African Heads of State committed themselves at a meeting in Abuja in 2001 to devoting a minimum of 15% of government funds to the health sector in order to address the massive burden of ill-health facing countries in Africa, particularly within the context of a growing burden of HIV, AIDS, TB and malaria, This report considers progress towards this target and is based on information provided by researchers in seven east and southern African countries. Of the countries reviewed, only Zambia and Malawi have made considerable progress towards the Abuja target, with the health sector’s share of total government expenditure increasing consistently from 8% and 5% respectively in 1997 to nearly 11% and 7% in 2000 and almost 18% and 11% in 2003 (thus exceeding the Abuja target in the case of Zambia). Although Namibia has not achieved the Abuja target, it has made good progress from 10% in 1997 to nearly 14% in 2003. Kenya is the furthest from the Abuja target, with only 5% of government resources going to health services in 2006 and with no consistent increase in government spending. Some seven years after the Declaration, many countries are still lagging well behind the target, although there are promising signs of increases in allocations towards the health sector in some.
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This report presents a review of the public health laws in Kenya, Uganda and Tanzania that impact on equity in health, to assess the extent to which the current legal framework addresses public health and health equity. Public health law has perhaps not had adequate profile in academic and professional practice, but is a critical area of work if countries in east and southern Africa are to protect public health and health equity in an environment increasingly influenced by global challenges and policies. Various areas of law are provided for in all countries, and it is more in their application that there may be deficits. Some areas of law are provided for in some laws but not in all relevant laws, or not in all countries. This calls for measures to harmonise the legal frameworks within countries to ensure consistency, and across the three countries to protect health across the region as a whole. In some cases there are policy commitments but omissions or gaps in law to reflect these policy commitments and ensure their application at national level across all sectors. The authors suggest that these areas be reviewed by health authorities, parliamentary committees, health professional associations and health civil society.
In the study, the researchers explore how policies are shaped and transformed in the process of implementation, using as a case study the implementation of two community health workers policies in a rural sub-district in South Africa. The researchers investigated how role players at different levels of the implementation process interacted with each other and the policy and how they used power at their disposal in this process. Rather than focusing on the gap between policy formation and policy outcome, with implementation being a mere administrative follow-on, the researchers took a 'bottom-up' perspective, which allows one to view implementation as an integral and continuing part of the policy process. Within this, the researchers particularly explored the use of discretionary power by front-line implementers, finding that selective communication and lack of information led to a 'thinning down' of a complex and comprehensive policy. While ftontline implementers did not have the power to change the rules that were set by the provincial actors, they used their knowledge of local conditions, control over local knowledge and distance from the provincial capital to shape implementation at the service level.
Very few east and southern African countries have health care spending levels anywhere near the 2001 WHO recommended US$80 per person per year. In 2001 in Abuja African heads of state committed to allocating 15% of government budgets to health -- the Abuja declaration. This brief shows that several countries (Malawi, Namibia, Zambia, Uganda) have made considerable progress in increasing domestic funding, towards the Abuja target. It outlines evidence to argue that devoting 15% of domestic public funds to the health sector is necessary – both to address the health and health care needs within east and southern Africa (ESA) and to ensure progress towards building a universal and comprehensive health system. The target of 15% is not unrealistic – it is very much in line with levels of public spending in other countries around the world Achieving the 15% target demands that public funds not be consumed by debt servicing, so rapid implementation of debt cancellation is critical. The 15% is understood to mean domestic public spending on health, excluding external funding. It should be regularly monitored and publicly reported by governments. Even if countries achieve the 15% target, for many there will still be a substantial gap in funding for health services. More resources flow out of Africa than into the continent, so sustainable health financing demands global solidarity. External funding support is thus critical, based on OECD countries’ commitment to contribute 0.7% of their GNP as official development assistance (ODA). Increased spending on health services should not be at the expense of spending on other social services, as this is fundamental to promoting human development, so that people benefit from and contribute to economic development.
This report of the second phase of this project outlines the work by a working group from the community in an informal settlement in Namibia and from the University to take forward community identified priorities for environmental health improvements, particularly sanitation. The report describes the engagement with the local authorities in a community driven process, and the challenges in building community empowerment for health actions in informal settlement areas. Community members have weak access to decision making on their services and actions to implement even the most basic PHC interventions take time to build the co-operation and responses from necessary stakeholders.
