Church groups, especially indigenous churches, are important providers of health services in many developing countries such as Congo, Burundi, Malawi, Cameroon, Ghana, Togo and Haiti. However, the potential for church groups to assist the Ministry of Health in the management of geographically defined health districts is often overlooked, ignored, or discouraged.

A conceptual framework for the management of health districts by church groups can be found in Getting to the 21^st Century by David Korten (see table on following page). The author identifies the potential for Athird generation@ NGOs in sustainable systems development. In this capacity, an NGO serves as a catalyst and strategic systems manager to facilitate collaboration between public and private institutions in the management of services for a geographically defined area.

Congo is a good demonstration of this concept in action. In Congo, formerly Zaire, 50% of hospitals are owned and managed by local churches. In 1975, the Ministry of Health opted to build on, rather than to compete with, the health infrastructure of churches. A national conference, organized jointly with the churches, discussed and adopted the concept of a decentralized health zone. During the next five years a few pilot health zones were allowed to develop as local initiatives.

In 1982, these pilot health zones became the basis of a national health plan to create 300 geographically defined health zones to cover the whole country. At the same time USAID and other donors agreed to fund the investment costs for the start-up of health zones. For example, a USAID-funded project, SANRU (Soins de Santé Primaries en Milieu Rural) helped create 100 health zones. Sixty percent of those health zones were co-managed by church groups. During the 1980s the number of functional health districts increased from ten to more than 200. Access to and utilization of primary health care increased dramatically.

I was the manager of the SANRU project from 1981-1991. In that capacity, I helped to negotiate the collaboration between church groups and the Ministry of Health regarding the co-management of health zones. In the process I identified a number of factors which contributed to this successful public-private partnership. These lessons learned are applicable, I believe, to other countries where a similar potential is being, or could be, developed:

1) Church-managed health facilities are more public than a private sector: The medical work of church groups is too often labeled as "private sector," a term which promotes competition rather than collaboration with the public sector. The not-for-profit philosophy of most church-related medical programs equates much more to a public than a private sector resource.
 

	Private Sector Not-for-Profit Non-Governmental Health Services
Public Sector Not-for-Profit Governmental Health Services		Private Sector For-Profit Non-Governmental Health Services

2) Most church groups are willing to adopt the health district concept: When given the opportunity, most church groups were quite willing to concentrate their efforts in serving the entire population of a geographically defined population, rather than working in scattered and isolated pockets of church members. Making a clear distinction between administrative/financial supervision and technical supervision was an element in coordination between partners.

3) Church hospitals provide a good infrastructure for the management of a health district: The presence of a functional referral hospital, office space and equipment, a garage and maintenance facilities, housing and gardens, electricity and fuel, supply line for medicines, and schools attract and retain competent staff even in isolated rural areas. This infrastructure helped these health zones to develop at a relatively rapid rate.

4) Church groups are generally quite effective in community mobilization: The presence of functioning health services are important in gaining the confidence of the population. This makes the population more receptive to participation in preventive and promotive health activities at the community level.

5) Church-managed facilities often have good user fee and financial management systems: These systems can be used as precedents and models for moving the public sector from a user-free to a user-fee system. They can also permit church groups to serve as the Aaccountants@ for handling funds for joint programs with governmental health facilities.

6) Church-related programs have access to funding not available to governments: Church groups can receive funding from international partners who do not normally provide assistance through Ministries of Health. This can provide a supplemental and complementary assistance to the development of a health district.

7) Indigenous church groups are a permanent and sustainable resource: The medical work of these groups will continue long after other international health projects and agencies are withdrawn. Church groups contribute, therefore, to creating a sustainable health system.