User fees are once again a hot topic of policy debate. This time the question is whether to remove primary care fees. At its conference in June this year, EQUINET took a clear position on the issue. We called for these fees to be removed. But we also stated that this action is not a cure-all for the problems facing health systems in Africa. User fee removal must be accompanied by actions that increase overall national resources for public sector health services and that deal with international conditions and policies that undermine this.
The two reasons why primary care fees must go are that:
- They contribute to the unaffordable cost burdens imposed on poor households;
- They signal to poor households that society does not care about them.
Fees at primary care are relatively low. Even so, there is widespread evidence to show that fees encourage self-treatment (using herbs or poor quality medicine bought in unregulated market places), deter people from taking full doses (so increasing the chances of drug resistance), and act as a barrier to early, or even any, use of health facilities. In these ways the small level of fees can increase the costs poor people bear when ill. So even though fees represent a smaller proportion of the total costs of accessing health care than transport or lost income, they contribute to levels of cost burden that can, in some instances, impoverish poor households. At one level, impoverishment results from selling key assets, cutting down on other necessary expenditures, or borrowing, often at exorbitant interest rates, to pay for health care. At another level, charging fees adds cost to the other immense barriers of accessing care, such as distance and abusive treatment. It signals to poor people that they are not valued or cared for by society.
However, removing primary care fees is not enough by itself to tackle the range of existing health care challenges in Africa. Other actions are also required.
First, the levels of funding available for health care must be increased. At least 15% of government budgets should be invested in the public health sector, as committed by African governments in Abuja. Only one country in southern Africa, Mozambique, is currently reported to be achieving this. This will support the sustained quality increases necessary to improve health system performance, as well as allowing the system to respond effectively to the utilization increases likely to result from fee removal.
Linked to this African country debt should be cancelled. The EQUINET June 2004 Conference called for international action to remove the debt burdens imposed on African countries, and for national action to increase the level of government funding to health systems. These changes in financing also need to be underpinned by changes in terms of trade for African countries that result in huge resource outflows from Africa, including market barriers in industrialized countries to trade in food products and the poaching of health personnel.
Second, the removal of fees must be undertaken in a way that actively strengthens the health system.
In particular, the responses of health workers and managers must be deliberately managed to avoid negative impacts on morale and performance. As front-line providers and managers are the point at which patients meet the health system, their morale and performance has a direct influence over how patients experience health care, and how policies are implemented. In South Africa, while the removal of fees had a powerful positive effect on health outcomes, health workers said they were not adequately informed or involved, and were thus unprepared for the resulting increases in utilization. This can lead to unnecessary tensions at primary care level, and patients complaining that health workers treat them badly. In countries where fees have been retained, they have allowed managers and local communities some control over the decision of how to use the revenue. In others they have been used to fund agreed incentives for staff. These issues need to be managed and alternative ways found of providing for local resource control and staff incentives to avoid demoralisation.
Experience from a wide range of policy actions indicates that managing this policy change must involve:
1. Giving a specific government unit the task of implementing fee removal in ways that strengthen the health system;
2. An effective public relations campaign to communicate the change with the general public, and to signal that removal of fees is about valuing patients and providers;
3. Ensuring that the policy goals are clearly explained to managers and health workers to promote support for the policy at all levels of the health system;
4. Preparatory planning to ensure adequate levels of drug and staff availability to cope with the likelihood of initial utilization increases -
and longer-term planning for how to tackle wider drug and staffing, including motivation, problems;
5. Establishing new, manager-controlled funds at local level that allow management freedom on small-scale spending decisions;
6. Clear communication with health workers and managers about what and when actions will be taken - through meetings, supervision visits, special information letters;
7. Expect that there will be unanticipated problems with implementation, and so set up monitoring systems that provide a basis for identifying what other actions need to be taken: monitoring utilization trends, including the relative use of preventive versus curative care, and giving health workers and managers opportunities to feed back on health facility experiences.
