The private for-profit sector in east and southern African (ESA) countries cannot be ignored. With private health insurance growing, considerable out-of-pocket payments at point of service, rising investment in private for-profit hospitals including for medical tourism and a widening spread of informal providers, ESA countries need to pay attention to this sector as part of measures towards achieving universal health coverage (UHC).
The for-profit sector can add new resources and services to the health sector. But if left unregulated it can also lead to distortions in the quantity, distribution, price and quality of health services that affect the ability of countries to provide adequate and accessible services. For example, for-profit providers may concentrate in areas where wealthy populations live, ignoring areas of high health care need. The cost of both private health care and insurance tends to be high and unaffordable for low income communities. The presence of a for-profit private sector in countries that have a shortage of health workers may lead to an internal brain drain of skilled health workers from the public sector, due to better pay, leaving poor people with poorly staffed public sector services.
A review of laws on the private sector in east and southern Africa for a forthcoming EQUINET discussion paper shows that while many ESA countries have laws to register or license new private providers, few, except Namibia, South Africa and Zimbabwe, have adequate laws to regulate private health insurance. Few countries monitor the type and quality of services provided by private practitioners, clinics and hospitals once they are registered. Charges for health care services or insurance do not seem to be controlled, directly or indirectly, to any meaningful extent in any ESA country, while there is evidence from some countries of unfair business practices. This means that the law does not adequately address the affordability, access or quality issues that are central to achieving UHC.
The current situation suggests that it is time to move from an over-reliance on voluntary self-regulation by private health professionals and associations to developing policies, laws and instruments that clarify and organise the operations of private for-profit health care providers and insurers in line with national health goals. Several countries have recognised this and are beginning to update and improve their laws, although in most cases without clear policy guidance.
So one starting point may be for Ministries of Health to develop with stakeholders, including Ministries of Finance, an over-arching policy on the private for-profit health sector to guide and set the objectives for the law, separating the roles and duties of funders, purchasers and providers. This requires proactive consultation, building communication and trust between stakeholders and the introduction of laws governing the sector. It would seem timely to initiate this in all ESA countries, given the growth of the sector, even if the private for-profit health sector is not yet large.
The policy and subsequent laws should facilitate and create incentives for private health professionals and organisations to address the health needs of disadvantaged populations. They should also control against any health market distortions that jeopardise national health goals.
The laws should set standards on service quality, on emergency services and on the benefit packages, enrolment practices and sustainability of health insurance plans. The law should set obligations for the private sector to report to regulators and inform patients, health insurance beneficiaries and the public at large of their entitlements. Penalties should be set at appropriate levels to discourage breaches of these obligations, but at the same time there should be positive incentives, such as alternative reimbursement mechanisms, that help to shift the behaviour of the private health sector.
Having the laws on paper is only one step of the process. Enforcement of the law is still a challenge in many ESA countries. Maintenance of appropriate databases and monitoring of the law is still not well developed. In some countries private stakeholders greatly influence the content and degree of enforcement of regulations. Governments thus need to invest in the resources and capacities to develop, use and enforce the law, whether at central level or in a decentralised system. For this, legal, financial and public health skills are required, as well as the ability to collect, analyse, use and communicate information. Governments need to ensure that the legal requirements of multiple pieces of legislation are well-understood by regulators, health sector institutions and personnel, and the public.
Licensing and facility inspection should be strengthened and extended to examining the quality of care. Anti-competitive behaviour should be investigated and acted against. Regulators need to negotiate and apply mechanisms to reduce rising costs within both the hospital and insurance sector and ensure that laws are regularly updated in line with public health and other objectives. From the lens of service providers, government should harmonise the functions of different regulatory authorities, to avoid multiple, burdensome and costly requirements.
In conclusion, in a globalising world, with liberalised economies and growing private markets, including in health, leaving such an influential and growing sector poorly regulated would be a major obstacle on the path to universal health coverage. Governments need to act soon to address this gap in their stewardship of the health system.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: email@example.com. For more information on the issues raised in this op-ed please visit www.equinetafrica.org and read the forthcoming EQUINET Discussion paper 99: Doherty J (2013) Legislation on the for-profit private health sector in east and southern Africa
2. Latest Equinet Updates
Performance-based funding (PBF) has become increasingly popular in global health financing. It is defined essentially as the transfer of resources (money, material goods) for health on condition that measurable action will be taken to achieve predefined health system performance targets such as particular health outcomes, the delivery of effective interventions (such as HIV prophylaxis), utilisation of services (like HIV counselling and testing), or quality care. This annotated literature review has been prepared for work on global health diplomacy and the role of African actors in global health governance in relation to PBF. The review highlights the theoretical thinking behind and strengths and weaknesses associated with PBF schemes in their use in Africa. It reviews documented evidence of the role of African actors in diplomacy and decision-making surrounding PBF. The review highlights that while national governments are generally involved in the design, implementation and evaluation of PBF schemes, some national actors and regional actors appear to be marginalised when it comes to the design and global decision-making process for performance-based funding schemes, even if they are heavily involved in their implementation.
For some time now, people working in the field of health at community level have expressed the need for a toolkit specifically focusing on participatory approaches to working on health. This toolkit was produced in response to this need, drawing on the experiences and knowledge of individuals and institutions working in this field. The toolkit shows how participatory methods can be used to raise community voice, both through health research and by training communities to take effective action and become involved in the health sector. Generally, this toolkit aims to strengthen capacities in researchers, health workers and civil society personnel working at community level to use participatory methods for research, training and programme support. At the end of the course, we hope that the users of the toolkit will have learned and be able to use various methods for participatory approaches to research and training within various areas of work aimed at building people-centred health systems. The toolkit uses experiences from different countries in the east and southern African region.
This review is part of EQUINETs work on contributions of global health diplomacy to health systems in east and southern Africa. It reviews documented literature to examine the extent to which the policy interests of African countries were carried (or not carried) into the Code in the negotiations around the code and the perceived factors affecting this; the extent to which countries in east and southern Africa view and use the Code as an instrument for negotiating foreign policy interests concerning health workers; and the motivations, capabilities and preparations for monitoring the code to engage in the diplomatic environment on African policy interests concerning health workers. The information was analysed using the policy analysis triangle to capture the changing context, processes, content and major actors in the development of the WHO Code, and documentation on its progress and implementation since its adoption. The review discusses the factors behind the relative lull in efforts on the issue of health worker migration following adoption of the Code.
3. Equity in Health
A United Nations Economic and Social Council (ECOSOC) panel discussion on universal health coverage (UHC) on 3 July 2013 highlighted the importance of science, technology and innovation for achieving UHC, especially in the context of the post-2015 development agenda. Speakers discussed the meaning and scope of UHC as well as the financing and promotion of UHC in various country contexts. World Health Organisation Director General Margaret Chan pointed to political commitment, investment, clear policy goals and tracking mechanisms as necessary conditions for UHC, but also emphasised state ownership in developing and implementing UHC. She argued that each state should develop its own healthcare system according to the needs of its population. She said that no major breakthrough, such as the introduction of vaccines, is possible without innovation; however, innovation has become expensive, at the cost of access for most people. On the matter of social innovation Chan remarked that often innovation is thought of as sophisticated science, but looking forward, the future of healthcare should be people-centred, integrated and based on primary healthcare and prevention.
4. Values, Policies and Rights
This United Nations resolution recognises that access to medicines is one of the fundamental elements in achieving progressively the full realisation of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. It stresses the responsibility of States to ensure the highest attainable level of health for all, including through access, without discrimination, to medicines, in particular essential medicines, that are affordable, safe, efficacious and of quality. At the same time, the resolution emphasises the crucial role of prevention, the promotion of healthy lifestyles and the strengthening of health systems. The central element of the resolution urges States, as appropriate, to take 16 measures to fulfil their obligations on access to medicines within the right to health framework. The resolution also recognises the innovative funding mechanisms that contribute to the availability of vaccines and medicines in developing countries, such as the Global Fund and the GAVI Alliance. It calls upon all States, United Nations programmes and agencies, relevant intergovernmental organisations and pharmaceutical companies to help safeguard public health from conflict of interest, as well as to further collaborate to enable equitable access to quality, safe and efficacious medicines that are affordable to all.
