This report updates the 2008 Zimbabwe Equity Watch report using a framework developed by EQUINET in cooperation with the eastern, central and southern African health community and in consultation with WHO and UNICEF. The report introduces the context and the evidence within four major areas: equity in health, household access to the resources for health, equitable health systems and global justice. It shows past levels (1980–2005), current levels (most current data publicly available) and comments on the level of progress towards health equity. The 2011 Equity Watch indicates that improvements have been made in priority areas identified in the 2008 Equity Watch report, such as in primary education, in supplies of medicines and staff to primary care and district levels, in immunisation coverage, in access to antiretrovirals, and in recognition and support of community capacities for health. Nevertheless, the report shows that poverty and inequality in wealth remain high. Economic inequality affects access to key inputs to health, like improved incomes or safe water and the uptake of health services.
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In recent years there has been increased private for-profit health sector activity in certain countries in East and Southern Africa. External funders and governments have subsidised some of these activities. Private ‘high-end’ hospitals have begun to service wealthy groups, even in very low income countries. A report published in 2007 by the World Bank’s International Finance Corporation (IFC) encouraged governments to facilitate further private sector growth. This policy brief explores these developments in East and Southern Africa. In contrast to the IFC report, it raises concerns about the adverse consequences of growth in the private for-profit sector, and proposes steps that Ministries of Health should take to protect the integrity and equity of their health systems.
The extent to which health rights are neglected or promoted is a major factor in the promotion of health equity in Africa. Central to this is the incorporation of the right to health in the national Constitution, as the supreme law of the country. Including the right to health as a constitutional right provides a bench mark for government, private sector and society to respect, protect, fulfil and promote it. In many countries in east and southern Africa (ESA) there is advocacy and debate on inclusion in the constitution of the right to health. This brief presents a review of how the constitutions of 14 countries covered by EQUINET include the right to health. It uses as a framework the six core obligations spelt out in General Comment 14 of the International Covenant on Economic and Social Rights (ICESR).
By involving citizens and health workers in producing evidence and learning, participatory action research has potential to organise community evidence, stimulate action and challenge the marginalisation that undermines achievement of universal health coverage, the authors of this paper argue. They begin by summarising and analysing the results of two sessions on this research model convened by the authors at the First Global Symposium on Health Systems Research in Montreux Switzerland, 16–19 November 2010. They then review case studies and experiences discussed, particularly their contribution to universal health coverage in different settings. The authors reflect on challenges faced by participatory action research, and outline recommendations from the two sessions, including the creation of a learning network for participatory action research.
In August 2011, the South African Minister of Health released a Green Paper on introducing a National Health Insurance (NHI). While there has been a relatively muted response to the release of the paper, there has been sufficient public commentary to identify positive and negative key areas. On the positive side, the proposals have been praised for: being based on universal coverage principles; adopting a carefully phased approach; focusing firmly on addressing the problems in the public health sector first; and building a strong foundation of improved primary care services. However, while there appears to be a commitment to a single public pooling and purchasing entity, the Green Paper mentions also considering a multi-payer option whereby private insurance schemes would act on behalf of the NHI, raising concerns about high administration costs, which would limit income and risk cross-subsidies, and reduce the cost-containment benefits that would accrue if government was a single purchaser. The proposal to purchase services from the private sector may also mean a two-tier system will be retained as wealthier groups live closer to private providers than the less well-off and, given the rapid increase in fee levels among private for-profit providers, may threaten the sustainability of the NHI. Although it is proposed that there will be no fees at the point of service, the Green Paper also mentions having to consider co-payments, which would limit the financial protection afforded to beneficiaries. There are clearly some contradictions within this policy document that need to be resolved, the author concludes.
Work on health equity in east and southern Africa was given profile at the World Conference on the Social Determinants of Health. Work on equity monitoring, including the Equity Watch in Zimbabwe and the ECSA Region was included in the background paper and reported on by the Hon Minister of Health Zimbabwe, also current chair of the ECSA Health Community. EQUINET as an equity catalyst bringing social forces across state, civil society, academic and parliament institutions was included in a panel on social participation. Community Working Group on Health, the cluster lead for social empowerment made input to the media cover and to the wider civil society platforms, especially of the People's Health Movement, and EQUINET publications were included in the material displayed by WHO Afro. TAC South Africa, the Ministers of Health of South Africa and of Kenya made inputs to panels on institutionalising participation in policy making and on changing the role of public health and Professor Sanders UWC in the final plenary on SDH and the life course. Case studies on work on social determinants of health for the conference from Namibia, Rwanda, Kenya, Uganda and Zimbabwe can also be found at www.who.int/sdhconference/resources/case_studies/en/index.html.
