This study aimed to assess equity in uptake of antiretroviral therapy in Malawi in 2005, especially according to age (children vs. adults), gender (men vs. women) and income. Particular reference is made to the scaling up of ART and the removal of fees for ART in 2004. Informal interviews were conducted with health sector antiretroviral programme implementers and key policy makers in the Ministry of Health. The researchers also searched both published and grey literature to collect information on the history and operations of the Malawi public sector-led ART programme. Retention rates remain high in Malawi's ART programmes (84%), which compare favourably with those elsewhere on the continent. Rates ranging from 44% to 85% of people remaining on treatment after 24 months of treatment have been reported in ART programmes throughout Africa (Rosen et al, 2007). While there were some reports from key informants that the change from fee-paying ART services to free systems may have improved patient adherence to treatment regimes, the research did not provide conclusive evidence of the impact of cost of patients' medications on their adherence to their treatment regimens. Different adherence rates in different areas and programmes suggest that other determinants may be affecting affect this outcome.
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In Uganda, community-based health insurance started in 1995; however, the number of schemes has remained small with very low coverage levels. This study examines issues of equity and sustainability in these prepayment schemes; if they are to contribute significantly to health sector financing, the schemes must be equitable and sustainable. A descriptive cross-sectional study employing qualitative techniques was carried out. Key informant interviews, focus group discussions and documents review were used. Data was tape-recorded, transcribed, typed, manually analysed thematically using a master sheet. Abolition of user fees did not have a big effect on enrolment into the schemes. People went for higher quality services, which were perceived to be provided in private health facilities rather than government services. Schemes were perceived to directly contribute towards health financing by providing funds for the procurement of drugs and equipment, allowing people to contribute to their own health care. An indirect benefit is that they would ease the pressure on public facilities by diverting patients from the public health sector. Whereas some thought the contribution of CHI schemes was insignificant due to low enrolment, others felt the schemes needed to be strengthened to build confidence in social health insurance. The researchers recommend that government increase funding to maintain the improvement in quality of health care in public facilities. Future health policy needs to address whether or not CHI has a role to play in the Ugandan context and in institutionalising SHI.
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.
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.