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106 Fighting the Diseases of Poverty
(Sari, Langenbrunner and Lewis, 2000).
Informal payments are much more widespread than commonly
thought. Indeed, donors and governments have urged banning user
charges in the interests of equity in access to health services.
Sweeping removal of a reliable source of revenue for equity reasons
means that those who can and cannot pay receive free care.
However the strategy could simply encourage under-the-table
payments from both sets of patients since patients already pay and
in some cases can afford treatment. While there is some suggestion
from Kyrgyz Republic (Kutzin et al., 2003) and Cambodia (Barber,
Bonnet and Bekedam, 2004) that instituting formal fees can serve to
curtail informal payments, the impact of removing fees has not been
assessed. Anecdotal evidence suggests a rise in informal arrangements,
but documentation has not confirmed this.
Mismanagement in health care service delivery
Often irregularities and poor governance simply stem from poor
management. Where incentives for strong performance either don’t
exist or are undermined by ineffective management it is not surprising
that productivity and performance suffer. For example, if
staff advancement caps after a single promotion, a common pattern
in many countries, then the incentives to excel are diminished. By
the same token the inability to fire public sector staff even in the
face of embezzlement or nonattendance erodes managers’ authority
and the public sector’s ability to hold staff accountable. The lack
of carrots and sticks dis-empowers public management and thwarts
efforts at accountability.
Evidence on mismanagement is spotty. The core issues include
human resource management and supervision, basic subsystems
function (e.g., procurement, drug logistics), efficiency of fiduciary
transfers, input availability, and satisfaction of the target population.
Overall management of health systems, hospitals and clinics typically
fall to physicians, few of whom have the training or experience
necessary to effectively carry out their jobs. This poses a major