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The)]TJ T* 0.0051 Tc [(paper would not have been possible)]TJ T* 0.005 Tc (without the pioneering studies by)Tj T* [(POLICY)-150.7(�)19.8(s overseas staf)-22.2(f, including Gadde)]TJ T* 0.0051 Tc [(Narayana, Issa Almasar)-73.2(weh, and Andriy)]TJ T* 0.005 Tc [(Huk. Finally)73.7(, we would like to thank)]TJ T* 0.0051 Tc [(Elizabeth Schoenecker of USAID for her)]TJ T* 0.005 Tc [(helpful comments. 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)Tj /F1 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 0.7174 0 TD -0.0001 Tc 0.0259 Tw (setting up a collaborative system with)Tj 0 -1.3043 TD -0.0002 Tc (managers and providers for identifying)Tj /F2 1 Tf 23 0 0 23 54 632.2268 Tm /Cs9 cs 1 scn 0.03 Tw [(Executive Summar)-38(y )]TJ ET Q endstream endobj 10 0 obj << /Type /Page /Parent 123 0 R /Resources 11 0 R /Contents 12 0 R /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 11 0 obj << /ProcSet [ /PDF /Text ] /Font << /F1 132 0 R /F2 136 0 R /F5 101 0 R >> /ExtGState << /GS1 140 0 R /GS2 97 0 R >> /ColorSpace << /Cs5 135 0 R /Cs9 138 0 R /Cs10 98 0 R >> >> endobj 12 0 obj << /Length 4856 >> stream 1 g /GS1 gs 0 792 m 0 792 l f q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 cs 1 scn 0 792.06 68.67 -172.14 re f Q q 1 i -9 670.62 117 -64.91 re W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.4 scn /GS2 gs -4.193 654.284 m 2.992 654.284 8.816 648.459 8.816 641.274 c 8.816 634.089 2.992 628.264 -4.193 628.264 c -4.193 654.284 l f 21.827 654.284 m 29.012 654.284 34.836 648.459 34.836 641.274 c 34.836 634.089 29.012 628.264 21.827 628.264 c 21.827 654.284 l f 47.847 654.284 m 55.032 654.284 60.856 648.459 60.856 641.274 c 60.856 634.089 55.032 628.264 47.847 628.264 c 47.847 654.284 l f 73.867 654.284 m 81.052 654.284 86.876 648.459 86.876 641.274 c 86.876 634.089 81.052 628.264 73.867 628.264 c 73.867 654.284 l f Q q 1 i 56.03 25.74 m 56.03 20.347 51.653 15.97 46.26 15.97 c 40.867 15.97 36.49 20.347 36.49 25.74 c 36.49 31.133 40.867 35.51 46.26 35.51 c 51.653 35.51 56.03 31.133 56.03 25.74 c W* n /Cs10 cs 0.8 scn /GS2 gs 36.49 35.51 19.54 -19.54 re f 0.65 scn 56.615 37.648 m 56.615 35.732 55.062 34.179 53.146 34.179 c 51.23 34.179 49.677 35.732 49.677 37.648 c 56.615 37.648 l f 49.919 34.383 m 49.919 32.467 48.365 30.914 46.449 30.914 c 44.533 30.914 42.98 32.467 42.98 34.383 c 49.919 34.383 l f 43.222 37.645 m 43.222 35.729 41.669 34.176 39.753 34.176 c 37.837 34.176 36.283 35.729 36.283 37.645 c 43.222 37.645 l f 56.615 30.71 m 56.615 28.794 55.062 27.24 53.146 27.24 c 51.23 27.24 49.677 28.794 49.677 30.71 c 56.615 30.71 l f 49.919 27.444 m 49.919 25.528 48.365 23.975 46.449 23.975 c 44.533 23.975 42.98 25.528 42.98 27.444 c 49.919 27.444 l f 43.222 30.707 m 43.222 28.791 41.669 27.237 39.753 27.237 c 37.837 27.237 36.283 28.791 36.283 30.707 c 43.222 30.707 l f 56.615 23.771 m 56.615 21.855 55.062 20.302 53.146 20.302 c 51.23 20.302 49.677 21.855 49.677 23.771 c 56.615 23.771 l f 49.919 20.505 m 49.919 18.589 48.365 17.036 46.449 17.036 c 44.533 17.036 42.98 18.589 42.98 20.505 c 49.919 20.505 l f 43.222 23.768 m 43.222 21.852 41.669 20.298 39.753 20.298 c 37.837 20.298 36.283 21.852 36.283 23.768 c 43.222 23.768 l f 56.615 16.832 m 56.615 14.916 55.062 13.363 53.146 13.363 c 51.23 13.363 49.677 14.916 49.677 16.832 c 56.615 16.832 l f 43.222 16.829 m 43.222 14.913 41.669 13.36 39.753 13.36 c 37.837 13.36 36.283 14.913 36.283 16.829 c 43.222 16.829 l f Q q 1 i 56.59 25.74 m 56.59 20.071 51.989 15.47 46.32 15.47 c 40.651 15.47 36.05 20.071 36.05 25.74 c 36.05 31.409 40.651 36.01 46.32 36.01 c 51.989 36.01 56.59 31.409 56.59 25.74 c W* n /Cs9 CS 0.4 SCN 0 J 0 j 2 w 10 M []0 d 56.59 25.74 m 56.59 20.071 51.989 15.47 46.32 15.47 c 40.651 15.47 36.05 20.071 36.05 25.74 c 36.05 31.409 40.651 36.01 46.32 36.01 c 51.989 36.01 56.59 31.409 56.59 25.74 c s Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F2 1 Tf 11 0 0 11 41.6865 22.8189 Tm /Cs5 cs 1 1 1 sc -0.0004 Tc 0 Tw (vi)Tj /F1 1 Tf 11.5 0 0 11.5 116.25 711 Tm 0.161 0.145 0.149 sc -0.0002 Tc 0.026 Tw [(operational bar)-30(riers to high-quality)]TJ 0 -1.3043 TD -0.0005 Tc 0.0263 Tw (reproductive health care; )Tj /F5 1 Tf /Cs9 cs 1 scn -0.7174 -1.3043 TD 0 Tc 0 Tw (
)Tj /F1 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 0.7174 0 TD -0.0001 Tc 0.0259 Tw [(conducting analyses to deter)-26(mine the)]TJ 0 -1.3043 TD -0.0003 Tc 0.0261 Tw [(operational policy roots of those)]TJ T* -0.0002 Tc [(bar)-30(riers; and)]TJ /F5 1 Tf /Cs9 cs 1 scn -0.7174 -1.3043 TD 0 Tc 0 Tw (
)Tj /F1 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 0.7174 0 TD -0.0002 Tc 0.026 Tw (adopting recommendations and)Tj 0 -1.3043 TD [(strategies to remove the operational)]TJ T* [(policy bar)-30(riers. )]TJ -0.7174 -2.6087 TD [(The process of analyzing operational)]TJ 0 -1.3043 TD [(policies and devising refor)-26.1(m strategies is)]TJ T* -0.0001 Tc [(most ef)-22.1(fective as a par)-11.1(ticipator)-69.9(y endeavor)]TJ T* [(that draws on the insights and perspectives)]TJ T* -0.0002 Tc [(of those who manage and provide)]TJ T* -0.0003 Tc [(reproductive health care ser)-72.1(vices and)]TJ T* -0.0002 Tc (those who set policies. )Tj 20.3478 19.5652 TD 0.031 Tc [(The paper also provides evidenced-)]TJ 0 -1.3043 TD (based examples of how operational)Tj T* [(policy analyses have illuminated the)]TJ T* [(debilitating ef)-22.2(fects of outdated or)]TJ T* (nonexistent policies on reproductive)Tj T* [(ser)-72(vices in a number of countries,)]TJ T* (including Guatemala, Haiti, India,)Tj T* (Jordan, the Philippines, Romania, and)Tj T* [(Ukraine. The analyses led to refor)-26.2(m)]TJ T* [(initiatives that helped gover)-26.2(nments at)]TJ T* (all levels. Analyzing operational policies)Tj T* [(and suppor)-11.3(ting policy refor)-26.2(m is a)]TJ T* [(highly ef)-22.3(fective tool for improving the)]TJ T* [(deliver)-70.2(y)-0.1( of much-needed reproductive)]TJ T* [(health care ser)-72(vices in developing)]TJ T* 0 Tw (countries. )Tj ET Q endstream endobj 13 0 obj << /Type /Page /Parent 163 0 R /Resources 14 0 R /Contents 15 0 R /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 14 0 obj << /ProcSet [ /PDF /Text ] /Font << /F1 132 0 R /F2 136 0 R /F3 99 0 R /F4 100 0 R >> /ExtGState << /GS1 140 0 R /GS2 97 0 R >> /ColorSpace << /Cs5 135 0 R /Cs9 138 0 R /Cs10 98 0 R >> >> endobj 15 0 obj << /Length 8436 >> stream 1 g /GS1 gs 0 792 m 0 792 l f q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F3 1 Tf 49.32 0 0 49.32 53.6241 561 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (T)Tj /F1 1 Tf 11.5 0 0 11.5 77.625 576 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0105 Tc 0.0259 Tw [(he purpose of this paper is to develop)]TJ 0 -1.3043 TD (an increased understanding of an area)Tj -2.0543 -1.3043 TD [(of public sector policies that must be)]TJ T* -0.0108 Tc 0.0262 Tw [(addressed in order to improve reproductive)]TJ T* -0.0106 Tc 0.026 Tw [(health ser)-72(vices. No matter how they are)]TJ T* [(defined, operational policies can be found)]TJ T* [(almost ever)-70.1(ywhere in the health systems)]TJ T* -0.0107 Tc (literature, and their consequences are)Tj T* -0.0106 Tc [(apparent in ever)-70.1(y clinic, health post, and)]TJ T* [(hospital. In simple ter)-26.2(ms, operational)]TJ T* -0.0107 Tc [(policies are the r)-33.3(ules, regulations, codes,)]TJ T* (guidelines, plans, budgets, procedures, and)Tj T* -0.0105 Tc [(administrative nor)-26.1(ms that gover)-26.1(nments use)]TJ T* [(to translate national laws and policies into)]TJ T* [(programs and ser)-72.1(vices)]TJ 7.59 0 0 7.59 163.4807 369.795 Tm 0 Tc 0 Tw (1)Tj 11.5 0 0 11.5 170.5135 366 Tm -0.0108 Tc 0.0262 Tw (\(Cross, 2000\).)Tj -10.1316 -1.3043 TD -0.0105 Tc 0.0259 Tw [(Operational policies gover)-26.1(n the �operating)]TJ T* [(system� for public sector programs. T)74.7(o)0( use)]TJ T* [(a computer analogy)73.8(, operational policies)]TJ T* [(are the �language� that gover)-26.2(ns the)]TJ T* (relationships between health system inputs)Tj T* [(and outputs. If the �language� does not)]TJ T* [(gover)-26(n ef)-22.1(ficiently)73.8(, the operating system is)]TJ T* -0.0107 Tc 0.0261 Tw [(bound to fail. The symptoms of failure are)]TJ T* -0.0106 Tc (not unlike the computer crash where the)Tj T* 0.0259 Tw [(machine simply stops functioning as)]TJ T* 0 Tw (intended. )Tj 20.3478 32.6087 TD -0.0001 Tc 0.0259 Tw (Operational policies also have a critical)Tj 0 -1.3043 TD -0.0002 Tc (economic aspect. Operational policies are)Tj T* [(one of the deter)-26.1(minants of how inputs to)]TJ T* -0.0004 Tc 0.0262 Tw (the health care system \(e.g., resources)Tj T* -0.0001 Tc 0.0259 Tw [(such as personnel, equipment, and)]TJ T* -0.0002 Tc [(transpor)-11.2(tation\) are deployed once health)]TJ T* [(care priorities have been deter)-26.1(mined.)]TJ T* [(Poor operational policies can limit the)]TJ T* -0.0004 Tc 0.0262 Tw [(production of high-quality health care)]TJ T* -0.0002 Tc 0.026 Tw [(outputs and lead to inef)-22.2(ficiency)]TJ 7.59 0 0 7.59 447.4042 444.795 Tm 0 Tc 0 Tw (2)Tj 11.5 0 0 11.5 454.6354 441 Tm -0.0002 Tc (and)Tj -14.49 -1.3043 TD -0.0003 Tc 0.0261 Tw (wastage in health care programs. )Tj /F2 1 Tf 15 0 0 15 288 381 Tm /Cs9 cs 1 scn -0.0002 Tc 0.03 Tw [(Gover)-19(nments Remain Pivotal)]TJ 0 -1 TD [(to Repr)-29(oductive Health)]TJ T* 0 Tw [(Ser)-27.1(vices)]TJ /F1 1 Tf 11.5 0 0 11.5 288 321 Tm /Cs5 cs 0.161 0.145 0.149 sc 0.026 Tw [(Despite growth in the private sector)]TJ 0 -1.3043 TD -0.0003 Tc [(provision of health care in developing)]TJ T* -0.0002 Tc [(countries, the public sector still plays a)]TJ T* -0.0003 Tc [(critical role in the deliver)-70.2(y of reproductive)]TJ T* -0.0001 Tc [(health ser)-71.9(vices. In many countries, the)]TJ T* -0.0002 Tc [(poor rely exclusively on gover)-26.1(nment)]TJ T* -0.0003 Tc (programs for family planning. In almost)Tj T* [(70 percent of the countries sur)-72.1(veyed in)]TJ T* -0.0001 Tc (the past five years, the public sector)Tj ET Q q 1 i 575.445 25.74 m 575.445 20.347 571.07 15.97 565.68 15.97 c 560.29 15.97 555.915 20.347 555.915 25.74 c 555.915 31.133 560.29 35.51 565.68 35.51 c 571.07 35.51 575.445 31.133 575.445 25.74 c h 467.06 201 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.8 scn /GS2 gs 555.84 35.58 19.68 -19.68 re f 0.65 scn 576.046 37.648 m 576.046 35.732 574.492 34.179 572.576 34.179 c 570.66 34.179 569.107 35.732 569.107 37.648 c 576.046 37.648 l f 569.349 34.383 m 569.349 32.467 567.795 30.914 565.879 30.914 c 563.963 30.914 562.41 32.467 562.41 34.383 c 569.349 34.383 l f 562.652 37.645 m 562.652 35.729 561.099 34.176 559.183 34.176 c 557.267 34.176 555.713 35.729 555.713 37.645 c 562.652 37.645 l f 576.046 30.71 m 576.046 28.794 574.492 27.24 572.576 27.24 c 570.66 27.24 569.107 28.794 569.107 30.71 c 576.046 30.71 l f 569.349 27.444 m 569.349 25.528 567.795 