In this article, the authors examine how major global health organisations, such as WHO, the Global Fund to Fight AIDS, TB and Malaria, UNAIDS, and GAVI approach human rights concerns, including equality, accountability and inclusive participation. The authors use examples of best practice to indicate how such agencies can advance the right to health, covering nine areas: 1) participation and representation in governance processes; 2) leadership and organizational ethos; 3) internal policies; 4) norm-setting and promotion; 5) organisational leadership through advocacy and communication; 6) monitoring and accountability; 7) capacity building; 8) funding policies; and 9) partnerships and engagement. The proposed UN Framework Convention on Global Health (FCGH) would commit state parties to support these standards through their board membership and other interactions with these agencies. The authors also explain how the FCGH could incorporate these organisations into its overall financing framework, initiate a new forum where they collaborate with each other, as well as organisations in other regimes, to advance the right to health, and ensure sufficient funding for right to health capacity building.
On 11 July 2013, the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women (the Protocol) turns 10. The author of this article argues that there is much to celebrate, as the Protocol remains one of the worlds’ most progressive women’s human rights instruments. While ratifications are a welcome measure, the provisions enshrined in the Protocol only have real meaning if governments go further and show their commitment to the protection and advancement of African women’s human rights by domesticating and fully implementing the instrument, she argues. Challenges that require mitigation exist and include limited technical and financial support in many states particularly with regard to the efforts to sensitise and build the capacity of government officials as well as the general public on the provisions of the Protocol; lack of political goodwill and weak institutional mechanisms to support the domestication and implementation of the Protocol; and lastly religious and cultural conservativism.
This study found that globally, 38% of all women who were murdered were murdered by their intimate partners, and 42% of women who have experienced physical or sexual violence at the hands of a partner had experienced injuries as a result. Partner violence was found to be a major contributor to women’s mental health problems, women experiencing intimate partner violence are almost twice as likely as other women to have alcohol-use problems and 1.5 times more likely to acquire certain sexually transmitted infections In some regions like sub-Saharan Africa, they are 1.5 times more likely to acquire HIV. Both partner violence and non-partner sexual violence were associated with unwanted pregnancy, as the report found that women experiencing physical and/or sexual partner violence are twice as likely to have an abortion than women who do not experience this violence. Women who experience partner violence also have a 16% greater chance of having a low birth-weight baby. The study highlights the need for all sectors to engage in eliminating tolerance for violence against women and better support for women who experience it, and was launched with new World Health Organisation’s clinical and policy guidelines (also included in this newsletter).
If access to equitable health care is to be achieved for all, policy documents must address different needs of groups that do not access health care. This paper reports on an analysis of 11 African Union (AU) policy documents to ascertain the frequency of mention of 13 core concepts in relation to 12 vulnerable groups, with a specific focus on people with disabilities. While reference is broadly made to vulnerable groups, there is lack of detailed specification of the different needs of different groups. The documents suggest that vulnerable groups are homogeneous in their needs, which is not the case. The authors argue for more information and knowledge on the needs of all vulnerable groups and more specific cover of these issues in policy documents.
In this study researchers investigated the reasons for poor implementation of Ghana’s legal abortion policy to better understand how providers shape and implement policy and how provider-level barriers might be overcome. They conducted in-depth interviews with 43 health professionals of different levels at three hospitals in Accra, as well as staff from smaller and private sector facilities, and analysed relevant policy and related documents. The findings show that health providers’ views shape provision of safe-abortion services. Providers experience conflicts between their religious and moral beliefs about the sanctity of (foetal) life and their duty to provide safe-abortion care. Obstetricians were more moderate while midwives were more driven by fundamental religious values condemning abortion as sinful. In addition to personal views and dilemmas, ‘social pressures’ (perceived views of others concerning abortion) and the actions of facility managers affected providers’ decision to (openly) provide abortion services. Providers tend to use personal discretion in deciding if and when to provide abortion services, and develop ‘coping mechanisms’ which impede implementation of abortion policy. The authors recommend that these findings be included in future evidence-based practice.
This paper aims to contribute to the existing knowledge around a Framework Convention on Global Health (FCGH) from the perspective that any international legal framework conceptualisation on the right to health must involve those whose health is at stake, namely civil society. The two case studies, Senegal and South Africa, were used to look at the international right to health framework within in the context of civil society’s role in combating the HIV and AIDS epidemic. The findings illustrate that these two African states face different challenges regarding the realisation of the right to health in the context of HIV and AIDS, yet civil society has played an important role in both countries in realising the right to health. The authors show the diverse roles that an FCGH could play in empowering civil society, through the formulation of a global standard and framework on the right to health, in the form of an FCGH, particularly if it is as a result of a movement of rights education and advocacy from below.
At the 23rd session of the Council held in Geneva on 27 May to 14 June 2013, the United Nations Human Rights Council adopted a resolution on access to medicines despite opposition from the United States and the European Union (included in this newsletter). According to this article, the resolution is a step forward in addressing the issue of access to medicines within the right to health framework. The new Resolution recognises access to medicines as one of the fundamental elements in the realisation of the right to health. Unlike some earlier resolutions, the scope of the new resolution is not limited to essential medicines and covers all medicines. It clearly calls for the regulation of prices of medicines to make them affordable for people, especially those in developing countries. It also clearly establishes the link between local production and the right to health framework and addresses the research and development (R&D) question within the right to health framework, especially referring to a new R&D model based on de-linking of cost of R&D from the price of health products. It also clearly states that the engagement with stakeholders is based on the principle of safeguarding public health from undue influence by any form of real, perceived or potential conflict of interest.
The continued success in global tobacco control is detailed in 2013’s WHO Report on the Global Tobacco Epidemic. It presents the status of the MPOWER measures, with country-specific data updated and aggregated through 2012. In addition, the report provides a special focus on legislation to ban tobacco advertising, promotion and sponsorship (TAPS) in WHO Member States, as well as in-depth analyses of TAPS bans were performed, allowing for a more detailed understanding of progress and future challenges in this area. The progress in reaching the highest level of achievement in tobacco control is a sign of the growing success of the WHO Framework Convention on Tobacco Control (WHO FCTC) and provides strong evidence that there is political will for tobacco control on both national and global levels. About 2.3 billion people are now covered by at least one tobacco control measure at the highest level of achievement. This is due to the actions taken by many WHO Member States to fight the tobacco epidemic. These countries can be held up as models of action for the many countries that need to do more to protect their people from the harms of tobacco use, the report concludes.
The idea of a Framework Convention for Global Health (FCGH), using the treaty-making powers of the World Health Organisation (WHO), has been promoted as an opportunity to advance global health equity and the right to health. The idea has promise, but the authors argue that it needs more thought regarding risks, obstacles, and strategies. The reform of global health governance must be based on a robust analysis of the political economy, drivers of inequality and the denial of the right to health arise. The authors warn against limiting analysis to questions of inter-governmental financial transfers because of the risk of neglecting the underlying structural determinants of health injustice, which would help to legitimise an unjust and unsustainable global economic regime. While a FCGH can alert to areas for global regulation, the authors call for popular mobilisation around the right to health in ways that link to the local priorities of different communities.
