues in their organization (45%). Reliance on these more informal information sources was found to lead to only a minority of officials being able to make “relatively accurate claims about their constituents.”⁶¹

Root Causes of These Challenges

Challenges related to data for decision making are not merely technical but rather the result of implicit and explicit incentives and systemic challenges, including a lack of stable funding for national statistical systems and minimal checks and balances to ensure that the data are accurate and timely.⁵⁷

• Dominance of donor data priorities over national priorities: “The different needs of donors and government present trade-offs between the comparability, size, scope, and frequency of data collection. Given that donors finance a large share of spending on statistics, these differing needs can imply that national statistical systems aren’t built to produce accurate data disaggregated for use by domestic policymakers and citizens.” An example of this is the DHS in Tanzania, which reported results for seven aggregate zones that did not correspond to any practical local unit of measure or political accountability.⁵⁹
• Weak demand for data from users: Data are not consistently utilized by senior officials and policymakers within ministries of health and education for a number of reasons. This can be due to a lack of capacity to make data available or “because senior ministerial staff choose not to use data that contradict official views or out of fear it will damage their credibility or subject them to heavy pressure from the executive branch of government.”⁵⁸

Policy Options for Data-Driven Decision Making

Option 1. Improve the Quality of Data

This can be achieved a number of ways, including through stronger systems, better monitoring, and by reducing the incentives to misrepresent data.

• Better funding national data collection systems: Improving the funding levels and structure of national statistical systems and organizations could help to improve their performance. Also consider increasing domestic funding allocation for National Statistical Offices, mobilizing more donor funding through government–donor compacts, and experimenting with pay-for-performance agreements.⁵⁷
• Improved data collection and reporting accuracy through enhanced data audits: Facility-level technology can be used to support more frequent quality audits of routinely collected data. Regular data audits by an independent third-party verifier are a central part of PBF systems to attempt to overcome asymmetric information between the providers and payers, create accountability, and minimize gaming. Effectively targeting these verification activities can help to balance the costs and benefits of having a large enough sample to carry out effective verification activities.²³
• Integrating different data streams: Redesigning data systems for improved accountability could also be achieved by getting administrative and survey data to “speak to each other,” whereby household surveys can be used to provide regular checks on administrative data at different levels.⁵⁹

Option 2. Strategically Selecting Data to Collect

The effort to generate data for international goals should not displace the focus from building the capacity of national statistical agencies.

• Diversifying and prioritizing indicators: Health and education systems should identify and prioritize key indicators for tracking progress toward SDG targets as well as answering questions of national relevance.^62,63 For measurement to promote accountability and quality improvement, it must capture the processes and outcomes that are most important to people. In many cases, data systems produce metrics that yield inadequate insight at a substantial cost both in terms of finances and front-line workers’ time. For example, a frequently used indicator is the proportion of births with skilled attendants, however, this does not adequately reflect the quality of care during childbirth and therefore may deceptively represent progress in maternal and newborn health.¹
• Introduce internationally recognized standard measures: Currently, few countries in the sub-Saharan African region perform international learning assessments of their students,¹ and most collect learning data in a “fairly haphazard fashion.”^14,60 Most school children should be able to take a test that can be compared year over year or globally benchmarked. Policymakers and citizens need a basis to assess the quality of schooling.

Option 3. Improve Demand for Data from Decision Makers

To improve the use of data at all levels, data systems and tools can be put into place.

• Develop decision-maker facing data dashboards: To complement smaller initiatives to present data to decision makers, other larger dashboards or toolkits have been introduced, including the World Bank’s multidimensional Global Education Policy Dashboard and the “Data4SDGs Toolbox,” which seeks to help countries “create and implement their own holistic data roadmaps for sustainable development.”⁶⁴
• Data briefs or review meetings: For data to be understood and digestible by potential users, they must be synthesized and disseminated in formats that are specific and adapted to users. Different targeted information products, focusing on “need to know” information, could include standardized reports and presentation templates for regular dissemination and feedback to decision makers.⁵⁶ “External briefings” were found to significantly reduce errors made by officials, particularly in contexts where organizational incentives for data use were in place.⁶¹
• Targeted capacity building for data utilization: These efforts can include ministries, national institutes, academia, and other stakeholders. Better linking the data producers with data users, who may otherwise be working at different levels of the health system and have an incomplete understanding of each other’s needs and roles. By addressing barriers to data use together, producers and users of data can also identify programmatic priorities and make data available to work on them.^56,59

¹ International assessments and regional initiatives such as LLECE in Latin America (Latin American Laboratory for Assessment of the Quality of Education) or PASEC (Program for the Analysis of CONFEMEN Education Systems) and SACMEQ (Southern and Eastern Africa Consortium for Monitoring Educational Quality) in Africa, cover relatively few developing countries (Source: Birdsall, 2016).

Annexes

Annex 1: Summary Table of Challenges and Policy Options

Annex 2: Framework for Analysis of Motivation

Source: Adapted from “Improving health worker performance: in search of promising practices” by Marjolein Dieleman and Jan Willem Harnmeijer (WHO, 2006)⁵

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Executive Summary

This case study examines the efforts led by Minister George Werner to create fiscal space in Liberia’s education sector through a teacher vetting and testing project. By February 2018, a third-party audit confirmed that Liberia’s education ministry had removed 83% of 2,046 ghost teachers; generated US$2.3 million in annual savings; and hired 1,371 new and qualified teachers. In addition to sharing the details of this implementation success story, this case study shares reflections from key actors, highlights unique political and funding relationships, and looks ahead to what remains to be done to improve education outcomes in Liberia.

Introduction

In 2013, all 25,000 high school graduates in Liberia who applied to the University of Liberia failed the entrance exam.¹ This wasn’t entirely surprising given that the average high school classroom in Liberia had 158 students; the estimated qualified teacher-to-pupil ratio ranged from 33:1 to 90:1;² and Liberia ranked 177th out of 199 countries on the UNDP education index.³ Furthermore, more than 90% of Liberian teachers did not have a university degree and 36% were untrained and unqualified.⁴ So when President Ellen Johnson Sirleaf appointed George K. Werner as Liberia’s Minister of Education in 2015, he knew there was work to be done.

Werner came to the Ministry of Education with experience in the education sector. He had studied education and social work, taught at the university level, and more recently served as the head of the Liberian Civil Service Agency where he worked to clean up government payroll. In his new role, Werner knew that education outcomes were poor and that Liberia was not seeing any progress despite the amount of aid that was being received. Starting his term in the shadow of the Ebola crisis, he was primarily charged with reopening schools, setting the school calendar, and making sure teachers and students were prepared to go back to school. However, from his time at the Civil Service Agency, he knew that education was the largest and most troubled government sector and that it comprised 40% to 45% of employees on government payroll in Liberia. Looking ahead, he saw the impending likelihood of donor fatigue and realized that in order to make any significant long-term progress in improving education outcomes, he would also have to address fiscal space for education domestically.

Problem: From listening to legacy

As a trained social worker, one of Werner’s first acts as minister was to conduct a listening tour around the country. In his words, “To know a problem, you first have to assess it.” Notebook and pen in hand, Werner traveled from community to community around the country, shadowed by some staff and members of the media, to meet with parents, students, teachers, school administrators, and more. In this capacity, Werner got a first hand account of the challenges in the education system in Liberia. He learned about the day-to-day problems of different stakeholders; he learned that ‘free education’ was not really free because of uniforms and learning materials; he saw the involvement of volunteer teachers who cared more for community than their salaries; he saw what schools looked like after months of abandonment during the Ebola crisis; and more. Most importantly, however, he got a sense of what children wanted for themselves.