23.975 565.879 23.975 c 563.963 23.975 562.41 25.528 562.41 27.444 c 569.349 27.444 l f 562.652 30.707 m 562.652 28.791 561.099 27.237 559.183 27.237 c 557.267 27.237 555.713 28.791 555.713 30.707 c 562.652 30.707 l f 576.046 23.771 m 576.046 21.855 574.492 20.302 572.576 20.302 c 570.66 20.302 569.107 21.855 569.107 23.771 c 576.046 23.771 l f 569.349 20.505 m 569.349 18.589 567.795 17.036 565.879 17.036 c 563.963 17.036 562.41 18.589 562.41 20.505 c 569.349 20.505 l f 562.652 23.768 m 562.652 21.852 561.099 20.298 559.183 20.298 c 557.267 20.298 555.713 21.852 555.713 23.768 c 562.652 23.768 l f 576.046 16.832 m 576.046 14.916 574.492 13.363 572.576 13.363 c 570.66 13.363 569.107 14.916 569.107 16.832 c 576.046 16.832 l f 562.652 16.829 m 562.652 14.913 561.099 13.36 559.183 13.36 c 557.267 13.36 555.713 14.913 555.713 16.829 c 562.652 16.829 l f Q q 1 i 575.945 25.74 m 575.945 20.071 571.346 15.47 565.68 15.47 c 560.014 15.47 555.415 20.071 555.415 25.74 c 555.415 31.409 560.014 36.01 565.68 36.01 c 571.346 36.01 575.945 31.409 575.945 25.74 c h 467.06 201 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 CS 0.4 SCN 0 J 0 j 2 w 10 M []0 d 575.945 25.74 m 575.945 20.071 571.346 15.47 565.68 15.47 c 560.014 15.47 555.415 20.071 555.415 25.74 c 555.415 31.409 560.014 36.01 565.68 36.01 c 571.346 36.01 575.945 31.409 575.945 25.74 c h 467.06 201 m S Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F2 1 Tf 11 0 0 11 562.3771 22.8189 Tm /Cs5 cs 1 1 1 sc 0 Tc 0 Tw (1)Tj 23 0 0 23 54 687.5029 Tm /Cs9 cs 1 scn -0.0002 Tc [(Intr)-29(oduction: )]TJ 0 -1.2 TD 0.03 Tw (Impact of Operational Policies on)Tj T* [(Repr)-29(oductive Health)]TJ ET 522.04 738.01 89.96 -36 re f Q q 1 i 519.549 751.827 105.64 -54 re W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.4 scn /GS2 gs 619.108 723.377 m 611.923 723.377 606.099 729.202 606.099 736.387 c 606.099 743.573 611.923 749.397 619.108 749.397 c 619.108 723.377 l f 593.088 723.377 m 585.903 723.377 580.079 729.202 580.079 736.387 c 580.079 743.573 585.903 749.397 593.088 749.397 c 593.088 723.377 l f 567.068 723.377 m 559.883 723.377 554.059 729.202 554.059 736.387 c 554.059 743.573 559.883 749.397 567.068 749.397 c 567.068 723.377 l f 541.048 723.377 m 533.863 723.377 528.039 729.202 528.039 736.387 c 528.039 743.573 533.863 749.397 541.048 749.397 c 541.048 723.377 l f Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs5 cs 1 1 1 sc 54 168.27 450 -132.26 re f BT /F4 1 Tf 6.6 0 0 6.6 54 163.8537 Tm 0.161 0.145 0.149 sc 0 Tc 0 Tw (1)Tj 10 0 0 10 60.288 160.5537 Tm -0.0001 Tc 0.0259 Tw [(The policy working group of the USAID-funded Evaluation Project defined four components of operational policies)]TJ -0.6288 -1.2 TD [(dir)-5(ectly r)-5(elated to the operation of national family planning programs: or)-8.9(ganizational str)-36(uctur)-5(e and process; the)]TJ T* [(legal and regulator)-75(y environment; provision of r)-5(esour)17.8(ces; and pricing \(Ber)-44(trand, Magnani, and Knowles, n.d.\).)]TJ T* [(This definition did not include the r)-36(u)0.1(les that gover)-27.9(n)0( how systems operate, which are the vital �glue� that holds)]TJ T* [(systems together)117.8(.)]TJ 6.6 0 0 6.6 54 102.8282 Tm 0 Tc 0 Tw (2)Tj 10 0 0 10 60.288 99.5282 Tm -0.0001 Tc 0.0259 Tw [(Microeconomic ef)-26.9(ficiency r)-5(efers to the scope for achieving gr)-5(eater ef)-26.9(ficiency from existing patter)-27.9(ns of r)-5(esour)17.7(ce use.)]TJ -0.6288 -1.2 TD 0 Tc 0 Tw (W)Tj 0.7959 0 TD -0.0002 Tc 0.026 Tw [(astage and inef)-27(ficiency occur in all health systems. Allocative inef)-27(ficiency occurs when r)-5.1(esour)17.7(ces ar)-5.1(e devoted to the)]TJ -0.7959 -1.2 TD -0.0001 Tc [(wrong activities while technical inef)-26.9(ficiency occurs when too many r)-5(esour)17.7(ces ar)-5(e used to achieve a given health)]TJ T* -0.0002 Tc [(inter)-69(vention or outcome \(WHO, 1999\).)]TJ ET /Cs9 CS 1 SCN 0 J 0 j 0.5 w 10 M []0 d 54 176.76 m 504 176.76 l S Q endstream endobj 16 0 obj << /Type /Page /Parent 163 0 R /Resources 17 0 R /Contents 18 0 R /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 17 0 obj << /ProcSet [ /PDF /Text ] /Font << /F1 132 0 R /F2 136 0 R >> /ExtGState << /GS1 140 0 R /GS2 97 0 R >> /ColorSpace << /Cs5 135 0 R /Cs9 138 0 R /Cs10 98 0 R >> >> endobj 18 0 obj << /Length 8515 >> stream 1 g /GS1 gs 0 792 m 0 792 l f q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 cs 1 scn 0 792.06 68.67 -172.14 re f Q q 1 i -9 670.62 117 -64.91 re W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.4 scn /GS2 gs -4.193 654.284 m 2.992 654.284 8.816 648.459 8.816 641.274 c 8.816 634.089 2.992 628.264 -4.193 628.264 c -4.193 654.284 l f 21.827 654.284 m 29.012 654.284 34.836 648.459 34.836 641.274 c 34.836 634.089 29.012 628.264 21.827 628.264 c 21.827 654.284 l f 47.847 654.284 m 55.032 654.284 60.856 648.459 60.856 641.274 c 60.856 634.089 55.032 628.264 47.847 628.264 c 47.847 654.284 l f 73.867 654.284 m 81.052 654.284 86.876 648.459 86.876 641.274 c 86.876 634.089 81.052 628.264 73.867 628.264 c 73.867 654.284 l f Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F1 1 Tf 11.5 0 0 11.5 108 711 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0004 Tc 0.0262 Tw [(accounts for 50 percent or more of family)]TJ 0 -1.3043 TD -0.0002 Tc 0.026 Tw [(planning ser)-72(vices \(DHS, 2001\). Similarly)73.7(,)]TJ T* -0.0001 Tc [(for mater)-26(nal and child health ser)-71.9(v)0(ices,)]TJ T* -0.0003 Tc [(poorer groups depend heavily on)]TJ T* -0.0002 Tc [(gover)-26.1(nment ser)-72(vices. Not only do)]TJ T* -0.0003 Tc [(gover)-26.2(nments provide a lar)-7.2(ge share of the)]TJ T* -0.0002 Tc [(ser)-72(vices thought to be most ef)-22.2(fective in)]TJ T* [(preventing deaths and illness, but they)]TJ T* -0.0003 Tc [(also pass and enforce the laws, regulations,)]TJ T* -0.0002 Tc [(and codes that greatly influence the)]TJ T* [(provision of these same ser)-72(v)-0.1(ices by)]TJ T* -0.0004 Tc 0.0262 Tw [(commercial providers and other)]TJ T* -0.0002 Tc 0.026 Tw [(nongover)-26.1(nmental or)-7.1(ganizations \(NGOs\).)]TJ 0 -2.6087 TD (Although the public sector plays an)Tj 0 -1.3043 TD -0.0005 Tc 0.0263 Tw [(impor)-11.5(tant role in providing reproductive)]TJ T* -0.0002 Tc 0.026 Tw [(health ser)-72(vices, most ef)-22.2(for)-11.2(ts to improve)]TJ T* -0.0003 Tc (family planning and reproductive health)Tj T* (\(FP/RH\) programs have addressed only)Tj T* -0.0001 Tc [(national public sector policies and focus)]TJ T* [(on ser)-71.9(vice deliver)-70(y per)-40.9(for)-26(mance and the)]TJ T* 0.0258 Tw [(private sector \(Seidman and Hor)-26(n, 1991;)]TJ T* -0.0002 Tc 0.026 Tw [(Ross and Frankenber)-7.1(g, 1993; Population)]TJ T* [(Council, 1998a, 1998b; Shane and Chalky)73.7(,)]TJ T* (1998; Miller et al., 1997; MSH, 2000\). The)Tj T* [(gap between national policy and improved)]TJ T* -0.0001 Tc [(ser)-71.9(vice deliver)-70(y per)-40.9(for)-26(mance has been the)]TJ T* -0.0002 Tc [(lack of attention to operational policies. )]TJ /F2 1 Tf 15 0 0 15 108 261 Tm /Cs9 cs 1 scn 0.03 Tw (Consequences of Faulty)Tj 0 -1 TD (Operational Policies:)Tj T* [(Inef)-50(ficiency and W)50.6(astage)]TJ /F1 1 Tf 11.5 0 0 11.5 108 201 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0001 Tc 0.0259 Tw (The past 50 years have witnessed)Tj 0 -1.3043 TD -0.0002 Tc [(tremendous expansion of gover)-26.1(nment-r)-33.2(un)]TJ T* (health care systems accompanied by)Tj T* [(bur)-7.1(geoning bureaucracies that have)]TJ T* [(become rigid and inef)-22.2(ficient \(WHO,)]TJ T* -0.0003 Tc 0.0261 Tw (2000\). Initially responsible for financing)Tj T* -0.0002 Tc [(and operating public hospital and primar)-70.1(y)]TJ T* -0.0003 Tc [(care systems, ministries of health are now)]TJ T* [(lar)-7.3(ge, hierarchical bureaucracies)]TJ T* -0.0001 Tc 0.0259 Tw (characterized by unwieldy administrative)Tj 20.3478 56.087 TD 0.0329 Tc 0 Tw (ru)Tj 1.0127 0 TD -0.0002 Tc 0.0259 Tw [(les and a per)-26.1(manent staf)-22.2(f protected by)]TJ -1.0127 -1.3043 TD [(civil ser)-72(vice regulations \(Bosser)-11.2(t)0( et al.,)]TJ T* [(1998\). The problems faced by ministries)]TJ T* [(of health are exacerbated by inef)-22.2(ficiently)]TJ T* 0 Tc 0 Tw (r)Tj 0.4329 0 TD -0.0002 Tc 0.026 Tw [(un gover)-26.1(nment systems on which)]TJ -0.4329 -1.3043 TD [(ministr)-70.1(y operations depend, including)]TJ T* [(civil ser)-72(vice regulations and public works)]TJ T* [(and transpor)-11.2(tation nor)-26.1(ms, among others.)]TJ T* -0.0004 Tc 0.0262 Tw [(As a result, policies and procedures that)]TJ T* (may be burdensome, conflicting, obscure,)Tj T* -0.0002 Tc 0.026 Tw [(outmoded, and dif)-22.2(ficult to change often)]TJ T* [(gover)-26.1(n quality)73.7(, access, and working)]TJ T* [(conditions at the point of ser)-72(vice)]TJ T* [(provision. Many of these operational)]TJ T* [(policies create conditions that act as)]TJ T* -0.0001 Tc [(disincentives for health workers to)]TJ T* -0.0002 Tc [(per)-41(for)-26.1(m)-0.1( their duties, or even show up for)]TJ T* 0 Tw (work. )Tj 0 -2.6087 TD -0.0001 Tc 0.0259 Tw (The consequences of flawed operational)Tj 0 -1.3043 TD -0.0002 Tc [(policies are well documented. In Kenya,)]TJ T* [(Owino and Korir \(1997\) estimated an)]TJ T* [(average inef)-22.2(ficiency level of 30 percent in)]TJ T* -0.0001 Tc (the public health sector as a consequence)Tj T* -0.0002 Tc [(of factors such as a shor)-11.2(tage of)]TJ T* -0.0003 Tc 0.0261 Tw [(professional staf)-22.3(f, a poor combination of)]TJ T* [(inputs, ir)-30.1(regular or nonfunctioning)]TJ T* -0.0001 Tc 0.0259 Tw (operating theaters and laboratories,)Tj T* -0.0003 Tc [(transpor)-11.3(t problems, lack of or poor)]TJ T* -0.0002 Tc [(distribution of dr)-33.2(ugs and medical supplies,)]TJ T* -0.0003 Tc 0.0261 Tw [(frequent breakdown of equipment,)]TJ T* -0.0001 Tc 0.0259 Tw [(and/or poor ser)-71.9(vicing of machines and)]TJ T* [(equipment. In Bungoma District, Kenya,)]TJ T* -0.0002 Tc (district health management boards are)Tj T* [(responsible for super)-72(vising the health)]TJ T* [(system in the district. However)83.7(, the boards)]TJ T* [(lack a budget, transpor)-11.2(tation, and the)]TJ T* -0.0001 Tc [(authority to discipline any medical)]TJ T* -0.0002 Tc [(personnel \(BDMI, 2000\). Nurses who r)-33.2(u)0.2(n)]TJ T* -0.0001 Tc [(health posts in Kenya have to travel to the)]TJ T* -0.0002 Tc (district hospital to receive their monthly)Tj T* -0.0001 Tc (pay; some travel as much as one day each)Tj T* -0.0003 Tc 0.0261 Tw [(way)73.6(, thus losing 10 percent of their)]TJ T* -0.0002 Tc (potential work time \(Sharif, 2001\). )Tj ET Q q 1 i 56.03 25.74 m 56.03 20.347 51.653 15.97 46.26 15.97 c 40.867 15.97 36.49 20.347 36.49 25.74 c 36.49 31.133 40.867 35.51 46.26 35.51 c 51.653 35.51 56.03 31.133 56.03 25.74 c h 520.292 66 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.8 scn /GS2 gs 36.48 35.58 19.56 -19.68 re f 0.65 scn 56.615 37.648 