5. Health equity in economic and trade policies
According to this book, governments across the globe are being persuaded by economists that government spending on services like education and health is unnecessary and can only worsen the global economic crisis. To this effect they have advanced a policy of draconian budget cuts – austerity - to solve the financial crisis. However, the author of this book argues that the source of the financial crisis is not in government spending but the direct result of bailing out, recapitalising and adding liquidity to the broken banking system. Through these actions private debt was reclassified as government debt, which now is the responsibility of taxpayers to pay off, hence the proposed cuts in government spending. Blyth argues that historical evidence shows that austerity doesn't work when all states try it simultaneously: all they do is shrink the economy. He shows how austerity policies aggravated the Great Depression of the 1930s and created the conditions for seizures of power by the forces responsible for the Second World War: the Nazis and the Japanese military establishment. He concludes that the arguments for austerity are tenuous and the evidence thin. Rather than expanding growth and opportunity, the repeated revival of this dead economic idea has almost always led to low growth along with increases in wealth and income inequality.
For too long Africans have been dependent on aid and medicines from the West, argues the author of this article, but Brazil, India, China and South Africa (BRICS) are emerging as dominant players in Africa’s health markets. In the late-1990s, Brazil played an instrumental role in shifting the paradigm of healthcare and human rights when it challenged the World Trade Organisation (WTO) and its intellectual property regime. Brazil violated a WTO clause to provide antiretroviral drugs and to lower their price. This reaffirmed medicine as a fundamental human right. While many drugs continue to be developed in the West, India has stepped in to manufacture generic medicines for the world's poorest countries. Through low-cost support and commodities, India has filled a gap in the global market. China has an increasing role to play in the global health arena. It invested $36.1 billion in 2011 in research and development, placing the country in a position to become a major player in healthcare innovation. Additionally, given the sheer scale of industry and financial resources available, China has the capacity to develop and supply HIV drugs and technologies to meet the needs of the African epidemic. The departure of traditional international funders like the United Kingdom and the United States presents an opportunity for new sources of engagement with the growing BRICS economies. Investing in the health of Africa will fuel development, enhance diplomacy and build South-South solidarity, the author argues.
In this article, the author discusses the ramifications of a 2013 legal battle in the United States that ended with the court ruling unanimously that human genes cannot be patented. He argues that the implications of this ruling are far-reaching in terms of public health and equity. He views the case as an example of how societal inequality is a result not just of the laws of economics, but also of how we shape the economy through politics, including through almost every aspect of our legal system, in this instance intellectual property regimes. The right to life and right to health should not be contingent on the ability to pay. He also argues that some of the most iniquitous aspects of inequality creation within our economic system are a result of ‘rent-seeking’, namely profits, and inequality, generated by manipulating social or political conditions to get a larger share of the economic pie, rather than increasing the size of that pie. The world’s poorly designed intellectual property system encourages pharmaceuticals to pursue such rent seeking. And while advocates of intellectual property rights emphasise their role in promoting innovation, the author counters that most key innovations in history were motivated by the quest for knowledge, not financial gain. He provides evidence that the patent actually prevented the development of better tests, and so interfered with innovation.
After an impressive acceleration in growth and poverty reduction since the mid-1990s, many African countries continue to register robust growth in the aftermath of the global financial crisis. Will this growth persist, given the tepid recovery in developed countries, numerous weather shocks, and civil conflicts in Africa? This paper "stress tests" African economies. The findings indicate that Africa's long-term growth is fairly impervious to a prolonged recession in high-income countries. Growth is, however, much more sensitive to a disruption of capital flows to the region, and to internal shocks, such as civil conflict and drought, even if the latter follow historical patterns. The broad policy implication is that with proper domestic production conditions African countries can sustain robust long-term growth. Because of the economic dominance of the agriculture sector and the share of food in household budgets, countries will need to increase the resilience of agriculture and protect it from unfavorable climate change impacts, to prevent food insecurity.
According to the latest edition of MSF’s report on HIV treatment price and access issues, the price of first- and second-line anti-retrovirals have declined due to increased generic competition, while third-line regimens remain “exorbitantly priced”. For newer HIV medicines, including integrase inhibitors, generic competition is mostly blocked because of patents, and these drugs are more expensive as a result. MSF finds that patents remain a barrier on newer drugs and in middle-income countries, but some countries are using World Trade Organisation-sanctioned flexibilities to issue compulsory licences to increase access to the medicines. Flexibilities are built in to the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). MSF has proposed patent opposition (when applications do not meet a country’s patentability requirements) and the issue of compulsory licences in the interest of public health, as ways to bring prices down further. Additionally, MSF claims that free trade agreements continue to pose a threat to access, pointing to the European Union-India Free Trade Agreement and the Trans-Pacific Partnership Agreement as examples of agreements with “harmful provisions”.
6. Poverty and health
While the challenges facing agriculture are clearly urgent, this paper questions the thrust of ‘sustainable intensification’. Sustainable intensification is reported by the author to include technology-based approaches through strategies developed without participation of small farmers. The author argues that most of the world’s food is grown by small farmers, without the use of industrial inputs, and using traditional seed varieties. Small farmers have raised their own priorities as a sustainable agriculture that builds on farmers’ own expertise and knowledge, with clear land rights, and rights for women, including agrarian reforms; agricultural research that starts by asking farmers what they need; knowledge and technologies that are based on agro-ecological principles, including compost, integrated pest management and mixed cropping; seed development based on traditional varieties; and mechanisms to protect local farmers from unfair competition from imported products.
The Comprehensive Africa Agriculture Development Programme (CAADP), launched by African heads of state in 2003, offered the prospect of a new, intensified focus on agriculture throughout the continent. Ten years on, how successful has CAADP been? This paper offers a brief assessment, with its authors examining if agricultural budgets have increased, if the focus of spending has improved, and if CAADP is providing ‘fair shares’ to the millions of smallholder farmers who do most of Africa’s farming and produce most of its food. The key CAADP commitment made by African states was to allocate 10% of public expenditure to agriculture. Yet, as of 2010, only eight countries have exceeded the 10% target. Although the adoption of CAADP-aligned national strategies has played a role in increasing agricultural investment in some (though not all) countries, there are serious problems with the focus of spending, especially in the lack of adequate support to the needs of smallholder farmers, notably women farmers. The authors note that CAADP is promoting a farming model associated with the Green Revolution, which promotes the use of expensive external inputs such as chemical fertilisers, pesticides and genetically modified or hybrid seeds bought from agribusiness companies; they argue this comes at the expense of promoting sustainable agriculture approaches that are likely to benefit poor farmers much more. One of the biggest failures for CAADP-aligned national investments is that they have not recognised the potential of smallholders’ own investments or their potential to build on their ‘fair share’, the authors conclude.
Household air pollution (HAP) from solid fuel (biomass or coal) combustion is the leading environmental cause of death and disability in the world. The health effects of HAP and unsafe stoves are documented in this paper to be in seven areas (cancer; infections; cardiovascular disease; maternal, neonatal, and child health; respiratory disease; burns; and ocular disorders). Gaps in four cross-cutting areas were found that are relevant to research on HAP (exposure and biomarker assessment, women's empowerment, behavioural approaches, and programme evaluation). The authors argue that it is vital that researchers partner with implementing organisations and governments to evaluate the impacts of improved stove and fuel programmes to identify and share evidence regarding the outcomes of the many implementation programmes underway, including the socio-behavioural aspects of household energy use.
The key message of this report is that without better understanding the determinants of smallholders’ participation in agricultural markets, and formulating appropriate measures to facilitate improved participation, initiatives seeking to promote the adoption of productivity enhancing technology by smallholder producers are likely to have limited success. Smallholders’ participation in markets is crucially important for improved food security and poverty reduction. Attempts to improve smallholder productivity will have limited success if smallholder linkages to markets are not strengthened simultaneously. Limited smallholder participation in markets is not necessarily a result of a lack of commercial orientation per se, but the result of constrained choice in a risky environment. Smallholders are very heterogeneous, facing different types of constraints and opportunities, and will react differently to new market opportunities. Public policy interventions are generally needed to foster smallholder market integration, the authors argue. These interventions need to be prioritised and sequenced according to evidence-based diagnosis of the constraints faced by different categories of smallholders. Evidence-based policy-making could help minimise the risks of policy failure.