With this knowledge in hand, Werner put together a list of 15 priorities he wanted to accomplish during his time as minister. The top five were 1) quality learning outcomes, 2) teacher training, 3) school infrastructure, 4) free early childhood education, and 5) increasing girls enrolment and completion rates. The cost of implementing his priorities was US$100 million. At the time, Liberia’s national annual budget was US$500 million, of which US$40 to $44 million was allocated to the Ministry of Education and approximately 92% of that was budgeted for payroll expenses. Werner had no funds to put behind his priorities. The education ministry applied for a US$11 million grant from the Global Partnership for Education (GPE) to support its work over four years but GPE required that the Liberia’s domestic financing for education show progress towards reaching 20% of government budget. Werner needed to show that Liberia was taking steps in that direction.

Funding: It takes money to get money

When Werner came in to office, a pilot project (funded by USAID and implemented by FHI 360) to identify “ghost workers” and unqualified teachers was already in place. Ghost workers were defined as “teachers who never showed up for their jobs but still received pay, or who were fraudulently included on the payroll.”⁵ Their presence in the education system used up government budget, affected education outcomes, and affected the government’s ability to implement other programs. The pilot was being conducted in three of Liberia’s 15 counties as part of the Liberia Teacher Training Program and President Sirleaf wanted Werner to complete the removal of ghost workers across the country. This was well-aligned with a 2014 government-wide pay-reform strategy that Werner had led as part of the Civil Service Agency but also an opportunity for Werner to free up domestic funds that could be leveraged to generate more external funds and used to implement his priorities.

Werner knew that the ghost worker removal strategy would eventually free up domestic funds but it would require significant initial funds to be implemented. As such, he decided to share Liberia’s story internationally and from that a series of fortunate meetings ensued. In September 2015 at the annual United Nations General Assembly in New York City, Werner shared his plan to remove ghost workers to free up personnel costs and implement his education sector priorities with Robin D’Alessandro, CEO of Vitol Foundation. A few months later in November 2015, D’Alessandro invited Werner to speak at a conference in London. Jamie Cooper, Chair & President of Big Win Philanthropy and Dr. Muhammad Pate, CEO, were at that same conference. Cooper and Pate were intrigued by Werner’s goals. After sending a delegation to visit the education ministry in January 2016 for a feasibility assessment, Big Win approved a US$1 million grant for the ghost worker removal program as well as mandatory competency testing for all teachers. This grant was made directly to the education ministry on the condition that the Liberian government committed to reinvesting any recouped funds back into the education sector. To verify Liberia’s commitment and efficient use of Big Win’s grant, President Sirleaf authored a letter to Big Win confirming reinvestment, PricewaterhouseCoopers was brought on board as a third-party auditor, and arrangements were made to release funds on a quarterly basis (based on achieving implementation targets). This grant from Big Win was critical as the ministry leveraged it to generate additional funds to support vetting and testing across the country.

Context: The challenge of finding ghosts

In Liberia, the Ministry of Education is responsible for supervising the education sector; the Civil Service Agency is the human resources arm of the government that sets policy for pay and benefits of all government employees and informs the Ministry of Finance of personnel costs; and the Ministry of Finance makes funds available for pay and benefits. The challenge of identifying and removing ghost workers was particularly challenging because of this joint governance structure and the presence of three payrolls.

Despite the fact that Liberia’s civil war had ended more than a decade prior, its effects lingered. During the war, thousands of teaching posts were abandoned as people lost their lives or fled and often community members who stayed behind filled in. To compensate these substitute and often under qualified teachers, the government instituted a “supplementary” payroll in addition to its “regular” payroll for qualified teachers and its “general” payroll for non-teaching government employees who worked at schools.

All three payrolls were managed by the Civil Service Agency and funds were disbursed by the Ministry of Finance. The Civil Service Agency crosschecked payroll numbers with the education ministry’s formal personnel listings, however the ministry’s listings were often incorrect because the ministry had neither the capacity nor resources to verify the teacher lists it received from district and county education officers.

By the time Werner came into office, the personnel listings had not been spot checked in years, the payrolls had not been integrated, and the distinctions between the different cadres of workers were not as clear. Anecdotally, it was well known that many teachers abandoned their posts or had intermittent attendance but continued to collect paychecks. It was also not uncommon for lower level decentralized staff within the ministry to add their family or friends to personnel listings. These acts of dishonesty were magnified by flawed policies. New teachers that were hired to replace old teachers automatically took their spot on whichever payroll, regardless of qualifications or experience. This replacement policy combined with the government’s inability to check qualifications meant that unqualified teachers could get hired on the higher paying regular payroll and qualified teachers could get hired on the lower paying supplementary payroll. Furthermore, the Civil Service Agency often took months to add new names to payroll so some new teachers chose to receive their salary in the name of the teacher they were replacing to avoid any lag in payment. And to top it all off, an additional cadre of unpaid volunteer teachers had emerged.

Ultimately, the three payrolls contained duplicate names and payroll numbers, incorrect names, and missing names. All of this exacerbated the ministry’s lack of control and potential for corruption. As of November 2016, the ministry of education had 13,403 teachers on the regular payroll, 6,024 teachers on the supplementary payroll, and 7,299 unpaid teachers.⁶

Implementation: From planning to action

With funding in hand, the teacher vetting and testing project was officially launched in July 2016. The deadline for the project was August 2017, two months ahead of the October 2017 presidential election when President Sirleaf’s term was due to expire. Political support for this project under a new administration was not guaranteed and thus time was of the essence.

To focus exclusively on this project, a project implementation unit was created within the ministry consisting of a project manager, financial manager, field operations manager, and an administrative assistant. This unit was additionally supported by staff from the education ministry’s human resources and teacher education departments.

Appendix A outlines the specific implementation steps of the teacher vetting and testing project.

Results: Changing the status quo

The teacher vetting and testing project is the most comprehensive assessment Liberia has ever done of its education workforce. It has communicated to teachers, principals, and staff that the ministry is making an effort to keep track and hold people accountable and that abandoning one’s post will result in removal.

By February 2018, a third-party audit confirmed that almost all of Liberia’s 19,500 teachers had their qualifications vetted and 73% of them wrote the competency test. Through this process, 2,046 ghost teachers were identified, 83% were removed, and US$2.3 million in annual savings were recouped. The outstanding 17% of ghost teachers were identified in the last six months of the program and will be removed shortly leading to an additional US$800 thousand of annual savings. Gbilia noted that while reaching higher levels of domestic financing can trigger other financing options, an added benefit is a changed mindset within the ministry that they can achieve things domestically over time going forward.

As a result of the fiscal space created within the ministry’s budget and the physical spots available for hire, the ministry of education was able to hire 1,371 new and qualified teachers who were recent graduates of Liberia’s teacher training institutes that provided ministry certification. Furthermore, at least 2,000 qualified teachers who were previously on the supplementary payrolls were transitioned to the higher paying regular payroll, reducing the supplementary payroll from approximately 6,000 to 3,762 teachers. Looking ahead, the data collected has allowed the ministry to estimate that it needs to hire an additional 10,782 principals and teachers to ensure that across the country every classroom has an appropriately paid and qualified teacher. However, despite these significant successes, the last field visits conducted by the ministry found that 15-20% of teachers that had been vetted were not present. It is evident that spot checks will be necessary going forward and norms need to be eroded to communicate to staff that showing up is mandatory and that monitoring is ongoing. Essentially, teacher vetting is important but it must be accompanied by a strategic plan for robust accountability and monitoring with district and county education officers going forward.