m 56.615 35.732 55.062 34.179 53.146 34.179 c 51.23 34.179 49.677 35.732 49.677 37.648 c 56.615 37.648 l f 49.919 34.383 m 49.919 32.467 48.365 30.914 46.449 30.914 c 44.533 30.914 42.98 32.467 42.98 34.383 c 49.919 34.383 l f 43.222 37.645 m 43.222 35.729 41.669 34.176 39.753 34.176 c 37.837 34.176 36.283 35.729 36.283 37.645 c 43.222 37.645 l f 56.615 30.71 m 56.615 28.794 55.062 27.24 53.146 27.24 c 51.23 27.24 49.677 28.794 49.677 30.71 c 56.615 30.71 l f 49.919 27.444 m 49.919 25.528 48.365 23.975 46.449 23.975 c 44.533 23.975 42.98 25.528 42.98 27.444 c 49.919 27.444 l f 43.222 30.707 m 43.222 28.791 41.669 27.237 39.753 27.237 c 37.837 27.237 36.283 28.791 36.283 30.707 c 43.222 30.707 l f 56.615 23.771 m 56.615 21.855 55.062 20.302 53.146 20.302 c 51.23 20.302 49.677 21.855 49.677 23.771 c 56.615 23.771 l f 49.919 20.505 m 49.919 18.589 48.365 17.036 46.449 17.036 c 44.533 17.036 42.98 18.589 42.98 20.505 c 49.919 20.505 l f 43.222 23.768 m 43.222 21.852 41.669 20.298 39.753 20.298 c 37.837 20.298 36.283 21.852 36.283 23.768 c 43.222 23.768 l f 56.615 16.832 m 56.615 14.916 55.062 13.363 53.146 13.363 c 51.23 13.363 49.677 14.916 49.677 16.832 c 56.615 16.832 l f 43.222 16.829 m 43.222 14.913 41.669 13.36 39.753 13.36 c 37.837 13.36 36.283 14.913 36.283 16.829 c 43.222 16.829 l f Q q 1 i 56.59 25.74 m 56.59 20.071 51.989 15.47 46.32 15.47 c 40.651 15.47 36.05 20.071 36.05 25.74 c 36.05 31.409 40.651 36.01 46.32 36.01 c 51.989 36.01 56.59 31.409 56.59 25.74 c h 520.292 66 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 CS 0.4 SCN 0 J 0 j 2 w 10 M []0 d 56.59 25.74 m 56.59 20.071 51.989 15.47 46.32 15.47 c 40.651 15.47 36.05 20.071 36.05 25.74 c 36.05 31.409 40.651 36.01 46.32 36.01 c 51.989 36.01 56.59 31.409 56.59 25.74 c h 520.292 66 m S Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F2 1 Tf 11 0 0 11 43.0051 22.8189 Tm /Cs5 cs 1 1 1 sc 0 Tc 0 Tw (2)Tj ET Q endstream endobj 19 0 obj << /Type /Page /Parent 163 0 R /Resources 20 0 R /Contents 21 0 R /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 20 0 obj << /ProcSet [ /PDF /Text ] /Font << /F1 132 0 R /F2 136 0 R /F3 99 0 R /F4 100 0 R >> /ExtGState << /GS1 140 0 R /GS2 97 0 R >> /ColorSpace << /Cs5 135 0 R /Cs9 138 0 R /Cs10 98 0 R >> >> endobj 21 0 obj << /Length 10071 >> stream 1 g /GS1 gs 0 792 m 0 792 l f q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F1 1 Tf 11.5 0 0 11.5 54 711 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0054 Tc 0.026 Tw [(In Uganda, an expenditure tracking)]TJ 0 -1.3043 TD [(exercise revealed that a significant por)-11.2(tion)]TJ T* -0.0053 Tc [(of funds allocated to basic social ser)-71.8(vices)]TJ T* -0.0054 Tc (never reached the intended health clinics)Tj T* [(or schools, par)-11.2(ticularly in r)-33.2(ural areas \(Ablo)]TJ T* -0.0053 Tc [(and Reinikka, 1998\). In Ghana in the early)]TJ T* -0.0055 Tc [(1990s, 70 percent of Ministr)-70.1(y of Health)]TJ T* [(\(MOH\) vehicles were repor)-11.3(ted to be)]TJ T* [(waiting for repair in gover)-26.1(nment)]TJ T* -0.0053 Tc [(workshops. Reor)-6.9(ganization of maintenance)]TJ T* -0.0054 Tc [(and repair ar)-30(rangements and budget)]TJ T* (practice led to rapid improvement, but)Tj T* [(Ghana�)19.5(s recent experience is widespread)]TJ T* -0.0053 Tc [(\(WHO, 2000\). A study of the management)]TJ T* [(infor)-26(mation system in Uttar Pradesh,)]TJ T* -0.0054 Tc [(India, found that too much infor)-26(mation is)]TJ T* -0.0053 Tc [(collected on too many for)-26(m)0(s, and most of)]TJ T* (it is never used. At the subcenter level,)Tj T* -0.0054 Tc [(auxiliar)-70(y nurse midwives had to fill in 13)]TJ T* [(registers and four for)-26.1(m)-0.1(s each month)]TJ T* (\(POLICY Project, 1998a\).)Tj /F2 1 Tf 15 0 0 15 54 366 Tm /Cs9 cs 1 scn -0.0002 Tc 0.03 Tw [(Operational Policies Ar)-23.2(e)]TJ 0 -1 TD 0 Tw (Neglected)Tj /F1 1 Tf 11.5 0 0 11.5 54 321 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0001 Tc 0.0259 Tw [(Over the past 30 years, gover)-26(nments and)]TJ 0 -1.3043 TD -0.0002 Tc [(donors have over)-73.2(whelmingly focused on)]TJ T* [(national policies and general program)]TJ T* (directions as well as on community-level)Tj T* -0.0001 Tc [(ser)-71.9(vice deliver)-70(y per)-40.9(for)-26(mance and)]TJ T* -0.0003 Tc 0.0261 Tw [(demand. Ef)-22.3(for)-11.3(ts to improve national)]TJ T* -0.0001 Tc 0.0259 Tw (policies have included follow-up strategic)Tj T* -0.0003 Tc 0.0261 Tw [(planning and, in some cases, program)]TJ T* -0.0002 Tc (planning and budgeting. As illustrated in)Tj T* [(Figure 1, these ef)-22.2(for)-11.2(ts have not extended)]TJ T* [(to analysis and cor)-30(rection of operational)]TJ T* [(policy bar)-30(riers that might impede the)]TJ T* [(implementation of a national policy or)]TJ 20.3478 49.5652 TD -0.0003 Tc [(strategic plan. Program ef)-22.3(for)-11.3(t)-0.1( scores)]TJ 7.59 0 0 7.59 470.4576 714.795 Tm 0 Tc 0 Tw (3)Tj 11.5 0 0 11.5 288 696 Tm -0.0002 Tc 0.026 Tw [(\(Ross and Stover)83.8(, 2000\) demonstrate that)]TJ 0 -1.3043 TD -0.0001 Tc [(national policies do not necessarily)]TJ T* -0.0002 Tc [(translate into program action, such as)]TJ T* -0.0001 Tc (family planning method availability�an)Tj T* -0.0002 Tc [(impor)-11.2(tant proxy for access and one)]TJ T* -0.0003 Tc [(indicator of quality)68.5(. Figure 1 also shows)]TJ T* -0.0002 Tc [(that in the �policy� categor)-70.1(y of the 1999)]TJ T* -0.0003 Tc [(program ef)-22.3(for)-11.3(t)-0.1( sur)-72.1(vey)73.6(, all nine countries)]TJ T* (score between 50 and 70 points out of a)Tj T* -0.0002 Tc (possible 100. In contrast, the �method)Tj T* [(availability� categor)-70.1(y shows scores ranging)]TJ T* -0.0003 Tc [(from 13 to 80 points�a huge deviation)]TJ T* -0.0002 Tc [(from the patter)-26.1(n)-0.1(s in the policy categor)-70.1(y)68.7(.)]TJ T* [(This deviation illustrates that the mere)]TJ T* -0.0001 Tc [(existence of laws, policies, national)]TJ T* -0.0003 Tc [(population councils, and of)-22.3(ficial program)]TJ T* -0.0001 Tc [(documents does not guarantee family)]TJ T* (planning access and use. )Tj ET Q q 1 i 575.445 25.74 m 575.445 20.347 571.07 15.97 565.68 15.97 c 560.29 15.97 555.915 20.347 555.915 25.74 c 555.915 31.133 560.29 35.51 565.68 35.51 c 571.07 35.51 575.445 31.133 575.445 25.74 c h 415.193 441 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.8 scn /GS2 gs 555.84 35.58 19.68 -19.68 re f 0.65 scn 576.046 37.648 m 576.046 35.732 574.492 34.179 572.576 34.179 c 570.66 34.179 569.107 35.732 569.107 37.648 c 576.046 37.648 l f 569.349 34.383 m 569.349 32.467 567.795 30.914 565.879 30.914 c 563.963 30.914 562.41 32.467 562.41 34.383 c 569.349 34.383 l f 562.652 37.645 m 562.652 35.729 561.099 34.176 559.183 34.176 c 557.267 34.176 555.713 35.729 555.713 37.645 c 562.652 37.645 l f 576.046 30.71 m 576.046 28.794 574.492 27.24 572.576 27.24 c 570.66 27.24 569.107 28.794 569.107 30.71 c 576.046 30.71 l f 569.349 27.444 m 569.349 25.528 567.795 23.975 565.879 23.975 c 563.963 23.975 562.41 25.528 562.41 27.444 c 569.349 27.444 l f 562.652 30.707 m 562.652 28.791 561.099 27.237 559.183 27.237 c 557.267 27.237 555.713 28.791 555.713 30.707 c 562.652 30.707 l f 576.046 23.771 m 576.046 21.855 574.492 20.302 572.576 20.302 c 570.66 20.302 569.107 21.855 569.107 23.771 c 576.046 23.771 l f 569.349 20.505 m 569.349 18.589 567.795 17.036 565.879 17.036 c 563.963 17.036 562.41 18.589 562.41 20.505 c 569.349 20.505 l f 562.652 23.768 m 562.652 21.852 561.099 20.298 559.183 20.298 c 557.267 20.298 555.713 21.852 555.713 23.768 c 562.652 23.768 l f 576.046 16.832 m 576.046 14.916 574.492 13.363 572.576 13.363 c 570.66 13.363 569.107 14.916 569.107 16.832 c 576.046 16.832 l f 562.652 16.829 m 562.652 14.913 561.099 13.36 559.183 13.36 c 557.267 13.36 555.713 14.913 555.713 16.829 c 562.652 16.829 l f Q q 1 i 575.945 25.74 m 575.945 20.071 571.346 15.47 565.68 15.47 c 560.014 15.47 555.415 20.071 555.415 25.74 c 555.415 31.409 560.014 36.01 565.68 36.01 c 571.346 36.01 575.945 31.409 575.945 25.74 c h 415.193 441 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 CS 0.4 SCN 0 J 0 j 2 w 10 M []0 d 575.945 25.74 m 575.945 20.071 571.346 15.47 565.68 15.47 c 560.014 15.47 555.415 20.071 555.415 25.74 c 555.415 31.409 560.014 36.01 565.68 36.01 c 571.346 36.01 575.945 31.409 575.945 25.74 c h 415.193 441 m S Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F2 1 Tf 11 0 0 11 562.3771 22.8189 Tm /Cs5 cs 1 1 1 sc 0 Tc 0 Tw (3)Tj ET /Cs9 cs 1 scn 522.04 738.01 89.96 -36 re f Q q 1 i 519.549 751.827 105.64 -54 re W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.4 scn /GS2 gs 619.108 723.377 m 611.923 723.377 606.099 729.202 606.099 736.387 c 606.099 743.573 611.923 749.397 619.108 749.397 c 619.108 723.377 l f 593.088 723.377 m 585.903 723.377 580.079 729.202 580.079 736.387 c 580.079 743.573 585.903 749.397 593.088 749.397 c 593.088 723.377 l f 567.068 723.377 m 559.883 723.377 554.059 729.202 554.059 736.387 c 554.059 743.573 559.883 749.397 567.068 749.397 c 567.068 723.377 l f 541.048 723.377 m 533.863 723.377 528.039 729.202 528.039 736.387 c 528.039 743.573 533.863 749.397 541.048 749.397 c 541.048 723.377 l f Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 cs 0.2 scn 289.46 410.09 285.04 -267.54 re f Q /Cs10 CS 1 SCN 1 J 0 j 2.585 w 4 M []0 d /GS2 gs 1 i 496.598 333.937 m 514.857 333.937 l S BT /F3 1 Tf 12 0 0 12 308.8497 168.5829 Tm /Cs5 cs 0.161 0.145 0.149 sc 0 Tc 0 Tw (0)Tj -0.6 2.7001 TD (20)Tj T* (40)Tj 0 2.6999 TD (60)Tj T* (80)Tj ET /Cs5 CS 0.161 0.145 0.149 SC 0 J 0.5 w 319.425 172.38 m 319.425 334.381 l 319.425 172.38 m 489.764 172.38 l 319.425 204.78 m 489.764 204.78 l 319.425 237.181 m 489.764 237.181 l 319.425 269.58 m 489.764 269.58 l 319.425 301.981 m 489.764 301.981 l 319.425 334.381 m 489.764 334.381 l S BT 12 0 0 12 294.45 330.5836 Tm (100)Tj ET /Cs10 CS 1 SCN 1 J 2 w 463.085 302.952 m 355.085 286.267 l S /Cs5 CS 1 1 1 SC 463.085 224.221 m 355.085 263.749 l S 0.427 0.431 0.443 SC 0 J [3 3 ]0 d 463.085 246.414 m 355.085 274.926 l S 0.651 0.659 0.671 SC [2 2 ]0 d 463.085 266.341 m 355.085 282.54 l S 0.161 0.145 0.149 SC 1 J []0 d 463.085 289.507 m 355.085 289.021 l S 0.573 0.58 0.592 SC 463.085 193.441 m 355.085 266.017 l S /Cs10 CS 0.5 SCN 463.085 251.599 m 355.085 271.362 l S /Cs5 CS 0.161 0.145 0.149 SC [3 3 ]0 d 463.085 251.275 m 355.085 253.704 l S /Cs10 CS 1 SCN 463.085 216.445 m 355.085 276.223 l S /Cs5 CS 1 1 1 SC 2.585 w []0 d 496.598 314.937 m 514.857 314.937 l S 0.427 0.431 0.443 SC 0 J 2.812 w [3.263 3.263 ]0 d 494.928 295.937 m 516.527 295.937 l S 0.651 0.659 0.671 SC 2.585 w [2 2 ]0 d 495.018 276.937 m 516.112 276.937 l S 0.161 0.145 0.149 SC 1 J []0 d 496.598 257.937 m 514.857 257.937 l S 0.573 0.58 0.592 SC 496.598 238.937 m 514.857 238.937 l S /Cs10 CS 0.5 SCN 496.598 219.937 m 514.857 219.937 l S /Cs5 CS 0.161 0.145 0.149 SC 2.656 w [3 3 ]0 d 496.089 200.937 m 515.366 200.937 l S /Cs10 CS 1 SCN 2.664 w [3.091 3.091 ]0 d 496.034 181.937 m 515.42 181.937 l S BT 10 0 0 10 519.657 330.5685 Tm (Bangladesh)Tj 0 -1.9 TD (Cambodia)Tj T* (Egypt)Tj T* (Ghana)Tj T* (India)Tj T* (Malawi)Tj T* (Nepal)Tj T* (Nigeria)Tj T* (T)Tj 0.4101 0 TD (anzania)Tj 12 0 0 12 339.6981 158.774 Tm [(Policy)-5567.7(A)22.9(vailability)]TJ -3.7415 15.6854 TD [(Per)-19.7(cent of Maximum)]TJ ET q -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 CS 1 SCN 0 J 3 w 10 M []0 d /GS1 gs 289.46 410.09 285.04 -267.54 re S /Cs9 cs 1 scn 288 411.63 288 -43.2 re f BT /F2 1 Tf 14 0 0 14 306 394.7594 Tm /Cs5 cs 1 1 1 sc -0.0002 Tc 0.0299 Tw [(Figur)-23.2(e 1. Pr)-29(ogram Ef)-50(for)-60(t Scor)-23.2(es by)]TJ 0 -1.2 TD 0 Tw [(Countr)-38(y)]TJ ET 54 110.25 450 -56.25 re f BT /F4 1 Tf 6.6 0 0 6.6 54 105.8381 Tm 0.161 0.145 0.149 sc 0 Tc (3)Tj 10 0 0 10 60.288 102.538 Tm -0.0001 Tc 0.0259 Tw [(The Program Ef)-26.9(for)-44(t Scor)-5(e \(PES\) study has a 30-year histor)-75(y \(Ross and Mauldin, 1996\). The PES contains a)]TJ -0.6288 -1.2 TD [(component on operational policy that measur)-5(es thr)-5(ee subdimensions that ar)-5(e dir)-5(ectly r)-5(e)0.1(lated to the operation of the)]TJ T* [(national program. 