Tackling the human resource barriers to effective fee removal will inevitably require the wider action that is necessary to address the overall human resource crisis in Africa. On this issue EQUINET has called for human resource policies and measures at national, regional and international level that promote the retention and improved working conditions of health personnel in public sector health systems, backed by compensation for regressive south-north subsidies incurred through health personnel migration. An editorial later this year will provide more detail on this.
User fee removal clearly provides an opportunity to begin to address the needs of poor people. However, their removal is not enough by itself. EQUINET calls for this to be backed at national level by increased public financing for health and at international level by a cancellation of debt. In addition, user fee removal must be implemented in ways that strengthen the health system. User fees were actively promoted internationally during periods of efficiency and market led health sector reforms that produced a huge cost to equity in health in southern Africa. User fee removal must be underpinned by actions at international and national levels that provide for the resources to achieve human rights to health and health equity goals.
* Information on EQUINET work on fair financing is available on the EQUINET website at www.equinetafrica.org EQUINET welcomes feedback to its editorials, suggestions, information and follow up enquiries to the EQUINET secretariat at TARSC, email admin@equinetafrica.org
1. Editorial
2. Latest Equinet Updates
This summary document presents: The principles for ensuring universal treatment access through sustainable public health systems; The major findings and issues from the work carried out in southern Africa on equity in health sector responses to HIV and AIDS, particularly in terms of access to antiretroviral treatment; The key challenges for follow up work identified at the southern African regional meeting on Strengthening Health Systems for treatment access and equitable responses to HIV/AIDS, in Harare, Zimbabwe, February 2004.
It is six years since EQUINET was formed to support the Southern African Development community (SADC) in its commitment to secure equity in health. In those six years many challenges have been faced, much has been achieved and much remains to be done. This report from the EQUINET steering committee faces the future squarely in the eye. It details the opportunities for equity that lie in the region and highlights the obstacles to equity that we must confront. It offers a vision of health systems that serve equity. It presents a rallying call for those striving to work for justice hand in hand with the poor and marginalised.
3. Equity in Health
Since the Kyafukuma Rural Health Clinic (RHC) in northwestern Zambia closed its doors in 2000 after the old building collapsed, villagers have had to make do with a cramped inadequate clinic. Now, growing frustration over the lack of satisfactory medical care has led to a community-driven initiative that promises improved access to health care. After years of waiting for the reopening of the RHC, a joint project by the state-sponsored Zambia Social Investment Fund (Zamsif) and local people is expected to hasten completion of a new RHC, including the construction and rehabilitation of quarters for five staff members.
"On 2 - 4 July 2004, more than 530 delegates - including more than 80 health workers and representing over 60 organisations and institutions - met at the first People's Health Summit (PHS) to discuss the crisis and inequity in the health system and the roll-out of antiretroviral (ARV) treatment. While recognising the impact of the legacy of injustice and inequality of apartheid on the health service of our country and our people, delegates to the PHS expressed grave concern that in spite of many good policies, laws and programmes, the public health service is in crisis and the quality of many services is in decline."
The second Equity Gauge seeks to place the goal of equitable health care within a broader framework that links socio-economic disparities with health outcomes. This publication highlights the fact that people do not get sick at random and that health is intimately tied up with living and working conditions. In focusing on this interdependence of socio-economic determinants with health outcomes, the document also points to the relationship between health status and geographical, racial and gender-related issues.
Political prevarication and weak management has hampered the implementation of the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa a new report has found. The preliminary report is the first in a series that will monitor the implementation of the Operational Plan. The report, researched and produced by the AIDS Law Project and the Treatment Action Campaign, deals with the first seven months since the Department of Health’s announcement of the Operational plan in November 2003.
The promotion of equity in health is one of the basic ideologies underlying South African health policy. Therefore, it is befitting after ten years of democracy to gauge how far the health system has moved towards providing equitable health services to all citizens is concerned. This 2003/04 South African Health Review, the 9th edition, consists of an overview and 24 chapters, each describing a key health concern. Unlike many of the previous Reviews, this year's is data driven. It uses different sources of information to measure and assess the health and well-being of South Africans quantitatively. An overview of the key achievements and challenges is given in the chapter Ten years on have we got what we ordered?