The teacher testing component of the project yielded jarring results. Only 6% of teachers passed with a combined score on the math and English papers above 70%. Forty-five percent received a conditional pass between 40% to 69% and 49% failed with less than 40%. While these results make the challenge ahead of improving education outcomes apparent, the data will be a valuable tool for the ministry to design customized training programs to better meet their needs. Werner notes that having this evidence base within the ministry means that they are owning their own data, rather than relying on donors, and that there is intrinsic pride in this. Sheeler adds that data had always been perceived as “for donors” but ministry ownership of data has changed the way the ministry views its role in collaborating with donors. In fact, the new administration now plans to use the results of the test assessment to design its first teacher training and implement it during the next school break for teachers.

As the data continues to be analyzed, it is now becoming apparent that missteps did occur with regards to data management. The project implementation unit prioritized data consolidation but in many cases inconsistencies in data collection and formatting meant that efforts are still being made to reconcile data to create the final consolidated personnel listings. This was likely magnified because of the change in management between the pilot study by USAID and FHI 360 and the remainder of the project by the education ministry.

The results above refer to public school teachers on the regular payroll but analysis to confirm the number of ghost teachers on the supplementary payroll is ongoing. The Civil Service Agency implemented a policy that ghost workers removed from the regular payroll could be replaced but that ghost workers removed from the supplementary payroll had to be deleted. The ministry still needs to analyze how many supplementary deletions occurred so that they can reallocate those funds to hire new teachers to the regular payroll. They estimate that for every two to four supplementary ghost workers deleted they can hire one new teacher on the regular payroll, and ultimately they aim to use the data to migrate all qualified supplementary teachers to the regular payroll.

Reflections: Blinded by the urgency of the moment

Based on conversations with a number of key stakeholders with various levels of involvement in the teacher vetting and testing project, some key reflections on political risk, funding relationships, and transformational leadership emerged.

Looking back as Werner reflects on his feelings at the conclusion of his listening tour, he says, “I was blinded by the urgency of the moment. What I saw in the field pains me and blinded me to the degree that I really wanted to solve problems in the here and now.” Perhaps this naiveté was a blessing as the political risk associated with undertaking the project was much higher than the technical risk. Jamie Cooper, President and Chair of Big Win Philanthropy, comments that “George may not have appreciated the potential political risk…but the upside of that is that he was focused on changing the system and not about protecting himself.” She also notes that Werner’s relationship with President Sirleaf and his efforts to nurture it were critical to her willingness to provide political cover when needed.

The funding relationship upon which this project was built is particularly unique. Toby Eccles, Cofounder and Development Director of Social Finance, reflects that, “In a place with as few resources as Liberia, room to use imagination is extremely limited because there are only incremental changes you can make to the budget.” However, distrust of government, especially those with a history of corruption, is a common sentiment in the international philanthropic space. While the story of Liberia’s project may be appealing to other countries, a key challenge to replicating this experience within a ministry is identifying funders who are willing to give funds directly to government. One of Werner’s clear successes was his ability to attract and develop a relationship with a funder that was open to such an arrangement. While a series of fortunate events led to their meeting, Werner’s plan to campaign externally for funding; President Sirleaf’s willingness to commit in writing to reinvesting funds; and the amenability of both the Liberian government and the Big Win Philanthropy team to negotiate terms of a target-based, incremental funding deal with a third-party auditor in place are all intentional factors that contributed to this unique funding arrangement. Government efforts to recreate some of these elements may be a foundational step to generating trust and allowing such funding relationships to occur more commonly in other settings.

One critical element associated with the aforementioned funding relationship that may not be as easily replicable is the need for a transformational leader. When asked about what attracted her to Werner’s mission, Cooper immediately noted his earnest commitment. She said, “What’s more unique about George than almost any minister I’ve met is his ability to think outside the box, to try something that is really different but can have a tremendous upside.” While his leadership and public speaking skills are well admired, Werner admits that he didn’t prioritize communication domestically as much as he could have. In hindsight he would have had a better communications architecture in place and made use of ‘palava,’ traditional Liberian peace huts, to increase communication with teachers, settle disputes, and promote inclusiveness. Despite the successes, the opportunities for improvement, and the work ahead, Cooper’s final reflection on Werner is that “he resonates with integrity” – and that basic quality may be the key to why the teacher vetting and testing project worked.

Appendix A: Detailed Implementation

The following sections outlining the specific implementation steps of the teacher vetting and testing project were obtained from “Managing the Business of Education: Liberia Cleans up its Teacher Payroll, 2015-2017,” an in-depth case study by Princeton University’s Innovations for Successful Societies.⁷

Winning Support

The implementation team’s first challenge was to work with Gbovadeh Gbilia, Deputy Minister of Education, to secure buy-in from two crucial stakeholders: the Civil Service Agency and the National Teachers’ Association. A lack of coordination between the education ministry and Civil Service Agency was a longstanding problem, and Werner hoped his past role as head of the agency would pave the way for better collaboration.

The Civil Service Agency initially did not see the vetting project as part of its responsibility, arguing that it was up to individual ministries to ensure that personnel listings were accurate. However, because the agency had to sign off on any changes to the listing, the education ministry felt it was vital for agency officials to see the vetting process was legitimate. “In response to the initial lack of cooperation, Werner’s ministry elevated [its lobbying efforts] to another level by going directly to the finance ministry,” said David Baysah, a sociologist and education planning strategist hired to lead the vetting project’s implementation unit.

By explaining that the vetting and testing exercise could save up to US$7.5 million per year—reducing the annual amount spent by the education ministry on salaries from US$34 million to US$26.5 million—the project team secured support from the finance ministry. The team also relayed to the agency and the finance ministry that President Sirleaf had agreed up front that the funds recovered would be earmarked for reinvestment in education, and would not be put into the government’s general coffers.

Convinced by the outreach effort, officials from the Civil Service Agency agreed to have their officials accompany the vetting team as they traveled around the country. The ministry also agreed to pay additional per diems to enable staff from the Civil Service Agency who became part of the team that traveled throughout the country.

In another step to address the disjuncture between the Civil Service Agency and other government departments, the finance minister worked with the agency to introduce a policy amendment in the cabinet. Whereas the agency previously had overarching responsibility for—and substantial control over—ministry payrolls, there was now “a policy, endorsed by the cabinet, that ministries will handle their own payroll and be held accountable for it,” Baysah said. In addition to smoothing the path for the project’s implementation, the finance ministry’s creation of the draft policy promised to give greater power to individual ministries to maintain their own payrolls.

Next, the education ministry turned to the teachers’ association. In negotiations with Werner and senior officials, the association’s main concerns were that no teacher should be fired summarily based on the outcome of the competency testing, that those who failed but held at least a high school qualification should receive training, and that the government should pay adequate severance to any teachers who lost their jobs because they were determined to be “untrainable” for various reasons.

The ministry used an existing forum to open a dialogue with the teachers. Under the teacher training program that ended in 2015, the ministry had established a committee that brought together the teachers’ association, senior education officials, donor partners, and nongovernmental organizations as well as civil society groups. In response to resistance that had emerged among some teachers during the USAID pilot, the ministry framed the new project as one that would remove cheaters and improve payroll management, leading to better salaries. The team presented its plan to the committee in the hope of winning the association’s support.