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Others have made)]TJ T* [(similar obser)-72(vations \(Ashford and)]TJ T* [(Makinson, 1999; For)-26.1(man and Ghosh, 2000;)]TJ T* 0 Tc 0 Tw (T)Tj 0.5878 0 TD -0.0054 Tc 0.026 Tw [(antchou and W)-18.1(ilson, 2000\). While)]TJ -0.5878 -1.3043 TD -0.0053 Tc (developing countries need national)Tj T* -0.0054 Tc (policies to provide leadership and)Tj T* (direction at the national level, they also)Tj T* -0.0053 Tc [(must have the political will and the means)]TJ T* [(to implement them. They need money)73.9(,)]TJ T* -0.0055 Tc [(other resources, and operational policies)]TJ T* -0.0053 Tc [(to make implementation possible.)]TJ 0 -2.6087 TD -0.0001 Tc [(Similarly)73.8(, investments in ser)-71.9(vice deliver)-70(y)]TJ 0 -1.3043 TD [(have focused on cer)-11.1(tain inputs such as)]TJ T* -0.0003 Tc [(training of staf)-22.3(f or procurement of)]TJ T* -0.0002 Tc (commodities. 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Tw [(for gover)-26.1(nment action. T)74.7(o)-0.1( succeed,)]TJ T* [(national policies must be translated into)]TJ T* (programs that will achieve the goals set)Tj T* [(for)-11.2(th at the national level. Such goals)]TJ T* (include, for example, a reduction in)Tj 20.3478 9.1304 TD [(mater)-26.1(nal mor)-11.2(tality or the incidence of)]TJ 0 -1.3043 TD 0.0051 Tc [(HIV/AIDS or expanded access to family)]TJ T* 0.0049 Tc [(planning. Moving from national policies)]TJ T* 0.0262 Tw [(to local programs requires the design and)]TJ T* 0.026 Tw [(implementation of operational policies)]TJ T* [(that, in tur)-26.1(n, have a deter)-26.2(mining)]TJ T* 0.0051 Tc [(influence on health management and)]TJ T* 0.0049 Tc [(ser)-72.1(vices \(see Figure 2\). )]TJ ET Q q 1 i 56.03 25.74 m 56.03 20.347 51.653 15.97 46.26 15.97 c 40.867 15.97 36.49 20.347 36.49 25.74 c 36.49 31.133 40.867 35.51 46.26 35.51 c 51.653 35.51 56.03 31.133 56.03 25.74 c h 462.28 471 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.8 scn /GS2 gs 36.48 35.58 19.56 -19.68 re f 0.65 scn 56.615 37.648 m 56.615 35.732 55.062 34.179 53.146 34.179 c 51.23 34.179 49.677 35.732 49.677 37.648 c 56.615 37.648 l f 49.919 34.383 m 49.919 32.467 48.365 30.914 46.449 30.914 c 44.533 30.914 42.98 32.467 42.98 34.383 c 49.919 34.383 l f 43.222 37.645 m 43.222 35.729 41.669 34.176 39.753 34.176 c 37.837 34.176 36.283 35.729 36.283 37.645 c 43.222 37.645 l f 56.615 30.71 m 56.615 28.794 55.062 27.24 53.146 27.24 c 51.23 27.24 49.677 28.794 49.677 30.71 c 56.615 30.71 l f 49.919 27.444 m 49.919 25.528 48.365 23.975 46.449 23.975 c 44.533 23.975 42.98 25.528 42.98 27.444 c 49.919 27.444 l f 43.222 30.707 m 43.222 28.791 41.669 27.237 39.753 27.237 c 37.837 27.237 36.283 28.791 36.283 30.707 c 43.222 30.707 l f 56.615 23.771 m 56.615 21.855 55.062 20.302 53.146 20.302 c 51.23 20.302 49.677 21.855 49.677 23.771 c 56.615 23.771 l f 49.919 20.505 m 49.919 18.589 48.365 17.036 46.449 17.036 c 44.533 17.036 42.98 18.589 42.98 20.505 c 49.919 20.505 l f 43.222 23.768 m 43.222 21.852 41.669 20.298 39.753 20.298 c 37.837 20.298 36.283 21.852 36.283 23.768 c 43.222 23.768 l f 56.615 16.832 m 56.615 14.916 55.062 13.363 53.146 13.363 c 51.23 13.363 49.677 14.916 49.677 16.832 c 56.615 16.832 l f 43.222 16.829 m 43.222 14.913 41.669 13.36 39.753 13.36 c 37.837 13.36 36.283 14.913 36.283 16.829 c 43.222 16.829 l f Q q 1 i 56.59 25.74 m 56.59 20.071 51.989 15.47 46.32 15.47 c 40.651 15.47 36.05 20.071 36.05 25.74 c 36.05 31.409 40.651 36.01 46.32 36.01 c 51.989 36.01 56.59 31.409 56.59 25.74 c h 462.28 471 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 CS 0.4 SCN 0 J 0 j 2 w 10 M []0 d 56.59 25.74 m 56.59 20.071 51.989 15.47 46.32 15.47 c 40.651 15.47 36.05 20.071 36.05 25.74 c 36.05 31.409 40.651 36.01 46.32 36.01 c 51.989 36.01 56.59 31.409 56.59 25.74 c h 462.28 471 m S Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F2 1 Tf 11 0 0 11 43.0051 22.8189 Tm /Cs5 cs 1 1 1 sc 0 Tc 0 Tw (6)Tj 23 0 0 23 108 632.2268 Tm /Cs9 cs 1 scn -0.0002 Tc 0.03 Tw [(The Policy Roots of Operational Bar)-22.2(riers)]TJ ET 0.2 scn 109.5 436.43 447 -366.77 re f Q BT /F5 1 Tf 8 0 0 8 181.214 376.1848 Tm /Cs5 cs 0.161 0.145 0.149 sc 0 Tc 0 Tw (
)Tj /F2 1 Tf 1.1244 0 TD (Constitution/laws)Tj /F5 1 Tf -1.1244 -1.125 TD (
)Tj /F2 1 Tf 1.1244 0 TD (National health/)Tj -1.1244 -1.125 TD ( )Tj 1.1244 0 TD (r)Tj 0.4029 0 TD [(epr)-28.8(oductive health policies)]TJ ET q 1 i 140.38 85.25 370.958 303.112 re W n /Cs10 CS 1 SCN 0 J 0 j 0.779 w 4 M []0 d /GS2 gs 168.575 387.972 142.847 -35.434 re S Q /Cs10 cs 1 scn /GS2 gs 141.026 328.124 196.678 -70.676 re f q 1 i 140.38 85.25 370.958 303.112 re W n /Cs10 CS 1 SCN 0 J 0 j 1.291 w 4 M []0 d 141.026 328.124 196.678 -70.676 re S Q BT 8 0 0 8 156.128 309.1999 Tm /Cs5 cs 1 1 1 sc (Operational policies)Tj /F7 1 Tf 0 -1.125 TD [(Rules, r)-17.8(egulations, guidelines, operating )]TJ T* [(pr)-13.9(ocedur)-17.8(es, and administrative nor)-9.7(ms that )]TJ T* 0.0001 Tc -0.0001 Tw (governments use to translate national laws )Tj T* 0 Tc 0 Tw [(and policies into pr)-13.9(ograms and ser)-32(vices.)]TJ /F2 1 Tf 0.161 0.145 0.149 sc 4.2165 -6.3924 TD [(Public sector r)-23(e)0.1(gulations)]TJ /F7 1 Tf -0.6045 -1.125 TD [(\(budget, civil ser)-32(vice, general )]TJ 1.24 -1.125 TD [(ser)-32(vices administration\))]TJ ET /Cs10 CS 1 SCN 0 J 0 j 0.779 w 4 M []0 d 1 i 169.053 233.857 142.847 -35.434 re S BT /F2 1 Tf 8 0 0 8 182.432 158.583 Tm (Health systems management)Tj /F7 1 Tf 0.87 -1.125 TD (\(centralized, decentralized\))Tj ET 169.053 174.38 142.847 -35.435 re S BT /F2 1 Tf 8 0 0 8 168.9874 102.723 Tm [(Repr)-28.8(oductive health ser)-26.8(vice deliver)-37.9(y)]TJ ET 0.639 w 159.916 115.231 161.121 -21.106 re S 1 1 1 sc 234.727 340.343 m 239.712 331.706 l 244.698 340.343 l 234.727 340.343 l f 1 w 239.728 352.606 m 239.728 338.883 l S /Cs10 cs 1 scn 234.727 340.343 m 239.712 331.706 l 244.698 340.343 l 234.727 340.343 l f /Cs5 cs 1 1 1 sc 234.544 244.629 m 239.53 235.992 l 244.516 244.629 l 234.544 244.629 l f 239.546 256.892 m 239.546 243.169 l S /Cs10 cs 1 scn 234.544 244.629 m 239.53 235.992 l 244.516 244.629 l 234.544 244.629 l f /Cs5 cs 1 1 1 sc 234.544 185.779 m 239.53 177.141 l 244.516 185.779 l 234.544 185.779 l f 239.546 198.042 m 239.546 184.319 l S /Cs10 cs 1 scn 234.544 185.779 m 239.53 177.141 l 244.516 185.779 l 234.544 185.779 l f /Cs5 cs 1 1 1 sc 234.544 126.269 m 239.53 117.633 l 244.516 126.269 l 234.544 126.269 l f 239.546 138.532 m 239.546 124.809 l S /Cs10 cs 1 scn 234.544 126.269 m 239.53 117.633 l 244.516 126.269 l 234.544 126.269 l f 510.838 319.64 m 510.838 290.876 493.582 267.557 472.297 267.557 c 451.011 267.557 433.754 290.876 433.754 319.64 c 433.754 348.406 451.011 371.724 472.297 371.724 c 493.582 371.724 510.838 348.406 510.838 319.64 c f q 140.38 85.25 370.958 303.112 re W n 510.838 319.64 m 510.838 290.876 493.582 267.557 472.297 267.557 c 451.011 267.557 433.754 290.876 433.754 319.64 c 433.754 348.406 451.011 371.724 472.297 371.724 c 493.582 371.724 510.838 348.406 510.838 319.64 c s Q BT 8 0 0 8 450.548 319.1408 Tm /Cs5 cs 1 1 1 sc [(Policy r)-28.8(oots)]TJ ET /Cs10 cs 1 scn 510.838 157.204 m 510.838 128.438 493.582 105.12 472.297 105.12 c 451.01 105.12 433.753 128.438 433.753 157.204 c 433.753 185.968 451.01 209.287 472.297 209.287 c 493.582 209.287 510.838 185.968 510.838 157.204 c f q 140.38 85.25 370.958 303.112 re W n 510.838 157.204 m 510.838 128.438 493.582 105.12 472.297 105.12 c 451.01 105.12 433.753 128.438 433.753 157.204 c 433.753 185.968 451.01 209.287 472.297 209.287 c 493.582 209.287 510.838 185.968 510.838 157.204 c s Q BT 8 0 0 8 453.3 167.932 Tm /Cs5 cs 1 1 1 sc (Impact of )Tj -0.46 -1.125 TD (operational )Tj -0.711 -1.125 TD -0.0001 Tw [(policy bar)-22(riers)]TJ ET 477.532 253.589 m 472.548 262.225 l 467.562 253.589 l 477.532 253.589 l f [3 3 ]0 d 472.531 216.453 m 472.531 255.049 l S /Cs10 cs 1 scn 477.532 253.589 m 472.548 262.225 l 467.562 253.589 l 477.532 253.589 l f 433.753 157.204 m 393.089 157.204 l f 1.291 w 433.753 157.204 m 393.089 157.204 l S /Cs5 cs 1 1 1 sc 386.734 107.913 m 378.099 102.926 l 386.734 97.94 l 386.734 107.913 l f 392.568 207.599 m 392.568 102.911 l 385.276 102.911 l S /Cs10 cs 1 scn 387.159 109.37 m 376.007 102.931 l 387.159 96.492 l 387.159 109.37 l f /Cs5 cs 1 1 1 sc 386.172 212.58 m 377.536 207.594 l 386.172 202.608 l 386.172 212.58 l f 392.004 207.578 m 384.713 207.578 l S /Cs10 cs 1 scn 386.597 214.038 m 375.444 207.598 l 386.597 201.159 l 386.597 214.038 l f 433.753 319.954 m 393.609 319.954 l f 433.753 319.954 m 393.609 319.954 l S /Cs5 cs 1 1 1 sc 386.734 270.662 m 378.099 265.676 l 386.734 260.691 l 386.734 270.662 l f 392.568 370.349 m 392.568 265.661 l 385.276 265.661 l S /Cs10 cs 1 scn 387.159 272.12 m 376.007 265.681 l 387.159 259.242 l 387.159 272.12 l f /Cs5 cs 1 1 1 sc 386.172 375.33 m 377.536 370.344 l 386.172 365.358 l 386.172 375.33 l f 392.004 370.328 m 384.713 370.328 l S /Cs10 cs 1 scn 386.597 376.788 m 375.444 370.348 l 386.597 363.909 l 386.597 376.788 l f q -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 CS 1 SCN 3 w 10 M []0 d /GS1 gs 109.5 436.43 447 -366.77 re S /Cs9 cs 1 scn 108 437.98 450 -24.77 re f BT 14 0 0 14 126 421.9239 Tm /Cs5 cs 1 1 1 sc -0.0002 Tc 0.03 Tw [(Figur)-23.2(e 2. Conceptual Framework for Operational Policies)]TJ ET Q endstream endobj 31 0 obj << /Type /Page /Parent 125 0 R /Resources 32 0 R /Contents 33 0 R /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 32 0 obj << /ProcSet [ /PDF /Text ] /Font << /F2 136 0 R /F3 99 0 R /F5 101 0 R /F6 102 0 R >> /ExtGState << /GS1 140 0 R /GS2 97 0 R >> /ColorSpace << /Cs5 135 0 R /Cs9 138 0 R /Cs10 98 0 R >> >> endobj 33 0 obj << /Length 11414 >> stream 1 g /GS1 gs 0 792 m 0 792 l f q 1 i 575.445 25.74 m 575.445 20.347 571.07 15.97 565.68 15.97 c 560.29 15.97 555.915 20.347 555.915 25.74 c 555.915 31.133 560.29 35.51 565.68 35.51 c 571.07 35.51 575.445 31.133 575.445 25.74 c h 0 792 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.8 scn /GS2 gs 555.84 35.58 19.68 -19.68 re f 0.65 scn 576.046 37.648 m 576.046 35.732 574.492 34.179 572.576 34.179 c 570.66 34.179 569.107 35.732 569.107 37.648 c 576.046 37.648 l f 569.349 34.383 m 569.349 32.467 567.795 30.914 565.879 30.914 c 563.963 30.914 562.41 32.467 562.41 34.383 c 569.349 34.383 l f 562.652 37.645 m 562.652 35.729 561.099 34.176 559.183 34.176 c 557.267 34.176 555.713 35.729 555.713 37.645 c 562.652 37.645 l f 576.046 30.71 m 576.046 28.794 574.492 27.24 572.576 27.24 c 570.66 27.24 569.107 28.794 569.107 30.71 c 576.046 30.71 l f 569.349 27.444 m 569.349 25.528 567.795 23.975 565.879 23.975 c 563.963 23.975 562.41 25.528 562.41 27.444 c 569.349 27.444 l f 562.652 30.707 m 562.652 28.791 561.099 27.237 559.183 27.237 c 557.267 27.237 555.713 28.791 555.713 30.707 c 562.652 30.707 l f 576.046 23.771 m 576.046 21.855 574.492 20.302 572.576 20.302 c 570.66 20.302 569.107 21.855 569.107 23.771 c 576.046 23.771 l f 569.349 20.505 m 569.349 18.589 567.795 17.036 565.879 17.036 c 563.963 17.036 562.41 18.589 562.41 20.505 c 569.349 20.505 l f 562.652 23.768 m 562.652 21.852 561.099 20.298 559.183 20.298 c 557.267 20.298 555.713 21.852 555.713 23.768 c 562.652 23.768 l f 576.046 16.832 m 576.046 14.916 574.492 13.363 572.576 13.363 c 570.66 13.363 569.107 14.916 569.107 16.832 c 576.046 16.832 l f 562.652 16.829 m 562.652 14.913 561.099 13.36 559.183 13.36 c 557.267 13.36 555.713 14.913 555.713 16.829 c 562.652 16.829 l f Q q 1 i 575.945 25.74 m 575.945 20.071 571.346 15.47 565.68 15.47 c 560.014 15.47 555.415 20.071 555.415 25.74 c 555.415 31.409 560.014 36.01 565.68 36.01 c 571.346 36.01 575.945 31.409 575.945 25.74 c h 0 792 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 CS 0.4 SCN 0 J 0 j 2 w 10 M []0 d 575.945 25.74 m 575.945 20.071 571.346 15.47 565.68 15.47 c 560.014 15.47 555.415 20.071 555.415 25.74 c 555.415 31.409 560.014 36.01 565.68 36.01 c 571.346 36.01 575.945 31.409 575.945 25.74 c h 0 792 m S Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F2 1 Tf 11 0 0 11 562.3771 22.8189 Tm /Cs5 cs 1 1 1 sc 0 Tc 0 Tw (7)Tj ET /Cs9 cs 1 scn 522.04 738.01 89.96 -36 re f Q q 1 i 519.549 751.827 105.64 -54 re W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.4 scn /GS2 gs 619.108 723.377 m 611.923 723.377 606.099 729.202 606.099 736.387 c 606.099 743.573 611.923 749.397 619.108 749.397 c 619.108 723.377 l f 593.088 723.377 m 585.903 723.377 580.079 729.202 580.079 736.387 c 580.079 743.573 585.903 749.397 593.088 749.397 c 593.088 723.377 l f 567.068 723.377 m 559.883 723.377 554.059 729.202 554.059 736.387 c 554.059 743.573 559.883 749.397 567.068 749.397 c 567.068 723.377 l f 541.048 723.377 m 533.863 723.377 528.039 729.202 528.039 736.387 c 528.039 743.573 533.863 749.397 541.048 749.397 c 541.048 723.377 l f Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 cs 0.2 scn 55.5 715.79 446.98 -647.95 re f /Cs9 CS 1 SCN 0 J 0 j 3 w 10 M []0 d 55.5 715.79 446.98 -647.95 re S BT /F2 1 Tf 14 0 0 14 66 695.6849 Tm 1 scn -0.0002 Tc 0.03 Tw [(Box 2. Levels of Policies Gover)-19(ning Public Sector Health)]TJ 0 -1.2 TD [(Pr)-29(ograms and Examples of Operational Policies)]TJ 12 0 0 12 66 649.085 Tm /Cs5 cs 0.161 0.145 0.149 sc (Constitution/Laws/National Policies)Tj /F5 1 Tf 10 0 0 10 66.5764 625.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 1.7424 0 TD -0.0002 Tc 0.03 Tw [(National laws af)-73.2(fecting r)-14.1(epr)-15.1(oductive health )]TJ /F5 1 Tf /Cs9 cs 1 scn -1.7424 -1.2 TD 0 Tc 0 Tw (
)Tj /F3 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 1.7424 0 TD -0.0002 Tc 0.03 Tw [(National r)-14.1(epr)-15.1(oductive health-r)-14.1(elated policies )]TJ /F5 1 Tf /Cs9 cs 1 scn -1.7424 -1.2 TD 0 Tc 0 Tw (
)Tj /F3 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 1.7424 0 TD -0.0002 Tc 0.03 Tw (Human rights guarantees)Tj /F2 1 Tf 12 0 0 12 66 576.085 Tm (Operational Policies)Tj /F6 1 Tf 10 0 0 10 66 551.085 Tm -0.0001 Tc (Public Sector Regulations)Tj /F5 1 Tf 11.5 0 0 11.5 66.5764 539.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 539.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0001 Tc 0.0299 Tw [(Budget \(pr)-15(ocess for deter)-32.1(mining annual funding, level and allocation, flexibility\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 527.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 527.085 Tm /Cs5 cs 0.161 0.145 0.149 sc (T)Tj 0.4102 0 TD -0.0002 Tc 0.03 Tw [(axes and duties \(excise, impor)-89.1(t, value-added tax \(V)65.7(A)53.9(T\), exemptions\) )]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 515.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 515.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Personnel \(r)-38(ules for hiring, firing, transfer\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 503.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 503.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Buildings and gr)-15.1(ounds \(utilities, building and maintaining the physical infrastr)-38(uctur)-14.1(e\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 491.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 491.085 Tm /Cs5 cs 0.161 0.145 0.149 sc (T)Tj 0.458 0 TD -0.0002 Tc 0.03 Tw [(ranspor)-89.1(tation/vehicles \(r)-14.1(esour)-20(ces and r)-38(u)0(les for obtaining and maintaining vehicles, fuel\))]TJ /F6 1 Tf -2.258 -2.5 TD (Health Systems Management)Tj /F5 1 Tf 11.5 0 0 11.5 66.5764 454.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 454.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Policy)63.8(, planning, and evaluation \(pr)-15.1(ocess and pr)-15.1(ocedur)-14.1(es\) )]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 442.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 442.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Or)-36.1(ganization \(centralized and decentralized r)-14.1(esponsibilities\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 430.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 430.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0001 Tc 0.0299 Tw [(Facility-based ser)-91.9(vices or)-36(ganization \(location, distribution, lines of authority\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 418.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 418.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Community-based ser)-92(vice or)-36.1(ganization \(location, distribution, lines of authority\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 406.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 406.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Standar)-17(ds and accr)-14.1(editations \(personnel, facilities\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 394.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 394.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Fees for ser)-92(vice \(levels, exemptions\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 382.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 382.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.0299 Tw [(Pr)-15.1(ocur)-14.1(ement/logistics \(pr)-15.1(ocedur)-14.1(es, r)-14.1(egulations\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 370.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 370.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0062 Tc 0.03 Tw [(Management infor)-32.1(mation systems, monitoring \(r)-14(egulations, cir)-19.9(culars, pr)-15(ocedur)-14.1(es\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 358.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 358.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Refer)-34.1(ral systems \(guidelines, cir)-20(culars\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 346.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 346.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Client rights \(r)-14.1(egulations, nor)-32.2(ms\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 334.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 334.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw (Regulation of the private health sector )Tj /F6 1 Tf -1.8 -2.5 TD [(Ser)-92(vice Deliver)-92(y \(including r)-14.1(epr)-15.1(oductive health\) )]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 297.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 297.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Or)-36.1(ganizational str)-38(uctur)-14.1(e \(lines of authority\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 285.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 285.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Personnel \(clinic and community-based: job descriptions, allocation of time, r)-14.1(ecr)-38(uitment,)]TJ 0 -1.2 TD [(deployment, pr)-15.1(ofessional development, training, super)-92(vision, per)-96.1(for)-32.2(mance appraisal\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 261.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 261.085 Tm /Cs5 cs 0.161 0.145 0.149 sc (T)Tj 0.4102 0 TD -0.0002 Tc 0.03 Tw [(angibles \(equipment, materials/supplies, pr)-15.1(ocur)-14.1(ement and maintenance of)]TJ -0.4102 -1.2 TD 0 Tw [(phar)-32.2(maceuticals\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 237.085 Tm /Cs9 cs 1 scn 0 Tc (
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)Tj /F3 1 Tf 10 0 0 10 84 225.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0001 Tc 0.0299 Tw [(Facilities maintenance \(cir)-19.9(culars, r)-14(egulations, guidelines\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 213.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 213.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Financial management \(guidelines on r)-14.1(etention of fees, management of funds, facility)]TJ T* [(budgeting, local pr)-15.1(ocur)-14.1(ement\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 189.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 189.085 Tm /Cs5 cs 0.161 0.145 0.149 sc 0.0178 Tc 0.03 Tw [(Clinic or)-36.1(ganization/patient flow \(hours of operation, availability of medical personnel\) )]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 177.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 177.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Clinic r)-14.1(ecor)-17(ds, management infor)-32.2(mation systems, including ser)-92(vice statistics \(guidelines,)]TJ T* [(cir)-20(culars on compiling and r)-14.1(epor)-89.1(ting infor)-32.2(mation\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 153.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 153.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Ser)-92(vice deliver)-92(y guidelines/pr)-15.1(otocols/nor)-32.2(ms/standar)-17(ds \(medical, counseling, education)]TJ T* [(ser)-92(vices, infor)-32.2(med choice/consent\))]TJ /F5 1 Tf 11.5 0 0 11.5 66.5764 129.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 129.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw (Quality assurance system)Tj /F5 1 Tf 11.5 0 0 11.5 66.5764 117.085 Tm /Cs9 cs 1 scn 0 Tc 0 Tw (
