This review of the capital flows in the health sector in Zimbabwe was carried out in 2008 and draws from secondary evidence. It presents evidence on the current composition of the health sector, particularly showing the public-private mix; trends over time post-1995 in private capital flows to the health sector showing key entry points for capital and the impact on the health care sector of these flows. The paper explores arguments used to support private flows, the role of trade agreements, and the policy, regulatory, institutional and public responses to the capital flows. It comments on issues arising in relation to methods used to analyse capital flows and their impacts, including data availability and bias. The rapid liberalisation of the health sector in Zimbabwe in the late 1990s created opportunities for private capital. While this was a policy objective of the time, it coincided with cuts in public expenditure during the 1990s and an economic crisis post-2000 that meant that private sector growth was not matched with public sector growth. The marked decline in public health investment reversed the major gains made during the 1980s, and private for-profit health care investments were concentrated in a few urban areas serving a minority of the wealthier population. The absence of a national health insurance system resulted in the 90% uninsured population having difficulties in accessing health services. Private health services were concentrated in a few vertically linked operations, sparking fears of anti-competitive behaviour, especially in the retail pharmaceutical sectors. Incentives given to private-for-profit health care providers did not lever public health gains, and the cost of both public and private health care soared, undermining access. The paper highlights areas for increased policy attention: for government to significantly increase public investment in health and control out of pocket expenditure; for the establishment of social health insurance; for the Ministry of Health to use its powers to monitor and regulate the expansion of private capital so that it serves policy objectives of universal coverage and equity. With powerful national interests gaining from profits in the health sector, including in the medical profession, monitoring and advocacy by communities is essential to engage on policy measures that protect equity and access. The paper further notes the regulatory role of the Competition and Tariff Commission.
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This study aimed to explore the understanding of and factors in adherence to ARV treatment in people living with HIV and AIDS (PLWHA) who are engaged in harmful alcohol use and to intervene on prioritised factors to improve adherence, using participatory research and action (PRA) methods. We sought to determine the perceptions of and understanding of alcohol abuse and ARV treatment among PLWHA, their peers, family members and health workers. We aimed to increase collaboration between the mental health workers from clinic and hospital level and the community to respond to identified barriers to improve adherence to ARV treatment in PLWHA who use alcohol in a socio-economically deprived urban area in Nairobi (Kariobangi). The work was implemented within an EQUINET programme that aimed to build capacities in participatory action research to explore dimensions of (and impediments to delivery of) Primary Health Care responses to HIV and AIDS. The majority of the PLWHA included in the study were socially disadvantaged, unemployed, and with low education. Social support was equally poor since a large number were widowed, separated or divorced. Most of the PLWHA who participated were single or divorced women, some of whom admitted that they sometimes engaged in commercial sex to cater for their basic needs. These factors, together with poor health, limited their economic opportunities and security. In this context, alcohol use, noted by PLWHA, community members and health workers to be prevalent in the community, is not only encouraged by poor living and social conditions, but also by cost (it is relatively cheap) and by the social pressure to use alcohol to escape the mental stress caused by poverty. This is exacerbated by social attitudes that do not discourage alcohol use, and misconceptions that in fact encourage alcohol use, such as that alcohol can kill the HIV virus. This study suggests that the problem of alcohol abuse is poorly recognised for both communities and health workers: It was generally under reported to services, with low numbers of people on ARVs reported to have alcohol related problems, so that health workers see only a small share of the problem. A survey of the local health centres providing ARVs showed that screening for alcohol use was not routinely done and protocols for managing alcohol related disorders were not available. For PLWHA on ARVs, there are already challenges in dealing with the timing, frequency of medication and appointments and the availability and cost of food to support treatment. For PLWHA who use alcohol these difficulties are compounded. There are a range of services in the community that could potentially address these barriers that are involved in nutrition, psychosocial, medical care, PHC, HIV prevention and treatment services, counselling, social, legal, information and referral support for PLWHA. However these do not explicitly deal with the treatment of alcohol and drug related problems in the community or the needs of PLWHA on ARVs who use alcohol, and their adherence to treatment. Reflecting on these problems, the participants implemented a programme of counselling and education. The health workers were taught how to use the AUDIT in identifying problem drinkers and how to recognise and manage alcohol related disorders such as withdrawal fits. The PLWHA and their family members were encouraged to support one another and to identify symptoms of harmful alcohol use among themselves. The process was perceived by those involved to have reduced the harmful use of alcohol in those involved; to have made some improvements in community and health service support; in management of mental health and communication with families and in reducing stigma around alcohol use and HIV. The scores of the PLWHA on the repeat AUDIT questionnaire were however significantly lower than the baseline level.