What do newer emerging external funders do in the field of agricultural cooperation in Africa? And how does this relate to the African Union’s Comprehensive Africa Agriculture Development Programme (CAADP)? This paper from ECDPM looks at Brazilian agricultural cooperation in Ghana side by side with the CAADP process in the country. It finds that while Brazil largely supports the country’s CAADP investment plan, it does not engage with the process around it. This is not necessarily the result of a conscious policy choice or bad will, but due to the fact that CAADP might not be very attractive for newer external funders as currently designed, the author argues. Yet, there are clear trends towards cooperation and joint learning between Brazil and Western external funders, which might provide some space for CAADP to play a role in facilitating these exchanges.
7. Equitable health services
To better understand trends in the burden of malaria and their temporal relationship to control activities, a survey was conducted to assess reported cases of malaria and malaria control activities in Mutasa District, Zimbabwe. Data on reported malaria cases were abstracted from available records at all three district hospitals, three rural hospitals and 25 rural health clinics in Mutasa District from 2003 to 2011. Results showed that malaria control interventions were scaled up through the support of several global initiatives, the newer artemisinin-based combination therapy was adopted by all health clinics by 2010, diagnostic capacity improved and vector control was implemented. The number of reported malaria cases initially increased from levels in 2003 to a peak in 2008 but then declined 39% from 2008 to 2010. The proportion of suspected cases of malaria in older children and adults remained high, ranging from 75% to 80%. From 2008 to 2010, the number of RDT positive cases of malaria decreased 35% but the decrease was greater for children younger than five years of age (60%) compared to older children and adults (26%). In conclusions, the burden of malaria in Mutasa District decreased following the scale up of malaria control interventions. However, the persistent high number of cases in older children and adults highlights the need for strategies to identify locally effective control measures that target all age groups.
The authors of this study undertook a programme evaluation of HIV and TB prevention and therapeutic services at facility level in South Africa to describe integration and how it is implemented. They evaluated 26 rural and 146 urban public primary-care facilities using secondary data generated from December 2008 and May 2009. Evidence of integration was found across two dimensions: disease programmes and the prevention–therapeutic axis. Smaller rural facilities did not always have staff trained in all the required services, nurses worked without the support of a doctor and supervision was weaker, threatening quality of care. However, in the rural district there were instances of clients receiving more integrated services. The quality of care in the TB programme was high in both districts. In both the districts evaluated, integration across programmes and the prevention-care-rehabilitation axis of services was achieved through co-location at primary-care level. Coupled with health system strengthening, this has the potential to improve access across the HIV/TB/STI cluster of services. The benefit is likely to be greater in rural areas. Quality of care was maintained in the long-established TB programmes in both settings.
Little is known about the health conditions and support needs of people living with intellectual disability (ID) in the African context. To address this gap, the authors conducted this study in residential facilities in the Western Cape Province, South Africa, for people over the age of 18 years with ID. They conducted in face-to-face interviews with the managers of 37 out of 41 identified facilities, as well as a survey of 2,098 residents (54% of them female), representing less than 2% of the estimated population of persons with ID in the province. The survey suggests that such persons experience a wide range of health conditions (notably mental health and behavioural issues) but have limited access to general healthcare and rehabilitation services. Furthermore, the daily living supports required for an acceptable quality of life are limited. The findings highlight the need for better health and support provision to persons with ID.
The authors of this paper hypothesised that just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. They present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique. Between April 2009 and September 2010, we conducted their study in six rural public primary healthcare facilities and found that one-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. They observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing) but despite these improvements, no progress attributable to one-stop, integrated MCH services was observed. Structural healthcare system limitations, such as staff absences and an irregular supply of essential commodities, appear to have a larger effect. Regular technical support and adequate basic working conditions form valuable motivators and are of critical importance for improved staff performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.
Malaria importation from neighbouring high-endemic Mozambique through Swaziland’s eastern border remains a major factor that could prevent elimination from being achieved. A nationwide formative assessment was conducted over eight weeks to determine if the imported cases of malaria identified by the Swaziland National Malaria Control Programme could be linked to broader social networks and to explore methods to access these networks. Interviews were carried out with malaria surveillance agents (6), health providers (10), previously identified imported malaria cases (19) and people belonging to the networks identified through these interviews (25). Network members and key informants revealed common congregation points, such as the urban market places in Manzini and Malkerns, as well as certain bus stations, where people with similar travel patterns and malaria risk behaviours could be located and tested for malaria. The authors of this study conclude that imported cases of malaria belong to networks of people with similar travel patterns. This study may provide novel methods for screening high-risk groups of travellers using both snowball sampling and time-location sampling of networks to identify and treat additional malaria cases. The authors argue that implementation of a proactive screening programme of importation networks may help Swaziland halt transmission and achieve malaria elimination by 2015.
8. Human Resources
In this paper, the authors assess the gender-based distribution of Tanzania’s health workforce cadres. They conducted a secondary analysis of data collected in a cross-sectional health facility survey on health system strengthening, consisting of 815 health workers (HWs) from 88 randomly selected health facilities. Results showed that the mean age of the HWs was 39.7, with 75% women. The proportion of women among maternal and child health aides or medical attendants (MCHA/MA), nurses and midwives was 86%, 86% and 91%, respectively, while their proportion among clinical officers (COs) and medical doctors (MDs) was 28% and 21%, respectively. The authors conclude that the distribution of the Tanzania’s health cadres is dramatically gender skewed, a reflection of gender inequality in health career choices. MCHA/MA, nursing and midwifery cadres are large and female-dominant, whereas COs and MDs are fewer in absolute numbers and male-dominant. While a need for more staff is necessary for an effective delivery of quality health services, the authors call for adequate representation of women in highly trained cadres to enhance responses to some gender-specific roles and needs.
In this study, the authors explored the hypothesis that programmes initiated under unprecedented health investments from the US President's Emergency Plan for AIDS Relief have possibly facilitated the drain of healthcare workers from the public-health system in Uganda. They conducted a cross-sectional study between January and December 2010 to survey graduates, using in-person, phone or online surveys using email and social networks. The setting was rural: Mbarara University of Science and Technology (MUST) is one of three government supported medical schools in Uganda. The authors interviewed 85.4% (796) of all MUST alumni since the university opened in 1989, and they found 78% were physicians and 12% of graduates worked outside Uganda. Over 50% worked for an HIV-related non-governmental organisation (NGO) whether in Uganda or abroad. Graduates receiving their degree after 2005, when large HIV programmes started, were less likely to leave the country, but were more likely to work for an HIV-related NGO. The increase in resources and investment in HIV-treatment capacity is temporally associated with retention of medical providers in Uganda, the authors argue. External funds should be channelled to develop and retain healthcare workers in disciplines other than HIV and broaden the healthcare workforce to other areas, they recommend.
This qualitative assessment was undertaken to identify factors that influence motivation and job satisfaction of health surveillance assistants (HSAs) in Mwanza district, Malawi, in order to inform development of strategies to influence staff motivation for better performance. Seven key informant interviews, six focus group discussions with HSAs and one group discussion with HSAs supervisors were conducted in 2009. Data were supplemented by a district wide survey involving 410 households, which included views of the community on HSAs performance. The main satisfiers identified were team spirit and coordination, the type of work to be performed by an HSA and the fact that an HSA works in the local environment. Dissatisfiers were low salary and position, poor access to training, heavy workload and extensive job description, low recognition, lack of supervision, communication and transport. Managers and had a negative opinion of HSA perfomance, while the community was much more positive: 72.9% of all respondents had a positive view on the performance of their HSA. Activities associated with worker appreciation, such as performance management were not optimally implemented. The district level can launch different measures to improve HSAs motivation, including human resource management and other measures relating to coordination of and support to the work of HSAs.