The health delivery capacity of public health institutions has been adversely affected by the poor economic environment and some clinics and hospitals are now operating without essential drugs and medical supplies. Zimbabwe's public health sector - once the best in sub-Saharan Africa - is now reeling as a result of neglect and inadequate funding by the government.
4. Values, Policies and Rights
Tradition and culture, the determination and ingenuity of women, and the concern and commitment of health care providers often circumvent the law to find expression. For example, though legal reform is not yet feasible in Mozambique, three large public hospitals have begun to provide elective abortions.
"I believe that we are at a turning point for public health - and that our choices are stark: either we reorient and strengthen public health within both modern and developing societies and institute a resilient system of global governance for health or we will face dire consequences in terms of human, social, and economic development. At present, it is the poorest countries that are paying the price for this negligence - but we have mounting signals that a new health divide is in the making as a large global underclass spreads out around the globe and defies the old definitions of vulnerable groups."
5. Health equity in economic and trade policies
In the last two months we have seen concerted attempts at reviving global trade talks which collapsed in Cancun, Mexico last year. This article from the SEATINI bulletin argues that the Doha round cannot be about anything other than development. At any rate, the Marrakesh Agreement which established the WTO speaks of a “need for positive efforts designed to ensure that developing countries and especially the least developed countries among them secure a share in growth in international trade commensurate with the needs of their economic development.” The outcome of any negotiations cannot be considered legitimate if they trash the concerns of the poor countries.
Jeffrey Sachs, special adviser to U.N. Secretary General Kofi Annan on anti-poverty targets, said Africa's heavy debt burden was untenable and urged the continent not to pay its debts if rich countries refused to cancel them. The U.S. economist, director of the Earth Institute at Columbia University, spoke at a conference in Addis Ababa, Ethiopia, on hunger on the eve of a summit of the heads of state of the African Union, which estimates sub-Saharan Africa's foreign debt at $201 billion.
6. Poverty and health
The Chronic Poverty Research Center's latest report examines what chronic poverty is and why it matters, who the chronically poor are, where they live, what causes poverty to be persistent and what should be done. A section of regional perspectives looks at the experience of chronic poverty in sub-Saharan Africa, South Asia, Latin America and the Caribbean, transitional countries and China. The report argues that the chronically poor need targeted support, social assistance and social protection.
Sub-Saharan Africa is the only region in the world where the proportion of people living in extreme poverty has continued to grow for 20 years, Reuters reports. In its annual Industrial Development Report released on Tuesday, the United Nations Industrial Development Organization (UNIDO) described the region as "the last frontier in the fight against abject poverty" and said the international community and the countries concerned needed to step up efforts to promote economic growth there. The rate of absolute poverty - people living on one dollar a day or less - in Sub-Saharan Africa is nearing 50 percent.
By 2010 more than one in five children in Botswana, Lesotho, Swaziland and Zimbabwe will be orphaned by AIDS, a joint UN and US report warned. "Children on the Brink 2004" is the fourth edition of this biennial report, based on surveys conducted by the UN Children's Fund (UNICEF), the UNAIDS and the US Agency for International Development (USAID). Alarmingly, the studies found that 20 percent of households with children in Southern Africa were taking care of one or more AIDS orphans.
* Children on the Brink report
http://www.unicef.org/publications/index_22212.html
7. Human Resources
Although the Organisation for Economic Co-operation and Development (OECD) member countries generally favour long-term policies of national self-sufficiency to sustain their medical workforce, such policies usually co-exist with short-term or medium-term policies to attract foreign physicians. As this is likely to continue, there is a need to create a global framework that enforces physician migration policies that confer benefits on home and host countries. In the long-term, OECD member countries need to put in place appropriate education and training policies rather than rely on physician migration to address their future needs.