This work sought to identify the barriers to delivery, coverage and uptake of Prevention of Mother to Child Transmission of HIV (PMTCT) services at primary health care and community level and to generate improved demand for and utilization of PMTCT within Kamwenge sub-county in Kamwenge district and Mulagi subcounty in Kiboga district in Uganda. The work was implemented by HEPs Uganda within an EQUINET participatory action research programme and was mentored by Training and Research Support Centre (TARSC) in co-operation with Ifakara Health Institute Tanzania. Participatory methods were used to explore the barriers to using services to prevent vertical transmission and to identify actions to improve uptake. The findings suggested a need to emphasise couple counselling and testing; encourage local leaders to mobilise communities for antenatal care, PMTCT and other primary health care services and to address cultural barriers like male dominance. The baseline survey indicated that even where services are provided, while health workers may be effective in referring those who attend services for testing, PMTCT and ANC, there is a gap in people actually getting to services which breaks this link. Weak links are also made with some other maternal health services. Communities need to be involved in designing interventions that encourage male participation in demand and utilisation of testing and PMTCT services. This would appear to be a core element of any PHC oriented AIDS programme to prevent vertical transmission, as essential as other more biomedical elements.
Health care financing in South Africa is inadequate, and in recent years we have been moving away from achieving the Abuja target of 15% government funding for health care. This has resulted in numerous crises in the public health sector, and most South Africans (about 41 million) are unable to access decent, adequate health care, as enshrined in our constitution. South Africans that do access decent, adequate health care primarily do so through private funding (typically private health insurance schemes), but even in this sector, costs are spiralling and the package of benefits on offer is declining. To increase public health funding in South Africa, the government has proposed the introduction of a National Health Insurance (NHI) scheme. A recent national household survey found that 71% of medical scheme members were willing to join a publicly supported health insurance scheme if their monthly contribution was less than for current medical schemes. The NHI has been proposed to create a mechanism to level the playing field and create equitable distribution of resources resulting in high quality of health services for all the people. Universal access to a basic package of services for both the rich and poor will be achieved by the NHI and the costs of health care for poor and middle class South Africans will decrease. In-studio guests on a radio show discussing these issues were: Proffessor Di Mc Intyre, Health Economics Unit, UCT and EQUINET Fair Financing Theme Co-ordinator; Sheila Barsel, Policy Unit for the National Health and Allied Workers Union (NEHAWU); and Dr Siva Pillay, Member of the Parliamentary Portfolio Committee of Health in South Africa.
This paper was commissioned under the umbrella of the Regional Network for Equity in Health in east and southern Africa (EQUINET), led by the Institute of Social and Economic Research, Rhodes University (ISER) to map and review documented (secondary) evidence on capital flows in the health sector and their implications for equitable access to health care services between 1995 and 2007 in South Africa. The paper finds that private intermediaries channel more funds than the public ones, yet a significant proportion of the population meets health service costs through out-of-pocket payments, and for many this is catastrophic expenditure. There have been successful pro-equity measures to increase access to both public and private health care services e.g. through removal of barriers, such as user fees at primary health care (PHC) facilities, increased coverage of medical aid and through regulation of the private sector. However, inequities in access persist, as do geographical barriers to access. The period reviewed is one where expansion of both public and private sectors has taken place. The challenge remains to translate this into equitable use of available resources, or increased access to health services, especially for those with higher health need. Improved monitoring of health systems impacts of trends described in this paper is urged, given the significant share of private sector services in the public-private mix in health in South Africa.
While there is much promotion of private capital flows into the health sector in Southern Africa in reality these flows have been minimal. Private health is the fifth most promoted sector in African after tourism, hotels and restaurants, energy, and computer services. To understand flows of private capital behind the growth of the for-profit health care sector in SADC, EQUINET working through Rhodes University Institute of Social and Economic Research (ISER) and other institutions in the region are examining health sector capital flows in ESA. Despite the minor movements of capital in the ESA health sector, Mauritius, South Africa, Botswana and Namibia appear as the growth points for big capital, with the rest of the region relegated to the margins in terms of large investments. Investment potential exists in the pharmaceutical, hospital and hospital services sectors, but most of new FDI in health is in the pharmaceutical sector often for the production of ARVs to absorb large donor funds. The pharmaceutical sector has also had the most significant amounts of overt privatisation of all health-related sectors, either through selling fixed assets or transfer of equity. The report argues that South Africa is likely to be the biggest destination for investment in health care, and the major regional source of private FDI flows to the health sector in ESA countries.
