This publication reports from stakeholders the information and knowledge gaps and research priorities on global health diplomacy (GHD) in Africa to inform regional discussion on a research agenda for GHD. The findings indicate that research on GHD should identify factors that support the effectiveness of GHD in addressing selected key challenges to health strengthening systems in Eastern and Southern Africa, in a way that strengthens the capacity of key African policy actors and stakeholders within processes of health diplomacy. . The findings indicate a preference from officials and policy makers to do this in three broad areas: i. Firstly, to explore the implementation of existing global commitments in the region, to learn lessons from the current experience, generate evidence for input to monitoring and review of the commitments, and to inform future health negotiations. ii. Secondly, to explore the extent to which African interests are advanced in areas under global health negotiation, to assess the implications, costs and benefits of specific issues for the diverse countries in the region, and the different negotiating positions of countries in and beyond the region. iii. Thirdly to explore how effectively interests in the region are being represented in the current global architecture and governance, including of the global initiatives that fund health, to inform African engagement on global governance reforms.
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The Equity Watch monitors progress in areas of equity in health, household access to the resources for health, equitable health systems and global justice. This report provides evidence on the performance of Uganda’s public policies and systems in promoting and attaining equity in health using the Equity Watch framework. The evidence presented in this report indicates progress in some key areas, such as in closing social and geographical gaps in access to education, safe water, immunisation and other areas of primary health care. It also highlights challenges, including in coverage of maternal health services and in the distribution of health workers.
At the World Conference on the Social Determinants of Health, held in Rio de Janiero Brazil from 19-21 October 2011, reports from countries indicated a promising range of actions being taken to assess or monitor equity and the social determinants of health (SDH), measures to plan and review action on SDH, as well as actions to strengthen constitutional protection of the right to health and to strengthen intersectoral action and comprehensive primary health care. However, few countries reported on actions on economic determinants, and countries that have regulated commercial interests for public health reasons, such as introducing taxes on foods high in fat or sugars, or in implementing legal controls over tobacco, allege they have faced counter litigation from companies. Despite persuasive evidence, health equity has been a marginal consideration in trade, economic or climate forums. Public health advocates argue that equity should be included at the centre of wider economic, trade and development agendas, including the UN Conference on Sustainable Development in June 2012 (Rio+20) and the UN Millennium Development Goals. While a task force of UN agencies was set at the WCSDH, key economic and trade agencies were not present.
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.
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.