Despite initial resistance, the teachers’ association’s long-serving president, Ellen Varfley, ultimately agreed to the planned vetting and testing, and the ministry agreed to provide future training opportunities to all teachers deemed trainable, and severance packages to others. In addition to being the teachers’ association president, Varfley also worked in the ministry’s teacher-training division, a position that allowed her to be involved in drafting the test.

In championing the project, Varfley said she hoped that the competency testing in particular would lead to further gains. “After doing the test, we would know if people need content or pedagogical training, which would allow us to design better training” plans, she said. “… We knew that one size does not fit all. Teachers would [ultimately] benefit by receiving better training.”

Managing Data

Before the team could begin collecting data, they needed a way to manage it. They decided to use a common software product, Microsoft Access, to create a database of information that would allow users to see the big picture as well as to focus on specific schools, districts, and counties. Data would enter the system both electronically and manually. After a teacher’s fingerprints were digitally scanned, a computer would generate a unique enrollment number. Using the same number, the team would manually upload information—including digital copies of the teacher’s qualification documents, photo, and ID materials—to the corresponding file in a database, which the team named the Payroll Data Access Tracking System.

When all the information on any particular person was in the system, “you can see the person’s face as well as all their bio data, their current status, their salary history, their health information and also all their academic credentials,” Baysah said. “It’s a one-stop shop.” The cost of setting up the system was minimal because the human resource team was able to use the ministry’s existing computer systems and worked with the ministry’s in-house IT specialist to design the platform.

Once completed, the database was a valuable management tool. In addition to forming the backbone of an integrated future payroll system, the ministry could use it for professional development and to track replacements and transfers between schools. Further, the ministry could use the database to predict how many teachers were set to retire in coming years, enabling the ministry to anticipate future costs and recruitment needs.

Gbilia’s team recognized that keeping the database up to date was crucial to its long-term effectiveness. After completion of the countrywide vetting and testing, education officers in each of the 15 counties would gain access to the database. The plan required the education officers to update the system whenever a teacher was hired, transferred, or otherwise changed status in their region. The national human resources department in Monrovia would then audit the central database every calendar quarter. The ministry’s hope was that, over time, the Access Tracking System managed by Gbilia “would not just be a data management system but also a planning system,” Baysah said.

Getting the Word Out

The team’s next task was to inform teachers about the planned project. In a nation where roads were poor and comparatively few people, particularly in isolated or densely forested rural areas, had access to television and less than half the population had cell phones,⁸ radio was the go-to communications medium. Aware of the need to assuage potential fears among teachers and to inform parents and the general public, the education ministry produced a series of radio spots that played on some of the more than 60 FM radio stations across the country. (Radio jingles and other productions were often used as tools to make public service announcements in Liberia). The education ministry’s radio spots aimed to head off any knee-jerk opposition among teachers by emphasizing that the vetting and testing would not lead to any arbitrary firings. At the same time, the messages reached the wider community, potentially galvanizing public support.

Prior to kicking off the vetting process in any specific county, the field team also distributed flyers at schools and engaged with community leaders and county authorities during town hall meetings. Their aim was not only to encourage public and parental support for the vetting project but to help teachers understand that they ultimately stood to benefit because the cleanup would free up more money for salaries.

“The communication was very clear that the process will lead to results and consequences: At the end of this process, teachers will have better salaries and access to training opportunities. But also, those that cannot be trained will be removed from the system,” Baysah said. “But no one will be just kicked out. … There will be severance packages.”

Public sentiment was on the side of the project team. Many parents were deeply concerned about the quality of education. Afrobarometer research network survey showed that half of all respondents felt the Liberian government handled education “very badly” or “fairly badly.”⁹ “When the teachers heard [the president saying that] if you want to boycott the vetting exercise or test you will be removed, protests stopped immediately,” Gbilia recalled.

The team also worked closely with local district education officers and their county-level supervisors. The local officers, who were well known in their communities, provided additional information to teachers in other areas of their counties. Before they traveled, the project unit and local education officers jointly decided on a feasible schedule and locations across a county (usually in public spaces like schools or town halls) to conduct the vetting and testing.

Vetting and Testing

Teachers from each school received assignments telling them when and where their vetting and testing would take place. While teachers were responsible for their own travel expenses, the ministry paid accommodation and food costs, as needed. The project team divided the teachers—usually about 150—into two groups. One group took the competency test in the morning, while the other group went through the vetting process. In the afternoon, the tasks were reversed. Baysah pointed out that bona fide teachers who happened to be sick on their assigned days were “provided a window for them to come to one of the other vetting venues in the county, or they would have to travel to Monrovia.”

On the assigned day, the vetting process began when school principals submitted personnel lists to the project team. The team then compared each principal’s list to lists submitted separately by district and county education officers, who monitored all schools in their areas. If principals and local officials could not explain why a name appeared on one list and not on the other, the name moved to the “ghost worker” category. This step would enable the ministry, working with the Civil Service Agency, “to get rid of some ghosts,” Baysah said. “It was the first filter.”

The competency test, designed by the education ministry’s teacher training division, contained two papers, one on mathematics and the other on English. Both tests included questions on teaching methods. The test incorporated a combination of different types of questions, including multiple choice, short one-paragraph answers, as well as one longer essay or sample lesson plan based on a prompt. Kammi Sheeler, an economist from the Overseas Development Institute (an independent London-based think tank) who worked with the education ministry on data management, noted that the ministry eventually created four different versions of the test in order to prevent cheating.

While the tests were mandatory only for salaried teachers, the ministry encouraged volunteer teachers to participate. The ministry recommended that volunteers who did well on the test but lacked formal qualifications should attend a teacher training institute and then apply for formal positions. Volunteers who scored well and held teaching qualifications would be in line to replace ghost workers on the payroll. After teachers completed the tests, the team sent the papers to Monrovia, where 25 staff members from Varfley’s teacher training division graded them. The team then uploaded the results to the digital Access Tracking System.

During the vetting part of the day, teachers formed lines behind their principals (all principals and vice principals also had their identities and qualifications reviewed as part of the project). Teachers submitted their credentials to the vetting team, including their national identity cards as well as any documents proving high school and other educational qualifications. Because some Liberians, especially in rural areas, did not have national ID documents, the vetting team also accepted voting ID cards, birth certificates, passports or driver’s licenses. “Almost everyone had at least a voting ID card, but we accepted any of these documents,” explained field supervisor Veekie Wilson.

It was particularly important to confirm dates of birth and the exact spellings of names in order to stop the practice where some teachers received salaries made out in someone else’s name. If the team identified a fake document, they seized the document, and placed the offending teacher’s name on the same list as personnel who did not show up for the vetting process. Just as was the case for teachers who missed the exercise, those who submitted fake documents were given up to two months to provide the proper documentation before their names were submitted to the Civil Service Agency for removal from the payroll.

Similarly, when the team identified a ghost worker, they submitted the name to the Civil Service Agency for removal from the payroll. The agency then sent a letter to the school where the person supposedly worked, calling on the teacher to present his or her credentials to the national education ministry. If the person in question failed to do so during a specified period, the name was removed from the payroll.

The team also regularly encountered qualified teachers who were older than the mandatory retirement age of 65. In some counties, over 10% of the teachers were eligible for pension. When a teacher was older than 65, the team issued the teacher a pensioner’s ID card from the Civil Service Agency, and the Agency official that accompanied the field team recorded that the teacher was eligible for pension. But due to a lack of funding, it often took the Civil Service Agency a long time to issue pensions and remove pensionable teachers from the payroll. In the meantime, many kept teaching to continue earning an income. (The government calculated pension benefits based on length of tenure. For example, a 65-year-old teacher with 30 years of service and a monthly salary of US$100 would get a monthly pension of about US$60).¹⁰

Project staff next made copies of all supporting documents and uploaded digital scans to the Access Tracking System. At the end of the process, teachers who submitted all of the required documents had their fingerprints scanned and were issued special biometric ID cards. (The cards were issued only to qualified teachers who also took the competency test.)