This study describes the perspectives and engagement of key stakeholders in advancing critical regulatory and educational reform in east, central, and southern Africa (ECSA). Researchers surveyed 32 leading stakeholders from 13 ECSA countries with regard to task shifting and the challenges related to practice and education regulation reform. Most (72%) reported task shifting is practiced in their countries; however only 57% reported their national regulations had been revised to incorporate additional professional roles and responsibilities. They also reported different roles and levels of involvement with regard to nursing and midwifery regulation. The most frequently cited challenge impacting nursing and midwifery regulatory reform was the absence of capacity and resources needed to implement change. While guidelines on task shifting and recommendations on transforming health professional education exist, the authors argue that their study provides new evidence that countries in the ECSA region face obstacles to adapting their practice and education regulations accordingly. Stakeholders such as community nursing organisations, nursing associations, and academicians have varied and complementary roles with regard to reforming professional practice and education regulation.
Under-resourced and poorly managed rural health systems challenge the achievement of universal health coverage, and require innovative strategies worldwide to attract healthcare staff to rural areas. One such strategy is rural health training programmes for health professionals. In addition, clinical leadership (for all categories of health professional) is a recognised prerequisite for substantial improvements in the quality of care in rural settings, argue the authors of this report. Rural health training programmes have been slow to develop in low- and middle-income countries (LMICs); and the impact of clinical leadership is under-researched in such settings. A 2012 conference in South Africa, with expert input from South Africa, Canada and Australia, discussed these issues and produced recommendations for change that will also be relevant in other LMICs. The two underpinning principles were that: rural clinical leadership (both academic and non-academic) is essential to developing and expanding rural training programs and improving care in LMICs; and leadership can be learned and should be taught. Lessons learned: The three main sets of recommendations focused on supporting local rural clinical academic leaders; training health professionals for leadership roles in rural settings; and advancing the clinical academic leadership agenda through advocacy and research. By adopting the detailed recommendations, South Africa and other LMICs could energise management strategies, improve quality of care in rural settings and impact positively on rural health outcomes, the authors conclude.
The authors of this paper consider the perspectives and experiences of key Mozambican public sector health managers who coordinate, implement, and manage a wide variety of donor-driven projects and agencies. Over a four-month period, they conducted 41 individual qualitative interviews with key Ministry workers at three levels in the Mozambique national health system, using open-ended semi-structured interview guides, as well as reviewed planning documents. All respondents emphasized the value and importance of international aid and vertical funding to the health sector and each highlighted program successes that were made possible by recent increased aid flows. However, three serious concerns emerged: difficulties coordinating external resources and challenges to local control over the use of resources channeled to international private organisations; inequalities created within the health system produced by vertical funds channeled to specific services while other sectors remain under-resourced; and the exodus of health workers from the public sector health system provoked by large disparities in salaries and work. The vertical approach starved the Ministry of support for its administrative functions.
9. Public-Private Mix
This pilot study on the quality of anti-malarial tablets for sale in retail outlets during the major fishing season was conducted in a malarious fishing village located along the coast of Tema in southern Ghana. Researchers randomly sampled blisterpacks of anti-malarial tablets and assessed them according to the International Pharmacopoeia and Global Pharma Health Fund Minilab protocols. When testing for genuine artesunate per tablet, 10% of one manufacturer’s tablets and 50% of the other’s passed the titrimetric test. While 100% of the first manufacturer’s tablets passed for genuine amodiaquine, 17% of a similar package by the second manufacturer failed spectrophotometric testing. The inadequate amounts of artesunate and amodiaquine detected in the tablets suggest that both pharmaceutical companies may not be following recommended drug formulation procedures, or the active pharmaceutical ingredients might have been degraded by improper storage conditions. The authors conclude that the drugs being sold at Kpone-on-Sea, Ghana may likely be classified as substandard drugs and are not suitable for malaria treatment.
Substandard and falsified medicines are major global health challenges that cause unnecessary morbidity and mortality around the world and threaten to undermine recent progress against infectious diseases by facilitating the emergence of drug resistance. According to this study, Rwanda has the lowest prevalence of poor quality tuberculosis drugs among African countries. This positive finding may be associated with Rwanda's efforts to ban the sale of monotherapies, ensure that private sellers of important medicines are qualified, and prioritise the prevention of falsified medicines entering the country, the authors argue. As policymakers in, and researchers of, Rwanda's health sector, they argue that the improvement of the country's supply chain and drug surveillance systems, combined with equity-oriented strategies for increasing geographic and financial access to high quality drugs through the public sector, has played an important role in the country's steep declines in mortality due to tuberculosis and malaria. In scaling up pharmacovigilance for malaria and tuberculosis, they call for a global treaty and leadership by the World Health Organisation to address manufacturing and trade in substandard and falsified medicines.
South Africa’s health minister Aaron Motsoaledi has argued that consolidation of the private health care market has created a situation where the three largest private health care providers now dictate, not negotiate, prices to medical schemes. As listed companies, these providers aim to maximise profits, which, he argues, means they have little concern for affordable care. Cost escalation and overprovision in South Africa’s private sector is also seen as a consequence of the fact that regulation of the private sector has focused more on medical schemes and less on providers. Lawyers say that the imbalance in legislation puts medical schemes in a weaker position when negotiating with hospitals. One economist points to utilisation increases by 3% every year, which he argues are being driven by specialists and private hospitals that have profit sharing arrangements, with a high probability of collusion between the hospital groups because of the way in which they share profits and incentives. Specialists, on the other hand, blame the high costs of new drugs as responsible for price increases in private care. They say the pharmaceutical industry is hiking its prices significantly, presenting a barrier to care in both the private and public sectors, where even drugs coming off patent remain costly.
10. Resource allocation and health financing
The authors of this study conducted a review of the international literature on funding issues faced by church- and faith-based service providers in Africa and in Papua New Guinea. They found that funding constraints have been overcome in some cases through greater collaboration between government and church health providers, through the restructuring of user fees to minimise the impact on the poor and through more streamlined and transparent financial reporting. However, failure to fully implement agreed government funding to church health services can cause facility closures and reduced treatments, driving up costs for government and increasing the burden on public provision. The authors also report mixed findings as to whether greater engagement by church health services with government has translated into broader participation in policy formulation, as well as of implementation of community-based health insurance schemes and micro-insurance. Funding constraints influenced the retention of skilled staff by church health services, as workers move from church-managed, rural and remote facilities to public facilities in urban centres.
On 10 July 2013, the International Peace Institute hosted Kieran Holmes, General Commissioner of the Burundi Revenue Authority, to present lessons and recommendations from countries emerging from conflict, while positing ways the wider international community can support the development of domestic revenue generation and revenue authority. In this video, he argues from the position that imposed decisions and models of the global agencies are often not the in the best interests of recipient countries. A relevant system should be determined by local conditions. International and national partners must radically change the way they engage with states emerging from conflict. African leaders need to find how to move away from the model of partnership according to which priorities, policies, and funding needs are determined in foreign capitals and development partners’ headquarters. Conflict-affected states need to be able to determine their own destinies.
The purpose of this study was to assess individual attitudes towards health insurance policy and the factors that influence respondents’ decision to renew their health insurance policy when it expires. It was conducted in the Volta region of Ghana. A total of 300 respondents were randomly sampled and interviewed for the study. The researchers also assessed factors that influence respondents’ decision to take up a health insurance policy and renew it. The study results indicate that 61.1% of respondents are currently being enrolled in the national health insurance system (NHIS): 23.9% had not renewed their insurance after enrollment and 15% had never enrolled. Reasons cited for non-renewal of insurance included poor service quality (58%), lack of money (49%) and experience of other sources of care (23%). The gender, marital status, religion and perception of health status of respondents significantly influenced their decision to enroll and remain in NHIS. The authors conclude that NHIS is experiencing good levels of uptake, with clients testifying to its benefits in keeping them strong and healthy. Efforts therefore must be put in by all stakeholders including the community to educate the individuals on the benefits of health insurance to ensure all have optimal access.