Policies in Malawi explicitly mention the need for focus on services for commercial sex workers (CSWs) because of their susceptibility to HIV infection and the potential risk they have of spreading the virus. This study aimed to explore and address barriers to coverage and uptake of HIV prevention and treatment services among CSWs in Area 25 Lilongwe district, Malawi, using Participatory Reflection and Action (PRA) methods. The work was implemented within a programme of the Regional Network for Equity in Health in east and southern Africa (EQUINET co-ordinated by Training and Research Support Centre (TARSC) in co-operation with Ifakara Health Institute Tanzania, REACH Trust Malawi and the Global Network of People Living with HIV and AIDS (GNPP+). An initial baseline survey in 20 health workers and 45 CSWs showed high knowledge but poor rating of access and uptake of HIV prevention, testing and treatment services, due to both barriers in the community and in the services themselves. A PRA process drew out further detail and experiences of the barriers faced, with priorities identified as: lack of early treatment seeking practices amongst CSWs; ill treatment of CSWs at health facilities by health practitioners; and lack of adherence to treatment by most of CSWs. The PRA process raised issues of the gender violence and abuse that CSWs face (including through attitudes and practices in health care services) that dehumanise them and perpetuate their own harmful behaviours. The group of CSWs and health workers as a whole identified interventions that were immediate and feasible to address the three barriers they prioritized. An intensive intervention, involving door to door counseling, engagement at places of work, formation of joint committees between CSWs and health workers and sensitization of health workers was implemented, steered and reviewed by the team with the CSWs and health workers themselves. Health workers and CSWs reported in a follow up survey improvements across all areas in the assessed baseline, except for quality of health services. Health workers reported improvements in the same areas noted by the CSWs, although their rating of improvements were generally a little more modest than the CSWs. We suggest that a public health PHC oriented approach to services for CSWs recognize, listen to, involve and build capacity in CSWs and ex-CSWs, and the civil society organisations that work with them, as a primary group for reaching and mobilizing uptake of services in CSWs.
A regional meeting was held to bring together the cross section of stakeholders from WHO/AFRO, SADC, ECSA-HC, EQUINET, government officials and researchers from the region to develop a harmonized approach for follow up research on health worker migration. The workshop report outlines the discussions and protocol developed to: highlight the key policy issues arising nationally, regionally and globally on the impacts of health worker migration on health systems; and identify key evidence gaps in negotiation of policy and agreements relating to protecting negative health systems impacts of health worker migration; review existing conceptual frameworks, parameters and indicators used for assessing health worker migration flows and for assessing dimensions of health systems; propose a conceptual framework and parameters for measuring impacts of health worker migration on health systems; review existing research initiatives on health worker migration in the region, the methodologies (design, tools) used, their limitations, and discuss and develop a shared standardised method for capturing evidence and analysing the impacts of health worker migration on health systems; and identify research capacities (research teams, funding, and political will) for the follow up work on health worker migration in the region, and a coordinated and harmonised approach to follow up research on health worker migration in the region.
A reminder to all who have registered that the third EQUINET Regional Conference on Equity in Health in East and Southern Africa is coming up next month! It provides a unique opportunity to hear original work and debate on the determinants of, challenges to and opportunities for equity in health in this region. The programme is broad and covers a range of topics including claiming rights to health, equitable health services, women’s health and social empowerment in health systems. Other main topics include retaining health workers, primary health care, developing and using participatory approaches, resourcing health systems fairly, building parliamentary alliances and people's power in health, policy engagement for health equity, trade and health, access to health care and monitoring equity. We will also show how to build country alliances and conduct regional networking. A post-conference workshop will be held on BANG (bits, atoms, neurons and genes), billed the Next Technological Challenge to Africa’s Health and Well-being. Further activities associated with the conference include photographic displays and skills meetings. Registration has closed, but the abstract book for the conference will be posted to the EQUINET website after the conference and a report will be produced from the conference that will also be on the site. Registered conference delegates should have received information on their delegate status, an information sheet on the conference arrangements and delegates sponsored for travel should have received their e tickets. Letters have been sent to those who need visas. For any queries around visa's or local arrangements please contact gloevents@infocom.co.ug. Speakers have been briefed by their session convenors. If you have not received relevant information above please contact admin@equinetafrica.org. To see the conference programme visit www.equinetafrica.org/conference2009/programme.php.
This work was implemented in Kasipul Division, Rachuonyo District, Kenya, where high poverty levels lead to food insecurity exacerbated by rising food prices, by the consequences of two devastating tropical storms and soaring transportation costs. Few PLWHIV own farms, or produce a marketable surplus, and illness and malnutrition interact in a vicious cycle. KDHSG and RHE implemented a participatory action research programme, within EQUINET, to explore dimensions of (and impediments to delivery of) Primary Health Care responses to HIV and AIDS. It used a mix of PRA and quantitative approaches to; • Identify the nutritional needs, issues and responses for PLWHIV on treatment • Increase voice and participation of PLWHIV and communication with health workers on their nutritional needs in relation to treatment and on responses to these needs in the clinics and community • Increase the capacity of health workers and community to identify specific areas for engagement of partners outside the health sector on intersectoral responses to support nutritional inputs for PLWHIV on treatment. This work indicates that expanding access to treatment services needs to be embedded within a wider framework of wider health support, including the intersectoral action to address food needs, if availability is to translate into effective coverage. Nutrition support is a vital element of the chronic care and health management strategies needed for PHC responses to AIDS. This includes shifting perception of PLWHIV from that of disabled dependents of emergency support to people able to know and address their nutritional needs through local food resources.