The process was not foolproof. Despite the team’s efforts to work with district and county education officers, local officials still might collude with school principals to get ghost names added to the payroll. For example, if a district and county officer, as well as a local principal, agreed to add a person’s name to their personnel listing, that person could theoretically show up and undergo vetting and testing. In an effort to curb fraud, the team carried out follow-up spot checks a few weeks after completing the vetting process, in order to identify any ghost workers who slipped through the net.

In addition, the biometric system fell short of expectations. The USAID pilot had planned to install biometric card readers at all public schools. Teachers who had been vetted could then use their biometric cards to clock in and out of work every day, reducing the opportunities available for ghosts, tracking absenteeism, and generating useful data. When the project team took over, they found that about 400 card scanners had already been purchased by the education ministry as part of the Liberia Teacher Training Program. “But we have around 3,000 public schools, so that was not enough. Many of the machines were already quite old, so we didn’t know how many still worked,” Baysah said. Another problem was that “every year you would have to pay a license fee of US$20,000 to continue using the software, but that did not include maintenance costs.”

The field team also experienced problems with the machines used to capture biometric IDs, which meant that some fingerprints were not recorded. The project team also decided not to install the 400 scanners. For those teachers who did receive IDs, the cards were still useful in proving their identities. But the money spent on the scanners was effectively wasted, and the technical problems with some data-capturing machines meant that not all teachers had their biometric information captured.

Refrences

1. David Smith, “All 25,000 candidates fail the Liberian university entrance exam,” The Guardian, August 27, 2013; https://www.theguardian.com/world/2013/aug/27/all-candidates-fail-liberia-university-test
2. Ministry of Education, Liberia education statistics report 2015-16; http://moe.gov.lr/documents/
3. United Nations Development Program, Human Development Data: Education Index (2015 ranking); http://hdr.undp.org/en/data
4. Ministry of Education and UNESCO, Assessment of teacher education and development needs to ensure education for all, June 12, 2014; http://unesdoc.unesco.org/images/0023/002330/233080E.pdf
5. Leon Schreiber, Blaykyi Kenyah, “Managing the business of education: Liberia cleans up its teacher payroll, 2015-2017,” 2018, Innovations for Successful Societies, Princeton University; https://successfulsocieties.princeton.edu/sites/successfulsocieties/files/LS_Liberia_Payroll_FORMATTED_27_Feb_18_LS-2%20TDedit2Apr17.pdf
6. Ministry of Education, Liberia Education Sector Analysis, November 2016.
7. Leon Schreiber, Blaykyi Kenyah, “Managing the business of education: Liberia cleans up its teacher payroll, 2015-2017,” 2018, Innovations for Successful Societies, Princeton University; https://successfulsocieties.princeton.edu/sites/successfulsocieties/files/LS_Liberia_Payroll_FORMATTED_27_Feb_18_LS-2%20TDedit2Apr17.pdf
8. The Mobile Economy 2014, GSMA Intelligence; http://www.gsmamobileeconomyafrica.com/GSMA_ME_SubSaharanAfrica_Web_Singles.pdf
9. Afrobarometer, Handling addressing educational needs, Round 6 2014/2015; http://afrobarometer.org/online-data-analysis/analyse-online
10. Civil Service Agency, Guide to Civil Servants’ Pension, October 2013; http://csa.gov.lr/public/doc/Pension%20Brochure_CSA_Oct3.pdf

Introduction and Overview

Policymakers can use investments in health and health systems to create value in two distinct but related ways: by generating “value for money” and “value for many”.¹ Value for money refers to the relative magnitude of a positive output or outcome relative to the size of investment, typically measured using cost effectiveness tools, whereas value for many refers to the distribution and equity of the outcome among the population. Thus, government officials must carefully consider how to prioritize budgets in order to generate the most value, defined broadly, in their country.

The total size and allocation of a budget for health expenditures can have direct and indirect impacts on population health.^2,3 Indeed, low- and middle-income countries (LMICs) with similar Gross Domestic Product (GDP) levels, similar health expenditures as a proportion of GDP, and similar per person expenditure levels on health have highly varying health outcomes on a number of dimensions, including life expectancy, infant mortality, maternal mortality, and availability of treatment for diseases such as HIV and diabetes.⁴

In addition, investing in health also brings distinct economic benefits for the country^5–10 and political benefits for the policymakers who choose to prioritize health. Microeconomic evidence suggests that healthy development of children allows for increased income later in life and general health of adults has positive impacts on their income. At the macroeconomic level, health of the population can lead to growth in the country’s economy through increased labor productivity, increased incentives for individuals to invest their incomes due to longer life expectancy, and a “demographic dividend.” With regards to the political implications of allocating resources for health, health is a major concern among the public in countries of all income levels, including low-income countries.¹¹ Cases from Turkey, Brazil, and the UK demonstrate that government prioritization of health investments can have a positive impact for governing parties that commit to investing in and strengthening health systems.

This document provides an overview of four key questions that policymakers can consider when determining how to generate the most value through health budget priority-setting:

1. What values underlie the government’s priorities for the country?
2. Based on these values, what goals for the healthcare system does the government hope to achieve?
3. Based on these goals, where should the government allocate its financial resources for health?
4. How should the government allocate its financial resources for health?

We will first address these questions and then consider the potential health, economic, and political consequences of various health budget allocation decisions.

What Values Underlie the Government’s Priorities for the Country?

Although a broad range of values can drive the government’s approach to resource allocation, these value sets generally fall into three broad categories: utilitarian, liberal, and communitarian.⁵

Utilitarians are consequentialists and focus on the value, or utility, that a policy or other decision will have. Using a consequence-based approach to decision-making, utilitarians generally believe “the ends justify the means” (assuming “the means” involve ethical and legal decisions). Policy analysis tools such as cost-effectiveness and cost-benefit analysis reflect utilitarian concerns of generating the greatest outcome for the greatest number of people using the fewest possible resources. Of course, predictive uncertainty about the total utility that a policy will generate causes difficulty for utilitarians. Further, utilitarians differ in how they would choose to measure total utility. Subjective utilitarians argue that value is subjective to the individual and that individuals must judge their own happiness for themselves. Accordingly, subjective utilitarians might measure the total utility of a product or service using the price that a person would willingly pay for it. In contrast, objective utilitarians argue that individual’s choices are not always rational or valid and that an objective index of well-being is better suited to measure utility. Such indices include Disability-Adjusted Life Years (DALYs) and Quality-Adjusted Life Years (QALYs), which are composite indices combining number of years lived as a result of an intervention (adjusted for disability or quality of those years lived); health economists employ these measures in cost effectiveness analyses in order to compare and argue for certain policies over others. Some might describe pure utilitarianism as “ruthless” in that it can justify excluding certain populations who would cost too much to treat (e.g. rural populations without easy access to a medical facility). Hence, equity is not the primary concern of utilitarians, who are more likely to prioritize efficiency and effectiveness.