In this paper, the authors consider how best to promote financial protection and access to needed health care for those outside the formal employment sector through prepayment funding, with a particular focus on the African context. The authors reviewed literature on alternative domestic prepayment funding mechanisms in relation to the three dimensions of universal coverage: population coverage, service coverage and cost coverage. Key messages from their review are the challenges of contribution arrangements for this population, even where legal provisions make membership mandatory. The authors recommend that additional health financing arrangements to cover poor and vulnerable groups (e.g. tax funding and innovative financing approaches) are adequately explored in terms of the principles of fair financing. This should be done before countries move towards implementing contributory schemes for those outside the formal sector which, as indicated in this review, have limited capacity to offer adequate financial risk protection to their members.
At the 2011 summit in Beijing, China, leaders of the BRICS countries (Brazil, India, China and South Africa) confirmed that public health is an essential element for social and economic development and should be reflected accordingly in national and international policies. Furthermore, they agreed to establish and encourage a global health agenda for universal access to affordable medicines and health commodities. However, achieving universal coverage will only be achieved if formal assessment becomes an acceptable key component, the author of this article argues. The BRICS development bank will require evidence of value for money to invest in health. The current approach asserts that health technology assessments have a major role in health services development. One criticism of this approach has been that an emphasis on efficiency means that equity and fairness are sacrificed. However, there are now initiatives in place that address these concerns, the author argues, and new approaches to value-based prioritisation are being developed to respond to concerns expressed about a health economic perspective, particularly by those advocating a rights-based approach.
11. Equity and HIV/AIDS
The aim of this study was to assess the effectiveness of a community-based natural resource management programme that “mainstreamed” HIV awareness and prevention activities within rural communities in Namibia. The authors used data from two rounds of the Namibia Demographic and Health Surveys (2000 and 2006/2007), including a total of 117 men and 318 women in 2000, and 170 men and 357 women in 2006/2007. They found that community-based conservation in Namibia has significantly reduced multiple sexual partnerships, the main behavioural determinant of HIV and AIDS infection in Africa. They argue that their results demonstrate the effectiveness of holistic community-based approaches centred on the preservation of lives and livelihoods, and highlight the potential benefits of integrating conservation and HIV prevention programming in other areas of communal land tenure in Africa.
Kenya’s National AIDS Control Council (NACC) and the National AIDS and STI Control Programme (NASCOP) have launched an HIV and AIDS strategy for transport corridors that aims to reach out to high-risk mobile populations along transport corridors. It will help ensure provision of eﬀective HIV and sexually transmitted infection (STI) prevention, treatment, care and support programmes for truckers, female sex workers, and men who have sex with men along with the communities they interact with such as border officials, police officers and the general population. The strategy will further provide a national framework within which HIV programming can be realised by various stakeholders providing HIV services along the transport corridors in Kenya.
In this paper, the authors describe lifetime prevalence of consensual male–male sexual behaviour and male-on-male sexual violence (victimisation and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus. The study was conducted in 2008 and included men aged 18–49 from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces, who provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimisation. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.
There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry disproportionate burden of HIV; however, their burden of HIV and prevention needs remains unknown in Swaziland. To address this gap, a respondent-driven-sampling survey was completed between August and October, 2011 of 328 FSW in Swaziland. Unadjusted HIV prevalence was found to be 70.3% among a sample of women predominantly from Swaziland with a mean age of 21, which was significantly higher than the general population of women. Just 23.5% reported always wearing condoms with sexual partners in the past month, while rape was common at 40% reporting at least one rape, with torture reported at 53.2%. While Swaziland has a highly generalised HIV epidemic, FSW represent a distinct population with a high burden of HIV compared to other women, according to the authors. These women are understudied and underserved resulting in a limited characterisation of their HIV prevention, treatment, and care needs and only sparse targeted programming. The authors argue that FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioural and structural interventions.
12. Governance and participation in health
CIDSE, an international alliance of Catholic development agencies, held a workshop in Brussels from 14-15 May 2013 to discuss ways of creating a new development agenda. This report contains the main findings from the workshop. Participants agreed that the new agenda should have a number of values and principles at its heart: human dignity, rights, freedom and responsibility; justice, equity, solidarity, and fair distribution; care for the earth; and participation and subsidiarity. To enable a paradigm shift towards a just and sustainable world, participants called for a prophetic new narrative of human well-being within creation, gender equity, and solidarity, with an economy at the service of society within planetary boundaries. They also called for transformation of the dominant GDP growth and development paradigm, towards just and sustainable societies and livelihoods. They argued for confrontation of unjust power structures, making common cause with those most affected by inequalities and unsustainability in both North and South. Bold actors for change are needed, those who challenge ourselves to deepen our partnerships, and to engage in alliances with those who share our goals of transformation.
This report presents the findings of a research and advocacy process that included consultative workshops with civil society organisations (CSOs) in all nine of South Africa’s provinces. The research found that the legislated ‘enabling environment’ for civil society was dysfunctional. The serious lack of current and reliable national data about the size, scope and activities of the sector negatively affects the ability of the sector and of government to support it. The sustainability and effectiveness of civil society to address poverty and equity is compromised by these problems. South African civil society sector is facing a funding crisis, which needs to be addressed on many fronts: the authors call for legislative reform and renewed work on an enabling policy environment for civil society, and for grant-making and other forms of investment in social development. International sources are now much less available, which means that local funding sources must be developed and leveraged, including private philanthropy, corporate social investment and the contributions from state-related agencies such as the National Lottery Board (NLB) and the national Development Agency (NDA). The authors urge these funding agencies to work with government leadership to commit to a cooperative process towards over-arching and systemic reform of the enabling environment for civil society. They further recommend that a cross-sectoral working group, which includes strong civil society representation, is established to plan the necessary changes.
A new campaign has been launched, Kenyans for Tax Justice, speaking out against a new Value Added Tax (VAT) Bill, known popularly as the “Unga tax bill”. Activists are trying to raise awareness and compile a petition against the bill, which seeks to apply a 16% value added tax rate on basic commodities that have remained untaxed until now. When the bill was introduced to parliament in 2012, citizen welfare groups strongly opposed its adoption but it is now up for debate in parliament. The activists mobilising against the VAT bill say they want to use the campaign to highlight the government’s hypocrisy in increasing taxes for ordinary citizens, while at the same time giving multi-national companies major tax breaks. Government estimates place Kenya’s lost revenue from tax incentives to foreign investors at 100 billion Kenya shillings (1.1 billion dollars). Tax Justice Network Africa estimates that in 2010 and 2011, the government spent more than twice the country’s health budget on providing tax incentives.
In Turkey, Brazil and Egypt, thousands have taken to the streets to voice their anger and frustration at the lack of social and economic justice in their countries. The author of this article argues this public unrest is directly linked to the wholesale adoption of neoliberal economic policies by these countries’ governments, which has led to social inequality. He argues that, despite mainstream perceptions, free markets don't automatically regulate themselves nor do they naturally respect individual or community rights. And while the power of transnational corporations has expanded exponentially to eclipse governments of small countries, income and wealth disparities have widened. But despite the grave warnings from civil society, governments and financial institutions continue to privatise services when they should be focusing on how to make the public sector fit for purpose. Political leaders and captains of industry have subjected ordinary people to double burdens of paying taxes to the state and paying profit-adjusted higher costs for privatised services like health, education and public transport, despite these services being part of the social contract between citizens and the state.