After much misinformation in the South African press about the proposed new National Health Insurance scheme, the author of this article restates the case for NHI. The proposed NHI is about achieving a universal health system, which means that everyone will enjoy financial protection from high health care costs and be able to access good health services when they really need them. To finance the scheme, government needs to increase public funding for health care to improve the efficiency of public health services and employ more staff in public health facilities – there are too few staff to cope with the current patient load. The government’s Green Paper on the NHI estimates that the scheme will cost about R125 billion in 2012, increasing to R256 billion in 2025. The author emphasises that this is the total amount of money needed for publicly funded health services, not extra funding. The government is already planning to spend over R112 billion in the 2011/12 financial year on the health system and has budgeted to spend over R120 billion in 2012/13. So, to move forward with the NHI, initially only a little extra funding is needed - about R5 billion in the first year. The gap for NHI funding could easily be funded by a relatively small health tax on personal income and a small payroll tax for employers, amounting to less than 2%. The author argues that, given that the richest 10% of the population has 51% of total income in South Africa, the idea of their cross-subsidising health care for the poor is perfectly equitable and affordable.
The author, citing evidence from World Health Organisation, argues that climate change raises challenges for health in Africa for a variety of reasons. African countries have a high burden of climate sensitive diseases and poor public health capability to respond. Under-nutrition and weak infrastructures may reduce the capacity to mitigate the effects of health risks from climate change. Negative effects of climate change on socioeconomic development may also seriously undermine health and well-being of people in such countries. WHO reports that many of the projected impacts on health are avoidable and could be dealt with through a combination of public health strategies, support for adaptation measures in health-related sectors such as agriculture and water management, and an overall long-term strategy to reduce health impacts. In Africa the author argues that countries should implement the priority actions outlined at the 2008 first Inter-ministerial Conference on Health and Environment held in Libreville, Gabon, contained in the Libreville Declaration. This Declaration was signed by 52 African countries and commits them to address challenges relating to health and the environment.
An Equity Watch is a means of monitoring progress on health equity by gathering, organizing, analysing, reporting and reviewing evidence on equity in health. The aim is to assess the status and trends in a range of priority areas of health equity and to check progress on measures that promote health equity against commitments and goals. This first scoping report in Zambia introduces the context and the evidence within four major areas: equity in health, household access to the resources for health, equitable health systems and global justice. It shows past levels (1980–2005), current levels (most current data publicly available) and comments on the level of progress towards health equity. The report describes the recovery in health indicators after 2000, given the harsh decline in health and health care from the period of structural adjustment reforms and the AIDS epidemic in 1980-2000. It also indicates that aggregate improvements do not tell the whole story. Inequality in wealth in Zambia remains high and is reflected in rural–urban, wealth, gender and regional differentials in health and in the social determinants of health. Within the health sector steps underway to organize and distribute funds, heath workers and medicines towards primary and district level services are identified AS fundamental to overcome inequalities, but limited by the limited improvement in per capita domestic public sector funding and the increasing reliance on external funding in the heath sector. The report shows that measures such as closing rural–urban inequalities in primary health care, reducing cost barriers by removing user fees or stimulating female uptake of schooling have contributed to overcoming inherited and unfair opportunities for health.
Three years have passed since the World Health Organisation (WHO) Commission on the Social Determinants of Health (CSDH) report was launched and adopted by the World Health Assembly. Progress since 2008 at the international level has been built on the experience and initiative of different countries. For example in Africa in April 2008, work on social determinants of health (SDH) was located in the context of commitments to revitalise primary health care. The first global ministerial conference on healthy lifestyles and non-communicable disease (NCD) control in April 2011 and the UN High-level Meeting on NCD Prevention and Control in September 2011 provide important global platforms to address the SDH. Nevertheless there is debate whether adequate attention has been given to SDH in these forums. On 19-21 October 2011, WHO and the Government of Brazil are convening a global conference on the SDH in Rio de Janeiro, Brazil. The conference will hopefully provide a platform to tackle issues of social justice in development, to address the deficiencies in present economic thinking on and measures in globalisation.