Liberals take a rights-based approach to allocation of health resources. Liberals believe that all humans have the capacity and obligation to display mutual respect to each other, and this mutual respect endows individuals with rights, or “claims that all individuals can make on each other by virtue of their humanity.” Some liberals, known as libertarians, focus only on negative rights, which guarantee individual freedom. For example, libertarians might focus on the rights of the individual to choose their physician. In contrast, egalitarian liberals also emphasize the importance of positive rights, or a minimum level of resources and services, which can guarantee the ability for an individual to exercise his or her free choices. Accordingly, egalitarian liberals tend to favor redistribution of resources in order to ensure that the entire population has access to basic positive rights. However, with regards to prioritizing health, egalitarian liberals differ in their views on whether individuals have a right to health services (i.e. provision of and access to care) or health status (i.e. the achievement of general well-being).

In contrast to the first two value sets described, communitarians do not focus on the level of the individual in assessing a policy, but rather on the level of the community or society; in other words, they recognize the social nature of life in their assessment of policies. As such, communitarians evaluate the merit of a policy on whether it adheres to a community’s value set and whether it promotes individuals and a society consistent with that value set. Thus, communitarians would generally oppose a health policy which achieved positive population health outcomes with an intervention that defied local cultural norms or values. Communitarians fall into two broad categories: those who believe in a single set of values which would promote a better society (universal communitarians), and those who argue that each society should set its own values and norms based on the context-specific factors (relativist communitarians).

Before moving on to discuss how values could lead to different goals for the healthcare system, one should note that these value sets are not necessarily mutually exclusive. Policymakers might include both a utilitarian and communitarian perspective in an analysis where they prioritize health interventions based on their objective utility, but choose to exclude any that overtly defy local norms. Further, governments can modify their ethical values as they learn more about a population’s needs and their ability to meet those needs. However, it is important to maintain adequate “coherence and explicitness” when articulating one’s values; doing so creates transparency for the population and gives others the opportunity to agree with the government’s choices because they can understand the rationale behind these choices.

Based on These Values, What Goals for the Healthcare System Does the Government Hope to Achieve?

Policymakers must consider which outputs and outcomes to prioritize when allocating resources for health investments. In this context, the term outputs refers to how well the health system performs its delivery of personal and public health services to the population, whereas outcomes, also known as goals, refer to the ultimate ends that the health system aims to achieve. These goals include health status, financial protection, and user satisfaction. (See Figure 1 for an overview of a health system’s functions, objectives, outputs, and outcomes.) In many cases, strong delivery of health systems outputs is necessary but not sufficient for strong performance on health systems outcomes. Below we discuss how a policymaker might prioritize health systems outputs and outcomes, and how the three value sets described above might influence the balance of objectives a policy maker might have in relation to health system outputs and outcomes.

A policymaker needs to balance four key objectives for the outputs achieved by a health system: equity, efficiency, effectiveness, and responsiveness.¹² The four objectives for health systems outputs are:

• Equity refers to the differences in how a policy affects people of different groups. The most common concern is equity among populations of different income groups in relation to access to health system outputs or in relation to health outcomes. Other equity issues, such as disparities between rural and urban populations, also should and often do inform policy. An analysis of a policy’s “vertical equity” takes into account its differential impact across populations at different income levels, whereas an analysis of “horizontal equity” looks at whether the policy treats individuals at the same income level the same.⁵
• Efficiency has been defined many ways in the fields of policy analysis. For the purposes of health systems analysis, we define efficiency using the concept of technical efficiency, drawn from economics. Technical efficiency accounts for whether society is producing the most goods and services for the least cost.
• Effectiveness refers to whether interventions are evidence-based and safe.¹² In other words, an effective intervention will achieve the desired health outcomes.
• Responsiveness refers to whether the health system meets the public’s legitimate nonmedical expectations. Responsiveness is a highly subjective measure and depends on the perceptions among citizens of a health system’s functioning.¹³

Without a doubt, policymakers’ values will influence which health system objectives they choose to prioritize for the health system outputs. For example, pure utilitarians will likely care most about efficiency and effectiveness, and they will less likely prioritize equity. They might also disregard the importance of responsiveness as an objective, unless they believe that a health system’s responsiveness generates value for the population. Liberals, who focus on individuals’ rights, will prioritize equity and responsiveness of the system, with libertarians emphasizing the importance of choice and egalitarian liberals emphasizing the equity in access to positive rights (e.g. basic health services and medicines). Communitarians, who emphasize society’s values, will prioritize the objectives most relevant for achieving the best possible society. Accordingly, they will likely emphasize responsiveness and equity of the system at a societal level.

In addition to setting objectives for health systems outputs, policymakers must also pay attention to the health systems outcomes, or the overall goals for a country’s health system. These fall broadly into three categories: population health status, financial risk protection, and citizen satisfaction.^5,12

• Health status refers to the actual health of a population. Measurements of population health status include life expectancy, burden of disease, mortality rates for specific groups (e.g. infant mortality and maternal mortality), and prevalence of specific diseases.
• Financial risk protection refers to helping people avoid very large and unpredictable payments for health, sometimes known as catastrophic expenditures. Mechanisms to provide financial risk protection typically involve insurance schemes with risk-pooling functions. Measuring levels of financial risk protection can be difficult because a person having insurance coverage does not necessarily mean that they have coverage for a complete package of basic medicines and services. In addition, individuals may technically have insurance to cover medicines and services, but they may not actually have access to these services (e.g. due to geographic disparities, physician shortages, or drug stockouts), thereby rendering their insurance coverage of little value.
• Citizen satisfaction refers to the degree with which users of the health system rate the system as satisfactory. Citizen dissatisfaction with the health system can serve as a major catalyst for reform, as we will discuss later. Measuring citizen satisfaction typically involves conducting surveys with citizens and possibly evaluating their willingness to pay for services.

As with health systems outputs, health systems outcomes also derive directly from the value sets described earlier. For example, objective utilitarians might concern themselves most with the population’s average health status, whereas egalitarian liberals might focus most on the range of health status (as a measure of equity levels). Egalitarian liberals will also emphasize the importance of financial risk protection as a means for ensuring minimum economic opportunities for all. Subjective utilitarians might place a high value on citizen satisfaction, as would libertarians (in the sense that satisfaction relates to an individual’s level of choice.)

Based on These Goals, Where Should the Government Allocate Its Financial Resources for Health?

Once the government has identified its objectives for the outputs and outcomes of the health system, it can decide upon specific programs or interventions to achieve these goals and allocate budgets accordingly. In this section, we describe the decisions a government faces about where to allocate its resources. In the next section, we describe a process and framework for making these allocation decisions.

As shown in Figure 1, a health system has four main functions which a government can prioritize for investment to develop a well-functioning health system: governance and organization, health financing, resource management, and healthcare / public health services. Governments can also choose to invest in specific disease programmes or interventions, as discussed below.¹²

• Governance and organization encompasses the organizations and institutions involved in delivering products and services to citizens.¹⁴ The organization of the health system includes hospitals, primary care clinics, and supply chains which provide medicines to providers. A government could choose to invest in the governance and organization of the health system, for example, by updating management policies for health facilities, changing the referral network of the system, or improving processes for decision-making at the programmatic level.
• Health financing involves the provision of insurance plans to offer financial risk protection to citizens. Mechanisms for doing so include public insurance, social insurance, and community-based health insurance.³ A government could choose to invest in health financing by creating a new insurance scheme, expanding coverage of existing insurance to new patient populations, or by expanding the range of services covered under existing schemes.
• Resource management entails overseeing the inputs that go into the provision of health care, such as human resources and labor, pharmaceuticals, and medical technologies.¹⁴ The government can invest in the management of resources by purchasing these resources (e.g. through the procurement of drugs or hiring of doctors), or by improving systems that oversee resources (e.g. budgeting tools, health information systems) or that deliver them (e.g. through supply chain management systems).¹⁵
• Healthcare and public health services refers to all of the activities actually involved in delivering care to patients and which can be facilitated by strengthening health systems. These activities include doctor’s visits, surgeries, health education and training for citizens, and the distribution of relevant health-related products. Governments also invest in specific services that generate value for money and value for many – for example highly cost effective interventions that have population impact. These include health promotion to change risk behavior (for example to stop tobacco smoking, reduce alcohol intake, exercise, eat healthy food, undertake physical activity, practice safe sex, among others), prevention services (immunization, voluntary male circumcision, condom use, use of insecticide treated nets, for example), and treatment (such as antiretroviral treatment for HIV, treatment for tuberculosis, malaria, chronic illness – high blood pressure, heart disease or diabetes mellitus for example) and care.