This paper describes the results of an environmental scan of organisations in Africa carrying out advocacy on cancer using a cross-sectional study. A total of 39 African advocates representing 17 countries participated in the project. Most participants have been advocates for more than five years; and mostly advocate for both males and females and individuals between the ages of 30 and 39. The most common cancers focused on by the advocacy organisations include breast, prostate, liver, cervix, stomach, bladder, pediatric, colorectal and neck. The information provided by participants offers clear guidelines on establishing and maintaining an advocacy programme in Africa despite the various challenges faced by these organisations. The authors call for more inclusive dialogue for advocates to share ideas with each other, connect with other advocates, learn about other innovative advocacy programmes and join forces.
In this open letter, civil society groups across Africa argue that the Alliance for a Green Revolution in Africa (AGRA) is failing in Africa, as it benefits relatively few farmers, often at the expense of the majority. AGRA-promoted technologies, like genetically modified crops, produce concentration of land ownership, increasing economies of scale and a declining number of food-producing households in a context of limited other livelihood options. Opening markets and creating space for multinationals to secure profits lie at the heart of the G8 and AGRA interventions, they argue. They also fear that the intellectual property of many plant types may be transferred to large multinational corporations as part of AGRA practices. As a solution, they call for differentiated agricultural strategies that recognise and vigorously support local and informal markets, proven low-input and ecologically sustainable agricultural techniques including intercropping, on-farm compost production, mixed farming systems (livestock, crops and trees), on-farm biofuel production and use, and intermediate processing and storage technologies. The International Assessment of Agricultural Knowledge, Science and Technology for Development (IAASTD) provides detailed and scientifically sound proposals in this regard.
The Ugandan Government wants non-government organisations (NGOs) to align their projects to government’s development priorities. At the national civil society fair held in Kampala early in July 2013, James Baba, the state minister for internal affairs, said NGOs should strive to understand government priorities and work on them both in the local and central governments. The Cabinet has charged the Ministry of Internal Affairs in consultation with the Minister of Finance to closely work with NGOs to ensure that all projects are aligned with government priorities. The National Development Plan outlines various strategies for the socio-economic transformation of Uganda from a peasant economy to a modern and prosperous country within 30 years. Baba promised to enhance the co-ordination of NGO stakeholders to ensure improved communication flow aimed at promoting smooth relations between the Government and the NGOs.
13. Monitoring equity and research policy
For this report, the authors conducted interviews with senior health systems researchers, high-level policy makers and policy brokers in 26 low- and middle-income countries (LMICs) in order to map health systems research capacity, health systems research undertaken and policy uptake of this research. They found that health systems research was dependent on a cluster of enabling factors: charismatic and strategically thinking individuals with a talent for networking, technical competence and scientific credibility, appropriate international alliances and trends, emergent local knowledge translation structures and increasing national ownership of research agendas, more and better training courses for researchers as well as workshops for decision makers to make them more attuned to each others’ world and constraints, increasing trust between decision makers and researchers, a critical mass of health systems researchers and competing institutions ‘able to deliver’, an entry point for health systems research in decision making circles, sufficient domestic and international funding, and even political transitions, shock events or other windows of opportunity. However, country contexts diverge widely. In most LMIC countries studied, health systems research appears to be gaining momentum, and its potential for informing policy is increasing.
Health systems research is widely recognised as essential for strengthening health systems, getting cost-effective treatments to those who need them, and achieving better health status around the world. However, there is significant ambiguity and confusion in this field’s characteristics, boundaries, definition and methods. Adding to this ambiguity are major conceptual barriers to the production, reproduction, translation and implementation of health systems research relating to both the complexity of health systems and research involving them. These include challenges with epistemology, applicability, diversity, comparativity and priority-setting. According to this report, three promising opportunities exist to mitigate these barriers and strengthen the important contributions of health systems research. First, health systems research can be supported as a field of scientific endeavour, with a shared language, rigorous interdisciplinary approaches, cross-jurisdictional learning and an international society. Second, national capacity for health systems research can be strengthened at the individual, organisational and system levels. Third, health systems research can be embedded as a core function of every health system. Addressing these conceptual barriers and supporting the field of health systems research promises to both strengthen health systems around the world and improve global health outcomes, the authors conclude.
The author of this article argues that one decade into the 21st century it is clear that the current situation in African leadership is not conducive to building strong national health research systems in the continent. Consequently, the promise of health systems strengthening may remain elusive, despite positive efforts. He says African countries are not acting according to international declarations, and are reneging on their commitment to take the lead by increasing their investments in health and research for health. More than two-thirds of external funding for health is bypassing government, in contradiction to the guidance of the Paris Declaration and the Accra Plan of Action. The author calls for broader dialogue on how international assistance for health is conceived will be needed to achieve results that can be scaleable and sustainable. Both African governments and external funders will need to examine how they engage to improve health systems, a critical step in improving population health.
This study describes the issue of research use in decision making from the perspective of embeddedness of research institutions in policy making. Its ﬁndings suggest that multiple forces converge to create context-speciﬁc pathways through which research enters the policymaking environment. The authors argue that while proximity to a decision making core does have advantages, it is not the position of the institution within the network, but rather, the qualities that institution possesses that enable it to be embedded: reputation, capacity, quality, and quantity of connections to decision makers. They also expected the policy environment to inﬂuence the uptake of research. Decision makers sourced evidence from research institutions in a variety of ways - leveraging personal networks, accessing peer-reviewed publications, developing formal links with national statistics agencies, academic, or independent research institutions, or by assembling expert committees for a well-deﬁned task. However, findings from key informants suggested that the quality – and not the quantity – of connections was important for embedding research institutions in policy making, particularly where researchers were involved in policy making, where research institutions were part of the decision making body or where collaborative planning occurred to identify and prioritise research needs.
In this article, the author considers the disadvantages of over-reliance on evidence-based medicine. He argues that a publishing bias exists against studies with negative or inconclusive findings, which skews overall results. Sometimes, there is a significant finding in favour of a trial drug if the study was funded by for-profit organisations, which could not be explained by methodology, statistical analysis or type of study. He also points to a growing trend in industry-sponsored studies: the initial draft is compiled by company employees, before academically affiliated authors, often regarded as key opinion leaders, are sourced as principal or second authors without having substantially contributed to the study. And with increasing levels of data fabrication, the author warns against abandoning clinical experience and judgement in favour of evidence-based approaches.
According to this report, the monitoring process for the Millennium Development Goals (MDGs) has taught important lessons on how to maintain focus on internationally agreed development goals and targets, while keeping stakeholders informed of achievements, problem areas and emerging issues. The Working Group argues that global statistics organisations should continue to occupy a strategic, oversight position on statistics and indicators for monitoring. One key lesson learned is that there is clear need for a broad-based technical but inclusive monitoring group, and for a succinct annual report for the public on progress and challenges. The Working Group argues that the UN System Task Team on the Post-2015 UN Development Agenda has played a critical role for the coordination, credibility and sustainability of global monitoring and reporting and should be maintained in some form post-2015. Another finding has been the importance of investment in country capacities for data collection and reporting, leading to progress in disaggregation as well as towards the development of new indicators. Finally, the monitoring process has brought to the fore the necessity of having well-defined, objectively measurable indicators that can be used to track progress across countries and be aggregated to represent regional and global trends.
14. Useful Resources
These consolidated guidelines provide guidance on the diagnosis of HIV infection, the care of people living with HIV and the use of antiretroviral (ARV) drugs for treating and preventing HIV infection. They are structured along the continuum of HIV testing, care and treatment. Behavioural, structural and biomedical interventions that do not involve the use of ARV drugs are not covered in these guidelines. The 2013 guidelines combine and harmonise recommendations from a range of World Health Organisation (WHO) guidelines and other documents. Comprehensive guidance is now provided on using ARV drugs across age groups and populations of adults, pregnant and breastfeeding women, adolescents, children and key populations. The guidelines also aim to consolidate and update clinical, service delivery and programmatic guidance. Consistent with previous WHO guidelines, the new guidelines are based on a public health approach to the further scaling up of ARV drugs for treatment and prevention that considers feasibility and effectiveness across a variety of resource-limited settings.