)Tj /F3 1 Tf 10 0 0 10 84 117.085 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.03 Tw [(Client outr)-14.1(each/follow-up)]TJ ET Q endstream endobj 34 0 obj << /Type /Page /Parent 125 0 R /Resources 35 0 R /Contents 36 0 R /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 35 0 obj << /ProcSet [ /PDF /Text ] /Font << /F1 132 0 R /F2 136 0 R /F4 100 0 R >> /ExtGState << /GS1 140 0 R /GS2 97 0 R >> /ColorSpace << /Cs5 135 0 R /Cs9 138 0 R /Cs10 98 0 R >> >> endobj 36 0 obj << /Length 7926 >> stream 1 g /GS1 gs 0 792 m 0 792 l f q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 cs 1 scn 0 792.06 68.67 -172.14 re f Q q 1 i -9 670.62 117 -64.91 re W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.4 scn /GS2 gs -4.193 654.284 m 2.992 654.284 8.816 648.459 8.816 641.274 c 8.816 634.089 2.992 628.264 -4.193 628.264 c -4.193 654.284 l f 21.827 654.284 m 29.012 654.284 34.836 648.459 34.836 641.274 c 34.836 634.089 29.012 628.264 21.827 628.264 c 21.827 654.284 l f 47.847 654.284 m 55.032 654.284 60.856 648.459 60.856 641.274 c 60.856 634.089 55.032 628.264 47.847 628.264 c 47.847 654.284 l f 73.867 654.284 m 81.052 654.284 86.876 648.459 86.876 641.274 c 86.876 634.089 81.052 628.264 73.867 628.264 c 73.867 654.284 l f Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F2 1 Tf 15 0 0 15 108 711 Tm /Cs9 cs 1 scn -0.0002 Tc 0.03 Tw (Levels of Operational)Tj 0 -1 TD 0 Tw (Policies)Tj /F1 1 Tf 11.5 0 0 11.5 108 666 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0003 Tc 0.0261 Tw [(Box 2 shows the hierarchy and range of)]TJ 0 -1.3043 TD -0.0002 Tc [(laws, regulations, and policies that af)-22.2(fect)]TJ T* -0.0004 Tc (the provision of reproductive health)Tj T* -0.0001 Tc 0.0259 Tw [(ser)-71.9(vices as or)-7(ganized by gover)-26(nmental)]TJ T* -0.0002 Tc (level. 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In Jordan, the)]TJ T* -0.0003 Tc 0.0261 Tw (MOH and the medical profession)Tj T* (interpret a provision of the public health)Tj T* -0.0001 Tc 0.0259 Tw [(law to mean that only licensed doctors of)]TJ T* -0.0002 Tc [(medicine may inser)-11.2(t an IUD, although no)]TJ T* -0.0003 Tc 0.0261 Tw [(explicit prohibition exists on inser)-11.3(tion by)]TJ T* -0.0001 Tc 0.0259 Tw (nurses and midwives. )Tj 0 -2.6087 TD -0.0002 Tc (In other cases, there is a policy vacuum)Tj 0 -1.3043 TD -0.0001 Tc [(such that policymakers must develop)]TJ T* -0.0002 Tc [(operational policies where none existed)]TJ T* -0.0003 Tc [(previously)68.5(. W)-18.2(ith India�)19.5(s tar)-7.2(get-free)]TJ T* 0.0261 Tw (approach implemented during the 1990s,)Tj T* -0.0001 Tc 0.0259 Tw [(the countr)-70(y)0( failed to develop operational)]TJ T* -0.0003 Tc 0.0261 Tw (policies to guide program)Tj T* -0.0001 Tc 0.0259 Tw [(implementation. A policy vacuum may also)]TJ T* -0.0002 Tc [(exist when health sector refor)-26.1(m is)]TJ T* [(introducing major changes to a countr)-70.1(y)0.1(�)19.6(s)]TJ T* [(health system \(POLICY Project, 1998b;)]TJ T* 0 Tw (2001b\). )Tj 20.3478 26.087 TD -0.0001 Tc 0.0259 Tw [(An operational policy vacuum continues)]TJ 0 -1.3043 TD [(to exist in many countries as they embark)]TJ T* [(on expanded national HIV/AIDS)]TJ T* -0.0003 Tc 0.0261 Tw [(programs. Owing to its completeness and)]TJ T* -0.0002 Tc [(adherence to inter)-26.1(national HIV/AIDS)]TJ T* [(principles and agreements, the)]TJ T* [(Philippines�)19.6(s national HIV/AIDS policy)]TJ T* [(and strategic plan provides a model that)]TJ T* [(other Asian nations have followed. Y)40.5(et, the)]TJ T* -0.0001 Tc 0.0259 Tw [(plan�)19.7(s operational policies actually foster)]TJ T* -0.0002 Tc [(an environment that is contradictor)-70.1(y to)]TJ T* [(the Philippines�)19.6(s national policy)68.6(. For)]TJ T* -0.0001 Tc [(example, while the Sanitation Code of)]TJ T* -0.0003 Tc [(1975 requires all female sex workers to be)]TJ T* 0.0261 Tw [(regularly tested, it places an age restriction)]TJ T* -0.0002 Tc [(on clients of gover)-26.1(nment health clinics)]TJ T* -0.0003 Tc [(responsible for detecting and treating)]TJ T* -0.0001 Tc 0.0259 Tw [(STDs and HIV/AIDS \(Gover)-26(nment of the)]TJ T* -0.0002 Tc (Philippines, 1975\). 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Once introduced,)Tj T* (registers are never withdrawn, resulting in)Tj T* -0.0053 Tc [(a misuse of labor by the most essential)]TJ T* -0.0054 Tc (health worker \(POLICY Project, 1998a\). )Tj 0 -2.6087 TD -0.0002 Tc [(Some operational policies are sound, but)]TJ 0 -1.3043 TD [(their implementation is slowed by the lag)]TJ T* (between the time that the policies are)Tj T* (developed and the time they are)Tj T* [(communicated to relevant levels of the)]TJ T* -0.0001 Tc [(health system. 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)Tj /F3 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 1.7424 0 TD -0.0002 Tc 0.03 Tw [(Medical nor)-32.2(ms)]TJ /F5 1 Tf /Cs9 cs 1 scn -1.7424 -6 TD 0 Tc 0 Tw (
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)Tj /F3 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 1.7424 0 TD (T)Tj 0.458 0 TD -0.0002 Tc 0.03 Tw [(raining, personnel, or)-36.1(ganizational)]TJ -0.458 -1.2 TD -0.0003 Tc 0 Tw [(str)-38.1(uctur)-14.2(es)]TJ /F5 1 Tf /Cs9 cs 1 scn -1.7424 -1.2 TD 0 Tc (
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)Tj /F3 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 1.7424 0 TD -0.0002 Tc 0.03 Tw [(Or)-36.1(ganizational str)-38(uctur)-14.1(es,)]TJ 0 -1.2 TD 0 Tw (communications)Tj ET 0.4 SCN 1 w 333.002 639.487 m 333.002 331.687 l S Q endstream endobj 43 0 obj << /Type /Page /Parent 125 0 R /Resources 44 0 R /Contents 45 0 R /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 44 0 obj << /ProcSet [ /PDF /Text ] /Font << /F1 132 0 R /F2 136 0 R >> /ExtGState << /GS1 140 0 R /GS2 97 0 R >> /ColorSpace << /Cs5 135 0 R /Cs9 138 0 R /Cs10 98 0 R >> >> endobj 45 0 obj << /Length 5326 >> stream 1 g /GS1 gs 0 792 m 0 792 l f q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F1 1 Tf 11.5 0 0 11.5 54 711 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.026 Tw (the late 1980s noted that eight months)Tj 0 -1.3043 TD -0.0003 Tc (elapsed for a directive to go from the)Tj T* -0.0001 Tc [(Depar)-11.1(tment of Health to the local level)]TJ T* -0.0003 Tc (\(Feranil, 2001\). 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0.0259 Tw [(operational policy bar)-29.9(riers. 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Most of these)]TJ T* -0.0053 Tc [(individuals and or)-6.9(ganizations neither have)]TJ T* -0.0054 Tc (the mandate to address policies beyond)Tj ET /Cs9 cs 0.4 scn 36 354.43 521.99 -204.8 re f 1 scn 0 792.06 68.67 -172.14 re f Q q 1 i -9 670.62 117 -64.91 re W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.4 scn /GS2 gs -4.193 654.284 m 2.992 654.284 8.816 648.459 8.816 641.274 c 8.816 634.089 2.992 628.264 -4.193 628.264 c -4.193 654.284 l f 21.827 654.284 m 29.012 654.284 34.836 648.459 34.836 641.274 c 34.836 634.089 29.012 628.264 21.827 628.264 c 21.827 654.284 l f 47.847 654.284 m 55.032 654.284 60.856 648.459 60.856 641.274 c 60.856 634.089 55.032 628.264 47.847 628.264 c 47.847 654.284 l f 73.867 654.284 m 81.052 654.284 86.876 648.459 86.876 641.274 c 86.876 634.089 81.052 628.264 73.867 628.264 c 73.867 654.284 l f Q q 1 i 56.03 25.74 m 56.03 20.347 51.653 15.97 46.26 15.97 c 40.867 15.97 36.49 20.347 36.49 25.74 c 36.49 31.133 40.867 35.51 46.26 35.51 c 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[(\(Str)-15.1(ong,)]TJ 0 -1.3333 TD (medium, )Tj T* (low\))Tj /F7 1 Tf 10 0 0 10 156.7687 334.5665 Tm (Complexity)Tj 0 -1.2 TD 0.03 Tw (of the)Tj T* 0.0004 Tc 0 Tw (barrier)Tj /F6 1 Tf 9 0 0 9 156.7687 178.5665 Tm -0.0001 Tc (\(High,)Tj 0 -1.3333 TD -0.0002 Tc (medium, )Tj T* (low\) )Tj /F7 1 Tf 10 0 0 10 213.716 334.5665 Tm (Potential)Tj 0 -1.2 TD 0.03 Tw [(suppor)-58(t or)]TJ T* 0 Tw (opposition)Tj /F6 1 Tf 9 0 0 9 213.716 154.5665 Tm (\(Describe\))Tj /F7 1 Tf 10 0 0 10 270.6633 334.5665 Tm 0 Tc (T)Tj 0.5466 0 TD -0.0003 Tc (ime)Tj -0.5466 -1.2 TD 0 Tc (r)Tj 0.3577 0 TD -0.0003 Tc [(equir)-18.1(ed )]TJ -0.3577 -1.2 TD -0.0002 Tc 0.03 Tw (to change)Tj /F6 1 Tf 9 0 0 9 270.6633 178.5665 Tm -0.0003 Tc 0 Tw [(\(Shor)-89.2(t,)]TJ 0 -1.3333 TD -0.0002 Tc (medium,)Tj T* (long\))Tj /F7 1 Tf 10 0 0 10 327.6106 334.5665 Tm [(Resour)-16.1(ces)]TJ 0 -1.2 TD 0 Tc (r)Tj 0.3577 0 TD -0.0003 Tc [(equir)-18.1(ed )]TJ -0.3577 -1.2 TD -0.0002 Tc 0.03 Tw (to change)Tj /F6 1 Tf 9 0 0 9 327.6106 166.5665 Tm -0.0001 Tc 0 Tw (\(Financial,)Tj 0 -1.3333 TD -0.0002 Tc (human\))Tj /F7 1 Tf 10 0 0 10 384.5579 334.5665 Tm (What)Tj 0 -1.2 TD (needs )Tj T* 0.03 Tw (to be)Tj T* 0 Tw (changed?)Tj /F6 1 Tf 9 0 0 9 384.5579 274.5665 Tm -0.0001 Tc (\(Policy)Tj 0 -1.3333 TD -0.0002 Tc 0.03 Tw [(pr)-14.1(esumed to)]TJ T* -0.0001 Tc (exist, policy)Tj T* -0.0002 Tc (based on)Tj T* -0.0001 Tc (lack of clarity)Tj T* -0.0002 Tc [(in the law)63.8(,)]TJ T* -0.0001 Tc 0 Tw (policy)Tj T* -0.0002 Tc (vacuum,)Tj T* -0.0001 Tc 0.0299 Tw (slow imple-)Tj T* -0.0002 Tc 0 Tw (mentation,)Tj T* 0.03 Tw (out of date\))Tj /F7 1 Tf 10 0 0 10 441.5052 334.5665 Tm (Ease of)Tj 0 -1.2 TD 0 Tw (decision )Tj T* 0.03 Tw (to change)Tj T* 0 Tw (operational)Tj T* (policy )Tj T* (\(e.g.,)Tj T* (executive)Tj T* -0.0003 Tc [(or)-20(der )]TJ T* -0.0002 Tc 0.03 Tw (rather than)Tj T* (act of)Tj T* 0 Tw (parliament\))Tj /F6 1 Tf 9 0 0 9 441.5052 178.5665 Tm -0.0001 Tc [(\(Dif)-73.1(ficult,)]TJ 0 -1.3333 TD -0.0002 Tc (medium,)Tj T* (easy\))Tj /F7 1 Tf 10 0 0 10 498.4525 334.5665 Tm (Priority)Tj 0 -1.2 TD (rank)Tj /F6 1 Tf 9 0 0 9 498.4525 178.5665 Tm -0.0001 Tc (\(High,)Tj 0 -1.3333 TD -0.0002 Tc (medium, )Tj T* (low\))Tj ET /Cs9 cs 0.2 scn 37.51 408.8 519 -56.3 re f 37.51 408.8 519 -56.3 re S BT /F2 1 Tf 14 0 0 14 48.0069 388.82 Tm 1 scn 0.03 Tw [(Box 5. 