Several investment frameworks have been developed to identify “good buys”, for example those identified by the Lancet Commission on Investing in Health¹⁶; UNAIDS HIV Investment Framework¹⁷; STOP TB Strategy¹⁸; the Global Strategy for Women’s and Children’s Health spearheaded by the UN Secretary General¹⁹; interventions identified in the Global Malaria Action Plan²⁰; and the Package of Essential Noncommunicable Disease Interventions (also known as WHO-PEN).²¹

How Should the Government Allocate Its Financial Resources for Health?

Of course, when deciding where to allocate resources for health, policymakers face many questions. Some relate directly back to the question of equity. For example, one must consider whether policy interventions should target populations that are poor or middle-class, urban or rural, working-age or the young and elderly? Others relate to the effectiveness and efficiency of the system. Should the government prioritize investment in health systems, in expensive interventions which lead to guaranteed improvements in outcomes, or in less expensive intervention that have some risk of failing? With regards to responsiveness, policymakers might face a dilemma when they decide whether to implement an effective intervention that may conflict with local cultural norms and demands.

Unfortunately, there is no algorithmic formula for determining which health interventions or areas to prioritize, and limiting analyses to comparisons of cost-effectiveness is insufficient. Without universal consensus on principles for prioritization, governments need another approach to make allocations and justify their decisions.²² Accordingly, several ethicists have proposed a framework known as “accountability for reasonableness” (A4R) to guide this decision-making process. A4R is a process, grounded in democratic principles, which aims to legitimize decision-making among “ ‘fair-minded’ people who seek mutually justifiable terms of cooperation.”²³

A4R has four key conditions, which we quote from Gruskin and Daniels (2008) below:

1. Publicity condition: Decisions that establish priorities in meeting health needs and their rationales must be publicly accessible.
2. Relevance condition: The rationales for priority-setting decisions should aim to provide a reasonable explanation of why the priorities selected were determined to be the best approach. Specifically, a rationale is reasonable if it appeals to evidence, reasons, and principles accepted as relevant by fair-minded people. Closely linked to this condition is the inclusion of a broad range of stakeholders in decision-making.
3. Revision and appeals condition: There must be mechanisms for challenge and dispute and, more broadly, opportunities for revision and improvement of policies in light of new evidence or arguments.
4. Regulative condition: There must be public regulation of the process to ensure that conditions 1, 2, and 3 are met.

One should note that A4R does not lay out priorities for government investments, but, rather, a process for publicly and legitimately determining these priorities in order to guide investment decisions. The principles of A4R have shaped priority setting for health in many places such as: UK, where the National Institute for Health and Clinical Excellence (NICE) takes social value judgments into account when making recommendations about coverage for new treatments; Mexico, where decisions about which diseases the public catastrophic insurance should cover involve working groups that evaluate the clinical, economic, ethical, and social considerations; and Oregon where, in 2008, a Health Fund Board made a plan to insure all legal residents of the state involving a wide group of stakeholders and extremely transparent decision-making / information-sharing.

The Impact of Government Health Spending (GHS) on Health Outcomes

In the preceding sections, we have discussed the various frameworks policymakers can use to determine where to allocate resources, as well as a process for doing so. It is also instructive to examine the evidence for the potential implications of these investments. In this section, we discuss the implications of allocating resources for health on the health outcomes of the population. In the next sections, we discuss the implications of allocating resources for health on the economy and political landscape of a country.

Changes in government health spending (GHS) can have a direct impact on cause-specific mortality. For example, in low-income countries (LIC) a 1% decrease in GHS is associated with an increase of 18 deaths for every 100,000 live births in the neonatal period and 98 deaths before the age of five for every 100,000 live births.²⁴ The statistical significance of this result held even when controlling for economic conditions, infrastructure, infectious disease rates, and private health spending rates. Similar results were found when only examining infant mortality in Africa and, with slightly less extreme results, for high-income countries (HIC).²⁵ Globally, a 1% increase in GHS is also associated with a significant decrease in cerebrovascular deaths.^24,26 And research among European Union countries has found that a 1% decrease in GHS is associated with increased maternal mortality.

Research coming out of IMF also suggests that increasing GHS and improving its efficiency can increase overall life expectancy in a country.⁹ For example, among African nations below the regional average for GHS, increasing GHS to the regional average would improve health adjusted life expectancy (HALE) by 1.2 years. In Asia / Pacific, this figure would improve by 0.9 years, and in Middle East / Central Asia, this figure would improve by 4.1 years. In addition, among African nations below the regional average for efficiency in GHS, increasing efficiency to the national average would result in an increase in HALE by 1.5 years. In Asia / Pacific, this figure is 1 year, and in Middle East / Central Asia, this figure is 1.3 years.

Achieving the health systems goal of financial risk protection through universal health coverage (UHC) can also improve population health status. Cross-country statistical evaluation of the influence of insurance coverage on health outcomes suggests that financial coverage has a causal influence on health, especially for low-income individuals, who gain better access to necessary care when they receive coverage.²⁷ Examination of individual countries’ experiences implementing UHC supports this finding. For example, Thailand’s Universal Coverage Scheme (UCS) included benefits such as inpatient and outpatient care, surgery, accident and emergency visits, dental care, diagnostics, prevention and health promotion, and medications, and UCS increased utilization of many health services, including inpatient and outpatient visits.^28,29 UHC in Turkey improved access to maternal and child health services, resulting in a significant decrease in infant mortality, as well as an improved ratio of physicians-to-patients across the country.¹²

Similarly, across many Latin American countries, health has been established as a constitutional or legal right, and many countries have expanded primary care as part of a platform universal health coverage.³⁰ This push for universal coverage has led to significant decreases in infant mortality, under-5 mortality, and maternal mortality across most Latin American countries between 1990 and 2010.

Finally, one should note that efficiency and effectiveness in treating specific sets of disease can change over time as medical technologies and approaches to care delivery shift.³¹ For example, treatments for cataracts and depression have shown increases in the productivity of care following a decrease in per-case treatment costs. In contrast, per-case treatment costs have increased for other complex treatments and procedures, such as those associated with childbirth, but the improved health outcomes associated with these costs make the investments worthwhile.

These data provide empirical evidence that governments can directly promote improved health outcomes for citizens through government health spending, but policymakers must allocate funds wisely in order to achieve their desired outcomes.

The Impact of Improved Health on the Economy

Evidence also suggests that improved population health has positive economic impacts for a country. Since, as we have already shown, GHS can have a positive impact on population health, one might argue that GHS has a “return on investment” in the form of stronger economic output for the country. Evidence for the linkage between health and increased economic output exists at both the microeconomic and macroeconomic level.

