The promotion of universal coverage means that health systems should seek to ensure that all citizens have access to adequate health care (adequately staffed with skilled and motivated health workers) at an affordable cost and which improve both income cross-subsidies (from the rich to the poor) and risk cross-subsidies (from the healthy to the ill) in the overall health system. This stems from our understanding of equity, which requires that people should contribute to the funding of health services according to their ability to pay and benefit from health services according to their need for care. Prior work in the fair financing theme in the network indicates that there is still a heavy dependence on donor funding in some east and southern African (ESA) countries and heavy burdens on poor people through high levels of out of pocket financing. There have been efforts to increase domestic funding of health services, and a number of countries are increasing government funding of health services. The Health Economics Unit, University of Cape Town and HealthNet Consult Uganda used evidence from work done in the past 5 years on tax and mandatory health insurance sources of domestic resource mobilisation as inputs to a regional research and policy review meeting in September 2009. The meeting presented and reviewed research, implemented in and beyond the network, on domestic public resource mobilisation; examined policy options, and country experiences in and barriers to improving domestic public resource mobilisation, with a focus on ‘success stories’ where countries have been successful in motivating for greater allocation of public resources towards the health sector. The meeting was held in Uganda just prior to the EQUINET Regional conference to connect delegates to the conference and to input into the wider network of equity actors and debates at the conference. The meeting identified knowledge gaps for follow up research, including on gender dimensions.
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Over the last five years the Regional Network For Equity In Health In East and Southern Africa (EQUINET) has generated a range of analyses of specific policy experiences in Southern and Eastern Africa and has developed the understanding and skills necessary to conduct this sort of work. Other work conducted by EQUINET, such as around governance and participation, is also relevant to understanding how to strengthen health system decision-making in ways that support health equity goals. It is time, now, to take stock of the range of health policy analysis work in Africa – and to draw out lessons from past experience, as well as identify new challenges for the years ahead. This workshop took place as part of the pre-conference activities of the EQUINET conference September 2009 on Reclaiming the Resources for Health. It was convened by Lucy Gilson, School of Public Health and Family Medicine, University of Cape Town and Ermin Erasmus, Centre for Health Policy, The University of the Witwatersrand. The workshop aimed to: reflect on health policy analysis and its role in health system development; share experience in the use of health policy analysis to support policy development and implementation; share experience in teaching health policy analysis (in short course, post-graduate programmes etc); and develop shared ideas of how to strengthen this field of work in Africa. It provided an opportunity to reflect on health policy analysis and its role in health system development. Participants shared experience in the use of health policy analysis to support policy development and implementation and on teaching health policy analysis. In the workshop participants shared ideas of how to strengthen this field of work in Africa. The workshop was held as a pre-conference workshop to the EQUINET Regional Conference and involved delegates drawn from the conference and thus the wider regional work on equity in health.
Over 200 government officials, parliamentarians, civil society members, health workers, researchers, academics and policy makers, as well as personnel from United Nations, international and non-governmental organisations from East and Southern Africa and internationally met at the Third EQUINET Regional Conference on Equity in Health in East and Southern Africa, held 23–25 September 2009 in Munyonyo, Kampala. This document presents the resolutions of the conference for action on equity in health.
As part of its ongoing skills development programme, the Regional Network fort Equity in Health in East and Southern Africa (EQUINET) has committed to developing the writing skills of health equity researchers in the region, particularly with regards to writing for peer-reviewed journals, as well as for improving writing skills on EQUINET discussion papers. This workshop took place as part of the post-conference activities of the EQUINET conference September 2009 on Reclaiming the Resources for Health. It was convened by Rebecca Pointer under the auspices of the Training and Research Support Centre. The workshop used the EQUINET writing skills raining manual found as its core resource material. It sought to equip researchers with a basic step-by-step approach to writing for peer-reviewed journals, and to approach scientific writing as a routine process. The participants were those working on publications in areas related to health equity from countries in east and southern Africa.
This paper presents a summary of the regional programme on incentives for health worker retention in the Regional Network for Equity in Health in East and Southern Africa (EQUINET) in co-operation with the East, Central and Southern Africa Health Community (ECSA-HC). The studies sought to investigate the causes of migration of health professionals, the strategies used to retain health professionals, how they are being implemented, monitored and evaluated, as well as their impact, to make recommendations to enhance the monitoring, evaluation and management of non-financial incentives for health worker retention. They aimed to have some comparability in design to share learning. The findings revealed that all four countries studied (Swaziland, Zimbabwe, Tanzania, Kenya) have put in place strategies to improve morale and retain staff in the public health sector. They were designed after some assessment of the drivers of attrition, often through prior surveys of push/pull factors. All the countries studied were applying a mix of non-financial incentives according to their strategies and plans, although implementation was not always uniform at all levels or for all cadres, or reached all those cadres intended. All implement non-financial incentives, together with some form of financial incentives. All studies indicated the presence of policies providing for non-financial incentives. The country studies observed that incentives were not uniformly applied to all health workers, and did not always reach all in the target category. The studies indicated a need to intensify focus on issues of operationalising and implementing non-financial incentives: moving from inserting incentives in policies and strategies to ensuring their application across all providers; moving from focused application for specific cadres of health workers to sector wide application of incentives for all health workers; and moving from experiments within the health sector to more sustained multi-sectoral policies that involve other sectors, including public service, finance, public works, education and housing. The results of the work were reviewed at a regional meeting to review the findings from this body of work and to explore the implications for policies and measures aimed at valuing and retaining health workers in ESA, develop proposals and guidelines for policy and action relevant to health worker deployment and retention, and identify knowledge gaps for follow up work. The recommendations from this meeting are presented.
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.
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.