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They can work on)Tj T* -0.0054 Tc (policy issues beyond the reach of the)Tj T* -0.0053 Tc [(operational-level staf)-22(f and, in collaboration)]TJ T* -0.0054 Tc [(with ser)-72(vice deliver)-70(y or)-7.1(ganizations, ensure)]TJ T* 0.0261 Tw (sound problem analysis and appropriate,)Tj T* [(practical refor)-26.2(m)-0.1(s.)]TJ 0 -2.6087 TD -0.0001 Tc 0.0259 Tw [(For example, the Maximizing Access and)]TJ 0 -1.3043 TD [(Quality \(MAQ\) Initiative focuses mainly)]TJ T* -0.0003 Tc 0.0261 Tw [(on the reproductive health ser)-72.1(vice)]TJ T* -0.0001 Tc 0.0259 Tw [(deliver)-70(y level by seeking inter)-71.9(ventions)]TJ 7.59 0 0 7.59 245.3633 459.795 Tm 0 Tc 0 Tw (5)Tj 11.5 0 0 11.5 54 441 Tm -0.0004 Tc 0.0262 Tw (that will improve the care received by)Tj T* -0.0002 Tc 0.026 Tw [(clients. However)83.7(, commitment of)]TJ T* -0.0001 Tc [(leadership is envisioned as the first of)]TJ T* [(many MAQ inter)-71.9(ventions needed to)]TJ T* -0.0004 Tc 0.0262 Tw [(ensure suppor)-11.4(t for change. Therefore,)]TJ T* -0.0002 Tc 0.026 Tw [(or)-7.1(ganizations with policy exper)-11.2(tise should)]TJ T* [(be included in the design and suppor)-11.2(t for)]TJ T* -0.0001 Tc [(MAQ activities. Other)-73.1(wise, these activities)]TJ T* -0.0003 Tc [(might not elicit suppor)-11.3(t from the requisite)]TJ T* -0.0001 Tc [(level of decision makers and may be)]TJ T* [(stalled, as demonstrated in some of the)]TJ T* -0.0003 Tc [(Francophone region MAQ ef)-22.3(for)-11.3(ts. )]TJ 0 -2.6087 TD -0.0002 Tc [(In a Francophone MAQ conference)]TJ 0 -1.3043 TD -0.0003 Tc [(\(Dakar)83.7(, March 1999\), par)-11.3(ticipants)]TJ T* 0.0262 Tw [(repor)-11.4(ted on progress with development of)]TJ T* [(protocols, nor)-26.3(ms, and procedures \(PNPs\).)]TJ T* -0.0002 Tc 0.026 Tw [(Despite the high quality of both the)]TJ T* (content of and process for developing)Tj T* [(many of the PNPs, nearly all par)-11.2(ticipants)]TJ T* (agreed that there was little evidence that)Tj T* [(the PNPs were being ef)-22.2(fectively)]TJ 20.3478 50.8696 TD -0.0001 Tc (implemented at the operations level.)Tj 0 -1.3043 TD -0.0003 Tc [(Reasons included �lack of resources� and)]TJ T* -0.0002 Tc [(�lack of training.� In other words, an)]TJ T* -0.0001 Tc [(impor)-11.1(tant component of operational)]TJ T* -0.0002 Tc [(policies existed but remained �on the)]TJ T* -0.0001 Tc [(shelf� because commitment to PNPs)]TJ T* -0.0002 Tc [(seldom went higher than a division or)]TJ T* -0.0003 Tc [(bureau chief or the staf)-22.3(f responsible for)]TJ T* [(the national family planning program.)]TJ T* -0.0001 Tc [(Policies that have an impact on the)]TJ T* -0.0002 Tc (implementation of PNPs include)Tj T* -0.0001 Tc [(personnel deployment, changes in job)]TJ T* -0.0002 Tc (descriptions and working conditions,)Tj T* -0.0003 Tc [(training needs assessments, resource)]TJ T* -0.0002 Tc [(allocation, and preser)-72(vice training. Those)]TJ T* [(with control over such policies include)]TJ T* [(high-level ministr)-70.1(y of)-22.2(ficials, professional)]TJ T* [(boards and associations, and faculties of)]TJ T* -0.0001 Tc [(medicine and nursing. In most cases,)]TJ T* -0.0002 Tc [(these decision makers were not engaged)]TJ T* -0.0003 Tc [(from the outset of the PNP process;)]TJ T* [(therefore, they had yet to be persuaded of)]TJ T* -0.0002 Tc [(the need for policy refor)-26.1(m in their)]TJ T* -0.0004 Tc 0.0263 Tw (respective areas. )Tj 0 -2.6087 TD -0.0002 Tc 0.026 Tw [(As a precursor to the MAQ Initiative,)]TJ 0 -1.3043 TD -0.0001 Tc [(several studies looked at the �medical)]TJ T* -0.0002 Tc [(bar)-30(riers� to family planning ser)-72(vices)]TJ T* [(\(Hardee et al., 1998; Ber)-11.2(trand et al., 1995;)]TJ T* [(Galway)73.7(, 1992; and MSP)57.6(AS, OPTIONS, and)]TJ T* (USAID, 1993\). Shelton, Angle, and)Tj T* -0.0001 Tc [(Jacobstein \(1992\) listed seven types of)]TJ T* -0.0002 Tc [(medical bar)-30(riers: inappropriate)]TJ T* -0.0003 Tc (contraindications, eligibility requirements,)Tj T* [(process or scheduling bar)-30.1(riers, provider)]TJ T* [(bias, regulator)-70.2(y hurdles, limits on who can)]TJ T* [(provide ser)-72.1(vices, and inappropriate)]TJ T* -0.0001 Tc [(management of side ef)-22.1(fects. A number of)]TJ T* [(these bar)-29.9(riers have policy implications. In)]TJ T* [(Guatemala, for example, an or)-7(ganization)]TJ ET Q q 1 i 575.445 25.74 m 575.445 20.347 571.07 15.97 565.68 15.97 c 560.29 15.97 555.915 20.347 555.915 25.74 c 555.915 31.133 560.29 35.51 565.68 35.51 c 571.07 35.51 575.445 31.133 575.445 25.74 c h 494.601 126 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.8 scn /GS2 gs 555.84 35.58 19.68 -19.68 re f 0.65 scn 576.046 37.648 m 576.046 35.732 574.492 34.179 572.576 34.179 c 570.66 34.179 569.107 35.732 569.107 37.648 c 576.046 37.648 l f 569.349 34.383 m 569.349 32.467 567.795 30.914 565.879 30.914 c 563.963 30.914 562.41 32.467 562.41 34.383 c 569.349 34.383 l f 562.652 37.645 m 562.652 35.729 561.099 34.176 559.183 34.176 c 557.267 34.176 555.713 35.729 555.713 37.645 c 562.652 37.645 l f 576.046 30.71 m 576.046 28.794 574.492 27.24 572.576 27.24 c 570.66 27.24 569.107 28.794 569.107 30.71 c 576.046 30.71 l f 569.349 27.444 m 569.349 25.528 567.795 23.975 565.879 23.975 c 563.963 23.975 562.41 25.528 562.41 27.444 c 569.349 27.444 l f 562.652 30.707 m 562.652 28.791 561.099 27.237 559.183 27.237 c 557.267 27.237 555.713 28.791 555.713 30.707 c 562.652 30.707 l f 576.046 23.771 m 576.046 21.855 574.492 20.302 572.576 20.302 c 570.66 20.302 569.107 21.855 569.107 23.771 c 576.046 23.771 l f 569.349 20.505 m 569.349 18.589 567.795 17.036 565.879 17.036 c 563.963 17.036 562.41 18.589 562.41 20.505 c 569.349 20.505 l f 562.652 23.768 m 562.652 21.852 561.099 20.298 559.183 20.298 c 557.267 20.298 555.713 21.852 555.713 23.768 c 562.652 23.768 l f 576.046 16.832 m 576.046 14.916 574.492 13.363 572.576 13.363 c 570.66 13.363 569.107 14.916 569.107 16.832 c 576.046 16.832 l f 562.652 16.829 m 562.652 14.913 561.099 13.36 559.183 13.36 c 557.267 13.36 555.713 14.913 555.713 16.829 c 562.652 16.829 l f Q q 1 i 575.945 25.74 m 575.945 20.071 571.346 15.47 565.68 15.47 c 560.014 15.47 555.415 20.071 555.415 25.74 c 555.415 31.409 560.014 36.01 565.68 36.01 c 571.346 36.01 575.945 31.409 575.945 25.74 c h 494.601 126 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 CS 0.4 SCN 0 J 0 j 2 w 10 M []0 d 575.945 25.74 m 575.945 20.071 571.346 15.47 565.68 15.47 c 560.014 15.47 555.415 20.071 555.415 25.74 c 555.415 31.409 560.014 36.01 565.68 36.01 c 571.346 36.01 575.945 31.409 575.945 25.74 c h 494.601 126 m S Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F2 1 Tf 11 0 0 11 559.0778 22.8189 Tm /Cs5 cs 1 1 1 sc -0.0002 Tc 0 Tw (15)Tj ET /Cs9 cs 1 scn 522.04 738.01 89.96 -36 re f Q q 1 i 519.549 751.827 105.64 -54 re W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.4 scn /GS2 gs 619.108 723.377 m 611.923 723.377 606.099 729.202 606.099 736.387 c 606.099 743.573 611.923 749.397 619.108 749.397 c 619.108 723.377 l f 593.088 723.377 m 585.903 723.377 580.079 729.202 580.079 736.387 c 580.079 743.573 585.903 749.397 593.088 749.397 c 593.088 723.377 l f 567.068 723.377 m 559.883 723.377 554.059 729.202 554.059 736.387 c 554.059 743.573 559.883 749.397 567.068 749.397 c 567.068 723.377 l f 541.048 723.377 m 533.863 723.377 528.039 729.202 528.039 736.387 c 528.039 743.573 533.863 749.397 541.048 749.397 c 541.048 723.377 l f Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs5 cs 1 1 1 sc 54 114.44 450 -61.43 re f BT /F4 1 Tf 6.6 0 0 6.6 54 105.3648 Tm 0.161 0.145 0.149 sc 0 Tc 0 Tw (5)Tj 10 0 0 10 60.288 102.0648 Tm -0.0002 Tc 0.026 Tw [(The 12 ar)-5.1(eas of inter)-69(vention in the MAQ Syner)-9(gy of Inter)-69(ventions framework include \(1\) leadership; \(2\) client)]TJ -0.6288 -1.2 TD -0.0001 Tc [(engagement; \(3\) community engagement; \(4\) provider r)-5(ewards/environment; \(5\) standards/guidelines; )]TJ T* -0.0002 Tc [(\(6\) or)-9(ganization of work; \(7\) training; \(8\) job aids; \(9\) supplies/logistics; \(10\) suppor)-44.1(tive super)-69(vision; )]TJ T* [(\(11\) indicators/cer)-44.1(tification; and \(12\) problem solving. )]TJ ET /Cs9 CS 1 SCN 0 J 0 j 0.5 w 10 M []0 d 54 116.03 m 504 116.03 l S Q endstream endobj 58 0 obj << /Type /Page /Parent 126 0 R /Resources 59 0 R /Contents 60 0 R /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 59 0 obj << /ProcSet [ /PDF /Text ] /Font << /F1 132 0 R /F2 136 0 R >> /ExtGState << /GS1 140 0 R /GS2 97 0 R >> /ColorSpace << /Cs5 135 0 R /Cs9 138 0 R /Cs10 98 0 R >> >> endobj 60 0 obj << /Length 8319 >> stream 1 g /GS1 gs 0 792 m 0 792 l f q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 cs 1 scn 0 792.06 68.67 -172.14 re f Q q 1 i -9 670.62 117 -64.91 re W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.4 scn /GS2 gs -4.193 654.284 m 2.992 654.284 8.816 648.459 8.816 641.274 c 8.816 634.089 2.992 628.264 -4.193 628.264 c -4.193 654.284 l f 21.827 654.284 m 29.012 654.284 34.836 648.459 34.836 641.274 c 34.836 634.089 29.012 628.264 21.827 628.264 c 21.827 654.284 l f 47.847 654.284 m 55.032 654.284 60.856 648.459 60.856 641.274 c 60.856 634.089 55.032 628.264 47.847 628.264 c 47.847 654.284 l f 73.867 654.284 m 81.052 654.284 86.876 648.459 86.876 641.274 c 86.876 634.089 81.052 628.264 73.867 628.264 c 73.867 654.284 l f Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F1 1 Tf 11.5 0 0 11.5 108 711 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.026 Tw (working on policy issues teamed with)Tj 0 -1.3043 TD -0.0001 Tc [(other par)-11.1(tners in a study of medical)]TJ T* -0.0003 Tc [(bar)-30.1(riers among providers \(Jewell, 2000\).)]TJ T* -0.0001 Tc [(By bringing a policy perspective to the)]TJ T* -0.0002 Tc [(study)73.7(, the team identified the policy issues)]TJ T* -0.0001 Tc [(underlying the identified bar)-29.9(r)0(iers. The)]TJ T* -0.0004 Tc 0.0262 Tw (providers are now addressing the policies)Tj T* -0.0002 Tc 0.026 Tw [(as they work toward making per)-26.1(manent)]TJ T* [(and long-ter)-26.1(m)0( improvements to access)]TJ T* [(and quality of ser)-72(vices \(MSP)57.6(AS et al.,)]TJ T* [(2000\). In a complementar)-70.1(y activity car)-30(ried)]TJ T* [(out by the same policy or)-7.1(ganization, a)]TJ T* -0.0003 Tc [(repor)-11.3(t on Guatemala�)19.5(s reproductive health)]TJ T* -0.0001 Tc [(laws and policies clearly set out the legal)]TJ T* -0.0002 Tc (and policy basis for the right to family)Tj T* [(planning infor)-26.1(mation and ser)-72(v)-0.1(ices.)]TJ T* [(Consequently)73.7(, advocates are using the)]TJ T* -0.0003 Tc [(repor)-11.3(t as a tool in their campaign to work)]TJ T* -0.0002 Tc (with the Minister of Health, who is known)Tj T* -0.0003 Tc [(as a strong family planning suppor)-11.3(ter)83.7(,)0( to)]TJ T* -0.0002 Tc [(promote the elimination of medical)]TJ T* [(bar)-30(riers identified in the study)68.6(.)]TJ 0 -2.6087 TD [(As a complementar)-70.1(y initiative to the MAQ)]TJ 0 -1.3043 TD -0.0003 Tc [(Initiative, inter)-26.2(national reproductive)]TJ T* -0.0002 Tc [(health or)-7.1(ganizations are under)-11.2(taking)]TJ T* [(another quality improvement initiative in)]TJ T* -0.0003 Tc [(the area of per)-41.1(for)-26.2(mance improvement)]TJ T* 0.0262 Tw (that focuses on human resources and)Tj T* -0.0002 Tc 0.026 Tw [(branches out to institutional factors when)]TJ T* [(such factors are deter)-26.1(mined to impede the)]TJ T* [(per)-41(for)-26.1(mance