Global Research Nurses is a free network for all nurses with an interest in research. The aim is to give nurses the support, guidance, information and peer support they need to conduct their roles and enhance their careers as nurses working in research. Global Health Research Nurses offers four facilities: 1. A professional network where you can find colleagues nearby or across continents, via the Blogs, Bookmarks and Groups. 2. A Professional Membership Scheme. 3. Certificated e-learning short courses for skills in medical research. 4. Links to online learning.
The World Health Organisation developed this handbook to provide an overview for health inequality monitoring within low- and middle-income countries, and act as a resource for those involved in spearheading, improving or sustaining monitoring systems. The handbook was principally designed to be used by technical staff of ministries of health to build capacity for health inequality monitoring in World Health Organization Member States; however, it may also be of interest to public health professionals, researchers, students and others. Users of this handbook will be expected to have basic statistical knowledge and some familiarity with monitoring related issues. The handbook serves as a comprehensive resource to clarify the concepts associated with health inequality monitoring, illustrate the process through examples and promote the integration of health inequality monitoring within health information systems of low- and middle-income countries.
These guidelines offer to equip healthcare providers with evidence-based guidance as to how to respond to intimate partner violence and sexual violence against women. They also provide advice for policy makers, encouraging better coordination and funding of services, and greater attention to responding to sexual violence and partner violence within training programmes for health care providers. The guidelines are based on systematic reviews of the evidence, and cover a range of topics: identification and clinical care for intimate partner violence; clinical care for sexual assault; training relating to intimate partner violence and sexual assault against women; policy and programmatic approaches to delivering services; and mandatory reporting of intimate partner violence. They aim to raise awareness of violence against women among health-care providers and policy-makers, so that they better understand the need for an appropriate health-sector response. The standards provided here can form the basis for national guidelines, and for integrating these issues into health-care provider education.
15. Jobs and Announcements
This call goes out to all African health economists and health policy analysts or those working in Africa or on research of relevance to Africa to submit abstracts for the Second Conference of the African Health Economics and Policy Association (AfHEA), which will be held in Nairobi, Kenya, from 11 to 13 March 2014. The overall theme of this conference is "The Post-2015 African Health Agenda and UHC: Opportunities and Challenges". Researchers and other actors are encouraged to submit abstracts on this broad theme or indeed on any other interesting, innovative or topical African health sector or systems research that may be presented orally or in poster format at the conference. Proposals for organised sessions are also invited from interested individuals or institutions.
The Human Rights Scholarship (HRS) is awarded to local or international applicants wishing to undertake graduate research studies at the University of Melbourne in the human rights field and who are able to demonstrate their commitment to the peaceful advancement of respect for human rights. Each year the University offers two HRSs. Applicants must be able to demonstrate that their commitment to the peaceful advancement of respect for human rights extends beyond their academic studies (such as voluntary work and/or work experience). Applicants must have applied for, or be currently enrolled in a graduate research degree in the human rights field at the University of Melbourne. Applicants who have commenced their graduate research degree must have at least 12 months full-time or equivalent candidature remaining. International students must have an unconditional course offer at the University of Melbourne for the course for which they seek the support of a HRS.
CIVICUS is calling for participants to a series of civil society events taking place between 10 and 15 November 2013 in Johannesburg, South Africa. Coming just two months after the UN General Assembly meetings in New York in September 2013, the week of strategising, dialogue and mobilisation will provide a space for global civil society to chart a route forwards on how to bring real citizen voice, accountability and mobilisation into the newly emerging development vision. Two major global civil society conferences, at the heart of the week, are being hosted for the first time outside of Europe. 1. The conference on Building a Global Citizens Movement, convened by CONCORD/DEEEP, will take place on 11-12 November, and bring grassroots activists and social movements together with organised civil society. A session hosted by CIVICUS and partners, with a special South African focus, will connect the experiences of yesterday’s struggle activists with more recent social justice movements. 2. The International Civil Society Centre's Global Perspectives 2013 conference engages global and national CEOs of leading international civil society organisations in a dialogue around navigating disruptive change. The conference is co-hosted by ActionAid International and CIVICUS and will take place on 13-15 November.
The Global Network for Health Equity (GNHE) has launched its Scholarships Programme for 2013–2014. The programme aims to build capacity in low and middle-income countries for health systems research into issues of health systems equity and universal health coverage, by supporting junior researchers from those countries undertaking research on any of the following topics: equity in health systems financing and financial protection; equity in health systems delivery, including access and utilisation; equity in health outcomes at the population level; and universal health coverage. Applications from health economics and all other relevant research fields will be considered as well as inter-disciplinary proposals.
The general objective of this course is to strengthen the capacity of planning, developing and governing the national efforts to improve Occupational Safety and Health (OSH). Content includes: the International Labour Organisation (ILO) experience: ILO Global Strategy on Occupational Safety and Health; the Conventions no. 155 and 187; OSH national policy, systems, programmes and proﬁles; OSH governance: principles, policies and decision making framework; the national policy on OSH; components of the OSH national system; elaboration of a National OSH Proﬁle; planning of policies and strategies on OSH; procedures to formulate a National Programme on OSH; launching, implementation and coordination, monitoring and evaluation mechanisms; OSH national models and experiences of selected countries; and the experiences of participating countries. The cost of participation, excluding international air travel, is EUR 3,250 (course fees EURO 1,920 and participant subsistence EURO 1,330) payable in advance by the participant or his or her sponsoring organisation. Please note that jointly with the application form, you must send a nomination letter in which the institution/sponsor should indicate how the candidate will be financed.
A total of four postdoctoral fellowships are available in the area of Health Policy and Systems Research (HPSR) for the Collaboration for Health Systems and Policy Analysis and Innovation (CHESAI) project, which is based at the School of Public Health and Family Medicine, University of Cape Town (UCT) and the School of Public Health, University of Western Cape (UWC), both in Cape Town, South Africa. The fellowships are for the period 2012-2016. Applicants must have citizenship of a sub-Saharan African country, be an expatriate African, or demonstrate commitment to future work in African health systems. They must have achieved a PhD in the last five years in any suitable field, such as health sciences or social sciences and not have previously held any permanent academic positions. Their work must show clear evidence of robust scholarly performance including a relevant publications record and have some relevant experience, specifically a track record of interest in health policy and systems issues, preferably including research. Applicants will be asked to propose an area of work relevant to one or more of the CHESAI themes, and to show how their past research provides a basis for this proposed work and/or what additional activities are proposed to contribute to the CHESAI community of practice. Please contact Jill Oliver and Thubelihle Mathole at the email address given.
The Social Aspects of HIV and AIDS Research Alliance (SAHARA), established in 2001 by the Human Sciences Research Council (HSRC), is an alliance of partners established to conduct, support and use social sciences research to prevent the further spread of HIV and mitigate the impact of its devastation in sub-Saharan Africa. The SAHARA 7 conference theme is "Translating evidence into action: Engaging with communities, policies, human rights, gender, service delivery".
The MPH at the University of the Western Cape aims to equip health professionals to: quantify and prioritise health needs; design, implement and evaluate Comprehensive Primary Health Care Programmes; and manage District Health Systems. The Programme is designed for a range of health and welfare professionals and managers from middle to senior level, at district, provincial or national levels, staff of NGO’s and academic research contexts. The Programme may be taken over two to three years. Admission requirements: A four year degree (Honours Degree) or its equivalent in any discipline, or in exceptional cases, five years of relevant experience assessed by the university through a Recognition of Prior Learning (RPL) process. Contact Mrs Janine Kader at the email address given.
The Department of Health and Rehabilitation Sciences at the University of Cape Town, South Africa, is holding its first Rehabilitation Conference in September 2013. The conference will host speakers from diverse disciplinary fields on a range of themes such as: policy: influencing development and implementation; evidence for action: a research agenda; responsive rehabilitation service delivery; and optimising human resourcing for rehabilitation.
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