At the microeconomic level, better health can improve the financial prospects for individuals and households.⁶ In particular, malnutrition, frequent illness, and unstimulating home environments can limit the physical and cognitive development of a child. On the other hand, proper nutrition and health allows for the adequate physical development of children and improved performance in school. Thus, investments at an early age “help to raise the potential for long-term academic and workplace success and lifelong well-being.”⁶ Among working individuals, research using the cost-of-illness approach indicates that falling ill can have direct, negative consequences for their income. The mechanisms linking ill health to reduced income include decreased productivity at work, long-term separation from the work force, and disengagement from other economic activities. Interventions targeting specific diseases and conditions, such as deworming for school children, iron supplements and iodine to treat malnutrition, and malaria prevention can all lead to improved education or income outcomes for individuals.⁷

Macroeconomic evidence also supports the idea that investing in health generates positive economic returns.⁷ In particular, there are four channels through which investments in health might improve the overall economic state of a country, all of which are corroborated by the microeconomic evidence described above. First, ceteris paribus, a healthy workforce will have higher labor productivity than an unhealthy workforce due to increased energy and reduced illness-related absenteeism. Second, a healthy population has increased educational opportunities, and education levels have a direct impact on income growth for a country. Third, populations with high life expectancies will tend to save more for the future and likely will have more working years. These increased savings can lead to increased investable capital, an important driver of growth.

Fourth, health investments that change mortality rates and total fertility can lead to demographic shifts which benefit the economy through a mechanism known as the “demographic dividend.” Often, when a country experiences a sudden improvement in health (e.g. due to the introduction of a new set of vaccines), the total fertility rate remains high for a while, but the infant mortality rate declines rapidly. This dynamic leads to a “baby boom.” Eventually, fertility rates begin to decline as couples realize that more of their infants will survive, and the original baby boom cohort reaches working age. Thus, the ratio of working-age to non-working-age people in the country increases and productive capacity increases on a per capita basis. In other words, countries that experience this demographic shift have a greater percentage of the population contributing to the economic output at any given time. Assuming that the country has or can create certain conditions to enable productivity of this working-age group (e.g. proper educational opportunities), the country will experience a “demographic dividend” that leads to its growth. This demographic dividend accounts for up to one-third of the economic boom that many East Asian countries experienced between 1965 and 1990.

Expenditures on antiretroviral therapy (ARVs) for people living with HIV/AIDS provide a useful case study of a health investment with significant health and economic returns.³² By the end of 2011, 3.5 million patients were on ARVs co-financed by the Global Fund, and 80% of those patients lived in 20 African countries. The total cost of treating these patients from 2011 to 2020 is estimated at $14.2 billion. This health investment will save up to 18.5 million life-years. Further, it will yield up to $34 billion in economic benefits (for a net benefit of up to $19.8 billion) through three primary channels: $31.8 billion in labor productivity improvements, $0.83 billion in orphan care costs averted, and $1.4 billion from the delay of end-of-life care.³²

The Impact of Health Investments on the Political Landscape

Without question, the process of formulating health policy and allocating resources to health depends on the political structure and climate of a country, and, as such, has implications for the country’s political outcomes. Although a complete analysis of the way that politics and health systems reform shape each other is beyond the scope our analysis is here, it is instructive to point out explicitly that the two do matter for each other.⁵ Political processes shape health sector reform, and health sector reform (or lack thereof) has direct and indirect consequences for politics and politicians. For example, the move towards universal health coverage (UHC) has had distinct positive political benefits in many countries over the last several decades.³³ (Figure 2 provides an overview of programs implementing UHC and the reasons for doing so in various countries.) In this section, we consider three case studies where health policy had direct implications for the political process: Turkey, the UK, and Brazil.

Brazil’s Health System Restructuring During Political Transition

In the decades leading up to the re-democratization of Brazil between 1985 and 1988, the military dictatorship had generally deprioritized the protection of social rights, including health, education, and adequate living conditions.^35,36 In particular, the fragmented health system left large portions of the population without access to care. Against a backdrop of general discontent with the government, a funding crisis in the social security system motivated a “public health movement” that prioritized UHC and decentralization of health delivery. Health reforms to address the system’s issues began in the 1980s. They gained a strong legal basis when the 1988 constitution formally defined health as a “citizen’s right and obligation of the state” and established the Unified Health System (SUS), which sought to unify the fragmented care delivery network into a national health system under the purview of the MoH.³⁵

In order to appease the private sector, who opposed the government overtaking all healthcare delivery activities and who already provided care for many who had social insurance, the government focused its strategy on primary care delivery. The main component of the primary care delivery system Family Health Strategy (FHS), which consists of “multidisciplinary teams of health professionals… responsible for a defined territory and population with whom they establish contact and share responsibility for health care.”³⁵ FHS involved transfers of funding to the municipality level based on the total number of people each municipality served (which incentivized expansion of the program to cover more people), clear roles and responsibilities at different levels of government, and a robust monitoring and evaluation (M&E) system that supported continuous improvement. The government made results from this M&E system publicly available in order to promote transparency and accountability to the public. This strategy has served expanded deliver healthcare to the poor and to place an emphasis on preventative care, although many are still left behind. Today, 75% of Brazil’s population, or 195 million people, receive services and coverage from SUS.³⁷

Today, Brazil is facing high levels of dissatisfaction once again. In the past two years, the public has staged protests against low GHS and a system which, once again, has become fragmented and somewhat unresponsive.³⁷ In the 2014 general election, the incumbent President, Dilma Rousseff, was re-elected by a narrow margin despite this public dissatisfaction of government resources, and many attribute her successful re-election to her government’s focus on anti-poverty programs.³⁸ She now has the challenge of fulfilling campaign promises to use increased government revenues to raise healthcare spending, with a particular focus on improving the quality and number of public hospitals and healthcare professionals.

Public Engagement with UK’s NHS

The UK’s National Health Service (NHS) provides an example of a health population deeply engaged in the political dimensions of health delivery.¹ A proud establishment of the UK’s public sector, the NHS is generally ranked as a high-performing health system among high-income countries.³⁹ Further, an overwhelming majority of the population supports the existence of the NHS and its founding principles, with 89% of the public agreeing with the idea of a tax-funded national health system which the government runs. In spite of this broad support, however, the NHS still faces a number of challenges with regards to user satisfaction and future directions. On the one hand, 65% of the population is satisfied with the care they receive, and only 28% of the public reports worsening standards of care among the NHS. At the same time, however, 51% of the public believes that the NHS “often wastes money,” and this figure exceeds 60% for individuals over age 48. Accordingly, 58% of the public would not support spending cuts to other public services in order to increase spending for the NHS. These perceptions vary by the level of engagement with NHS, with individuals who have received more care from the NHS having better views of the organization than those who have had less contact with the system.³⁹

The high level of engagement among the public with the NHS, coupled with some perception issues, poses a challenge to the NHS, particularly as it faces a funding issues. Indeed, projections show that by 2030, the NHS will have a £65 billion funding gap. In addition, the NHS will face four key transitions that will force the government to rethink the structure and role of the NHS: a demographic transition to an older population, an epidemiologic transition to more chronic illness and multimorbidity, an economic transition with a widening income gap across the country, and a social transition to a public that places a high degree of value on responsiveness of the system and personalization of care. UK policymakers will have to balance the competing health, financial, and social demands placed on the NHS in order to maintain its relevance going forward.³⁹

Figures

Figure 1. Health systems functions, outputs, and outcomes.

Figure 2. Representative list of reforms implementing universal health coverage.

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