of a health care worker)79.6(. For)]TJ T* (example, if a worker is not doing his or)Tj T* (her job, one �root cause� may be)Tj T* -0.0001 Tc (inadequate facilities, equipment, or)Tj T* (supplies. Inadequate facilities, equipment,)Tj T* [(and so for)-11.1(th have their causes in)]TJ T* [(management systems but also in the)]TJ T* -0.0002 Tc [(operational policies that gover)-26.1(n those)]TJ T* [(systems. T)74.7(o)-0.1( date, per)-41(for)-26.1(mance)]TJ T* [(improvement has focused primarily on the)]TJ T* -0.0001 Tc [(ser)-71.9(vice deliver)-70(y level. Adding a policy)]TJ T* -0.0002 Tc (approach can extend the focus to all levels)Tj T* [(of the public sector system. )]TJ 20.3478 56.087 TD -0.0001 Tc [(Situation analysis studies can uncover a)]TJ 0 -1.3043 TD -0.0003 Tc [(problem with par)-11.3(ticular subsystems in a)]TJ T* (family planning or reproductive health)Tj T* -0.0002 Tc [(program but do not necessarily identify)]TJ T* -0.0001 Tc [(the operational policy issues perpetuating)]TJ T* -0.0004 Tc 0.0262 Tw [(the problem. Fur)-11.4(ther)-26.3(more, the)]TJ T* -0.0001 Tc 0.0259 Tw [(or)-7(ganizations conducting the operations)]TJ T* -0.0004 Tc 0.0262 Tw [(research are often not the or)-7.3(ganizations)]TJ T* -0.0001 Tc 0.0259 Tw [(char)-7(ged with making the necessar)-70(y)]TJ T* -0.0003 Tc 0.0261 Tw [(changes to programs or policies. )]TJ 0 -2.6087 TD 0.0103 Tc 0.0259 Tw [(Situation analyses that show changes over)]TJ 0 -1.3043 TD (time \(e.g., Burkino Faso, Kenya, Senegal,)Tj T* [(and Zimbabwe\) provide an oppor)-11.2(tunity)]TJ T* 0.01 Tc 0.0262 Tw (to identify areas where improvements)Tj T* 0.0103 Tc 0.0259 Tw [(over a long period have not been)]TJ T* [(significant and to deter)-26.1(mine whether)]TJ T* 0.0101 Tc 0.0261 Tw (underlying policies impede progress. For)Tj T* 0.0102 Tc [(example, one study in Kenya found that,)]TJ T* 0.0101 Tc (while more education materials were)Tj T* 0.0103 Tc 0.0259 Tw [(available in clinics over a six-year period,)]TJ T* 0.0101 Tc 0.0261 Tw [(there was no improvement in health talks)]TJ T* (provided to waiting clients and no)Tj T* [(improvement in the frequency of)]TJ T* 0.0102 Tc [(super)-72(vision�despite similar findings and)]TJ T* [(recommendations in earlier studies)]TJ T* (\(Ndhlovu et al., 1997\). The findings)Tj T* [(could be fur)-11.2(ther examined for policy)]TJ T* 0.01 Tc [(roots that may prevent personnel from)]TJ T* 0.0102 Tc [(taking action. Do personnel policies)]TJ T* 0.0101 Tc [(block ef)-22.3(for)-11.3(ts to ensure that job)]TJ T* 0.0102 Tc (descriptions, working conditions,)Tj T* [(training, and placement for clinic staf)-22.1(f)]TJ T* (accommodate the need for more health)Tj T* [(talks, more super)-72(vision visits? Do vehicle)]TJ T* [(maintenance, repair)83.8(,)0( and use policies)]TJ T* 0.0101 Tc [(suppor)-11.3(t more frequent super)-72.1(vision visits? )]TJ /F2 1 Tf 15 0 0 15 342 126 Tm /Cs9 cs 1 scn -0.0002 Tc 0.03 Tw (Analyze the Operational)Tj 0 -1 TD [(Policy Bar)-22.2(riers)]TJ /F1 1 Tf 11.5 0 0 11.5 342 81 Tm /Cs5 cs 0.161 0.145 0.149 sc 0.026 Tw [(In view of the wide ar)-30(ray of possible)]TJ 0 -1.3043 TD (problems and causes and the range of)Tj ET Q q 1 i 56.03 25.74 m 56.03 20.347 51.653 15.97 46.26 15.97 c 40.867 15.97 36.49 20.347 36.49 25.74 c 36.49 31.133 40.867 35.51 46.26 35.51 c 51.653 35.51 56.03 31.133 56.03 25.74 c h 533.681 66 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs10 cs 0.8 scn /GS2 gs 36.48 35.58 19.56 -19.68 re f 0.65 scn 56.615 37.648 m 56.615 35.732 55.062 34.179 53.146 34.179 c 51.23 34.179 49.677 35.732 49.677 37.648 c 56.615 37.648 l f 49.919 34.383 m 49.919 32.467 48.365 30.914 46.449 30.914 c 44.533 30.914 42.98 32.467 42.98 34.383 c 49.919 34.383 l f 43.222 37.645 m 43.222 35.729 41.669 34.176 39.753 34.176 c 37.837 34.176 36.283 35.729 36.283 37.645 c 43.222 37.645 l f 56.615 30.71 m 56.615 28.794 55.062 27.24 53.146 27.24 c 51.23 27.24 49.677 28.794 49.677 30.71 c 56.615 30.71 l f 49.919 27.444 m 49.919 25.528 48.365 23.975 46.449 23.975 c 44.533 23.975 42.98 25.528 42.98 27.444 c 49.919 27.444 l f 43.222 30.707 m 43.222 28.791 41.669 27.237 39.753 27.237 c 37.837 27.237 36.283 28.791 36.283 30.707 c 43.222 30.707 l f 56.615 23.771 m 56.615 21.855 55.062 20.302 53.146 20.302 c 51.23 20.302 49.677 21.855 49.677 23.771 c 56.615 23.771 l f 49.919 20.505 m 49.919 18.589 48.365 17.036 46.449 17.036 c 44.533 17.036 42.98 18.589 42.98 20.505 c 49.919 20.505 l f 43.222 23.768 m 43.222 21.852 41.669 20.298 39.753 20.298 c 37.837 20.298 36.283 21.852 36.283 23.768 c 43.222 23.768 l f 56.615 16.832 m 56.615 14.916 55.062 13.363 53.146 13.363 c 51.23 13.363 49.677 14.916 49.677 16.832 c 56.615 16.832 l f 43.222 16.829 m 43.222 14.913 41.669 13.36 39.753 13.36 c 37.837 13.36 36.283 14.913 36.283 16.829 c 43.222 16.829 l f Q q 1 i 56.59 25.74 m 56.59 20.071 51.989 15.47 46.32 15.47 c 40.651 15.47 36.05 20.071 36.05 25.74 c 36.05 31.409 40.651 36.01 46.32 36.01 c 51.989 36.01 56.59 31.409 56.59 25.74 c h 533.681 66 m W* n -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n /Cs9 CS 0.4 SCN 0 J 0 j 2 w 10 M []0 d 56.59 25.74 m 56.59 20.071 51.989 15.47 46.32 15.47 c 40.651 15.47 36.05 20.071 36.05 25.74 c 36.05 31.409 40.651 36.01 46.32 36.01 c 51.989 36.01 56.59 31.409 56.59 25.74 c h 533.681 66 m S Q q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F2 1 Tf 11 0 0 11 39.7059 22.8189 Tm /Cs5 cs 1 1 1 sc -0.0002 Tc 0 Tw (16)Tj ET Q endstream endobj 61 0 obj << /Type /Page /Parent 126 0 R /Resources 62 0 R /Contents 63 0 R /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 62 0 obj << /ProcSet [ /PDF /Text ] /Font << /F1 132 0 R /F2 136 0 R /F5 101 0 R >> /ExtGState << /GS1 140 0 R /GS2 97 0 R >> /ColorSpace << /Cs5 135 0 R /Cs9 138 0 R /Cs10 98 0 R >> >> endobj 63 0 obj << /Length 9001 >> stream 1 g /GS1 gs 0 792 m 0 792 l f q 1 i -1 793 614 -794 re 0 792 m W n 0 792.06 612 -792 re W n BT /F1 1 Tf 11.5 0 0 11.5 54 711 Tm /Cs5 cs 0.161 0.145 0.149 sc -0.0002 Tc 0.026 Tw [(oppor)-11.2(tunities for inter)-72(vention, many)]TJ 0 -1.3043 TD [(methods are available for studying)]TJ T* -0.0001 Tc [(operational policies. The selected method)]TJ T* -0.0002 Tc [(should, however)83.8(, adhere to cer)-11.2(tain)]TJ T* -0.0003 Tc [(principles that are likely to lead to)]TJ T* -0.0002 Tc (successful outcomes. First, all)Tj T* [(methodological approaches should be)]TJ T* [(based on two integral components of total)]TJ T* -0.0001 Tc [(quality management: the principles of)]TJ T* -0.0002 Tc [(mapping or diagramming operational)]TJ T* (processes and root-cause analysis, which)Tj T* -0.0003 Tc (identifies a problem and follows it to its)Tj T* -0.0001 Tc [(primar)-70(y cause \(or causes\) \(Juran and)]TJ T* -0.0002 Tc [(Gyr)-26.1(na, 1988; Ishikawa, 1982; Omachonu,)]TJ T* -0.0001 Tc [(1991\). Second, analysts need to collect)]TJ T* -0.0002 Tc [(accurate and thorough infor)-26.1(mation about)]TJ T* [(the bar)-30(riers or inef)-22.2(ficiencies, including)]TJ T* [(data about the extent of the problem, its)]TJ T* -0.0001 Tc (impacts, and the operating policies that)Tj T* [(cause the bar)-29.9(riers. The infor)-26(mation must)]TJ T* [(include the exact operational policy)]TJ T* -0.0004 Tc 0.0262 Tw [(document \(decree, joint circular)83.6(,)]TJ T* [(regulations\) and infor)-26.2(mation about who is)]TJ T* -0.0002 Tc 0.026 Tw (responsible for and can change the)Tj T* [(operational policy)68.6(. )]TJ 0 -2.6087 TD -0.0003 Tc [(Third, a par)-11.3(ticipator)-70.2(y process is critical. In)]TJ 0 -1.3043 TD -0.0002 Tc [(addressing operational bar)-30(riers and their)]TJ T* -0.0001 Tc [(policy causes, the involvement of)]TJ T* -0.0003 Tc [(managers and staf)-22.3(f from appropriate levels)]TJ T* -0.0001 Tc [(is cr)-33.1(ucial for accurately identifying the)]TJ T* -0.0002 Tc [(most impor)-11.2(tant and the most wasteful)]TJ T* [(bar)-30(riers. 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)Tj /F1 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 0.7174 0 TD -0.0001 Tc 0.0259 Tw [(Collaborative studies of operational)]TJ 0 -1.3043 TD -0.0003 Tc 0.0261 Tw [(problems that focus on a par)-11.3(ticular)]TJ T* -0.0001 Tc 0.0259 Tw [(perspective \(e.g., medical bar)-29.9(riers,)]TJ T* -0.0002 Tc [(maximizing access and quality)73.7(, situation)]TJ T* -0.0001 Tc [(analyses\) in which a policy or)-7(ganization)]TJ T* -0.0002 Tc [(has joined with counterpar)-11.2(t institutions)]TJ T* -0.0003 Tc 0.0261 Tw [(for the express purpose of identifying)]TJ T* (and addressing the policy-related causes)Tj T* (whose resolution is beyond the reach of)Tj T* -0.0002 Tc 0.0259 Tw [(operations staf)-22.2(f)-0.1( \(Galway)73.7(, 1992\).)]TJ /F5 1 Tf /Cs9 cs 1 scn -0.7174 -1.3043 TD 0 Tc 0 Tw (
)Tj /F1 1 Tf /Cs5 cs 0.161 0.145 0.149 sc 0.7174 0 TD -0.0002 Tc 0.026 Tw [(Legal-regulator)-70.1(y)-0.1( studies that inventor)-70.1(y)]TJ 0 -1.3043 TD [(relevant legal and policy texts and)]TJ T* -0.0001 Tc (examine their impact at the operational)Tj T* -0.0002 Tc [(level through key infor)-26.1(mation inter)-72(views)]TJ T* -0.0003 Tc (\(JNPC and POLICY Project, 2000;)Tj T* -0.0002 Tc [(Iknane et al., 2000; Rudiy)73.7(, 1999;)]TJ T* [(Ravenholt, 1999; Minist�re de la Sant�)]TJ T* (Publique, 1994\).)Tj /F5 1 Tf /Cs9 cs 1 scn -0.7174 -1.3043 TD 0 Tc 0 Tw (
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Common symptoms in the)Tj T* [(public sector are a lack of essential dr)-33.2(ugs,)]TJ T* -0.0001 Tc [(inaccessible health facilities or absent staf)-22.1(f,)]TJ T* (nonfunctioning vehicles and equipment,)Tj T* -0.0003 Tc [(and dilapidated premises. Where these)]TJ T* -0.0002 Tc [(symptoms occur)83.8(,)0( health outcomes suf)-22.2(fer�)]TJ T* (\(WHO, 1999: 34�35\). This description of)Tj T* [(public sector programs applies to many)]TJ T* -0.0004 Tc 0.0262 Tw [(reproductive health programs around the)]TJ T* (world. As resources become increasingly)Tj T* [(scarce, the conditions in public sector)]TJ T* -0.0002 Tc 0.026 Tw [(health programs worsen. Donabedian)]TJ T* (\(1980: 81\) noted 20 years ago, �I believe)Tj T* [(that good str)-33.2(ucture, that is, suf)-22.2(ficiency of)]TJ T* -0.0004 Tc 0.0262 Tw [(resources and proper system design, is)]TJ T* [(probably the most impor)-11.3(tant means of)]TJ T* [(protecting and promoting the quality of)]TJ T* -0.0006 Tc 0 Tw (care.� )Tj 0 -2.6087 TD -0.0106 Tc 0.0259 Tw [(Operational policies are an integral par)-11.3(t of)]TJ 0 -1.3043 TD [(this �good str)-33.2(ucture� and make themselves)]TJ T* [(apparent ever)-70.1(y day in their impacts)]TJ T* -0.0107 Tc 0.0261 Tw [(throughout the health care system. T)74.6(o)-0.1( the)]TJ T* -0.0106 Tc (extent that operational polices are)Tj T* 0.0259 Tw [(inef)-22.1(ficient, they cause fur)-11.2(ther strain on)]TJ T* -0.0109 Tc 0.0263 Tw (scarce resources. 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