Over the past fourteen years considerable effort has been made to restore the functional capacity of the health sector, reactivate disease control programmes and re-orient services to Primary Health Care in Uganda. Ensuring that the resources for health fairly reach those with greatest need and that all have fair opportunities for health is a priority and not a matter for the Ministry of Health alone, but for all sectors whose activities affect health, and for all sections of society. As a part of this there is a body of work taking place in Uganda in government, academic and civil society institutions to explore, understand and propose options for reducing inequalities in health in Uganda. This abstract book presents the papers from a national meeting that aimed to assess the progress of equity in health in Uganda, review gaps and needs in the Ugandan health sector, to feed into and draw from experience in East and Southern Africa.
In this study, authors aimed to identify the impact of the migration of human resources for health on health services in Kenya. The World Health Organization (WHO) 2004 framework on health systems performance was used. The study concentrated on impacts on resource generation, stewardship and service provision and was limited to doctors and nurses. Despite data limitations, the study shows a general trend in migration both locally, from rural to urban areas and internationally, from Kenya to developed countries, with a high emigration rate of 51% for doctors and 71% of respondents indicating an intention to emigrate. From data collected, authors made a rough estimate of inward remittances of about US$90 million annually for nurses and doctors which, however, are not available to the health system and may not match outflows from the health system. In training doctors (schooling and university) alone, about US$95 million invested was lost in Kenya due to migration. Even if remittances were to be accounted for, there still appears to be a net outflow of capital from the country and its health system due to migration. This loss has negative impacts on workloads, especially at peripheral facilities and in some rural districts, which may impact on health service provision and on the referral chain. Increased workloads caused by understaffing result in stress, burn out and demotivation. These become push factors that lead remaining health workers to leave. There was some improvement in workloads in 2005/6 despite increases in service uptake, suggesting that there has been some policy response to the staff crisis in those facilities surveyed.
This study is a first attempt at gathering evidence on the effects of effects of user fee removal on aspects of utilisation and quality of services. The study was based on data collected from a sample of 23 districts in Zambia. The data included total utilisation, attendance levels at health centre outpatient and inpatient maternal and child health facilities, levels of respiratory infections, skin infections, diarrhoea and supervised deliveries, and the availability of drugs. Utilisation data is categorised by age (under-five years of age and over five years) and according to rural or urban districts. There was a substantial increase in total utilisation of public health services (50% increase in rural populations over 5) and an increase in drug consumption. Districts with a greater proportion of poor people recorded greater increases in utilisation of their facilities. Drug consumption in rural districts was estimated to have increased by about 40%. Staff workloads (calculated as the staff-to-patient ratio per day) in rural districts also showed a slight increase after user fees were removed. Based on patients' perceptions, there was no evidence of deterioration in the quality of care since user fees were removed. However, inadequate numbers of skilled health workers presents a major human resources threat to improving access by all. With sustained budget support from government to the DHMTs, the health system can continue to achieve its desired outcomes without relying on user fees.
To promote policies for equity in health HEPS-Uganda, Makerere University Institute of Public Health with EQUINET organised a National Meeting on equity in health in Uganda in March 2008. The meeting reviewed the body of work taking place in Uganda within government, academic and civil society institutions to explore, understand and propose options for reducing inequalities in health in Uganda. The meeting provided an opportunity to exchange evidence, strengthen networking in Uganda, and feed experience into regional networking. The report outlines the papers nd the deliberations. The meeting set up a task force that would take the work forward within key areas of focus, including fair financing; trade and health; health rights and governance and protection of vulnerable groups. HEPS and Makarere University Institute of Public Health are co-ordinating the task force. It was proposed that a follow up national meeting be held in a year to review issues and work.
The manual is intended for use by researchers in preparing papers, in writer’s training workshops; and will be updated in later editions with additional areas of writing skills. This edition of the manual is a guide to producing scientific reports, peer-reviewed articles, EQUINET policy and discussion papers, briefs and reports. It is intended for those involved in EQUINET and related research programmes to prepare papers for publication in reports, papers and in peer-reviewed, scientific journals; to communicate work on health equity; to understand and work with peer review processes; and to improve writing skills generally, including for meeting reports.