"The nations of the world are setting ambitious health and development goals, including the World Health Organization (WHO) target of providing AIDS treatment to 3 million people by 2005 and health-related UN Millennium Development Goals. Unless greater attention by donors and governments is given to developing human resources, these goals almost certainly will not be met. Many of the countries in sub-Saharan Africa, the region that will be the focus of this report, are experiencing severe shortages of skilled health care workers. There are multiple causes, the significance of which varies by country, but one of the most important factors is brain drain. Brain drain is defined in this report as the exodus of health care workers from developing nations to the wealthier countries of the North."
The quality of health care is hugely dependent on the skills of health professionals. Clinical skills centres are neutral and protected settings in which a variety of skills and techniques can be taught. In developing countries, resource constraints and pressure to direct skilled staff away from teaching to working in health service facilities can limit the opportunities for developing and implementing an effective training curriculum.
8. Public-Private Mix
Contracts can be used to govern the relationship between the public and the private sectors where the private sector delivers services on behalf of the state. On occasion, this allows the state to offer services such as basic medical provision where public sector provision does not reach. Researchers examine the case of primary care in South Africa where such contracts are being utilised. They argue that understanding the relationship between client and contractor requires a thorough understanding of some of the factors that govern the relationship, such as the role played by individual motivation.
The market for primary health care in South Africa represents a growing opportunity for private providers targeting lower income employed workers, who often prefer not to use the public sector. A new model of service provision is emerging in the form of private companies providing fixed price primary care services in urban areas. Whilst the range of services delivered was quite limited compared to the public sector, apparently effective delivery, clearly better patient experiences, and a similar cost to the public sector, all suggest that the public sector can learn about some aspects of service delivery from these companies.
The growing movement in favour of the privatisation of public services and the reliance on market forces in many developing countries suggests that the critical role of the district health system needs to be restated. Research by the Institute of Development Studies, UK, indicates that district health services are the best means of delivering primary health care and basic hospital care and should be made a priority for public funding. The most important task is to develop a special programme of rehabilitation for a demoralised workforce, including improved management of staff mix and distribution, incentives for good performance, support and training as well as better pay.
9. Resource allocation and health financing
This PRHPlus article outlines the key advantages of using the National Health Accounts (NHA) Subanalysis to track resource flows for HIV/AIDS. In light of the HIV/AIDS epidemic, many countries are facing increased pressure to expand health care resources with limited and unreliable public funding. While global initiatives have responded in part to these concerns, there is growing need to use available funds efficiently, and to track resources which promote transparency and accountability. The authors maintain that financial indicators to track resource use, which link to health outcomes, are an integral part of the monitoring and evaluation strategy.
10. Equity and HIV/AIDS
In late 2003, largely as a result of pressure exerted by TAC, the government formally committed itself to rolling out HIV treatment. This policy shift has posed several questions related to TAC’s interim and long term political future, given the reality of the roll-out. Will the ‘centre fail to hold’ as factions emerged in the politically ‘broad umbrella’ social movement that is TAC? Will it simply become a service-delivery focused NGO working for the Department of Health? Will the government’s commitment to HIV treatment policy reform lead to TAC’s co-option? Will it render itself obsolete through its own success lobbying for wider HIV treatment access?
"Yesterday, July 11th, at the opening of the Conference, UN Secretary-General, Kofi Annan, used the words "a terrifying pattern" to describe the toll that the pandemic has taken on the women of the world, and the women of Africa in particular. He was both scathing and unsparing in his characterization of male behaviour which has led to the carnage. In the process of his remarks, he talked particularly of the vulnerability of young women and girls in Africa, the 15-24 year-old age group, and then noted that on a world-wide basis, the numbers of women and girls in that age group represented nearly two-thirds of the total infected."
Ongoing coverage of the International AIDS Conference in Bangkok is bewildering to those who are familiar with the current political battles in the HIV/AIDS arena, and no doubt disheartening or annoying to those reading from a distance. The AIDS industry is in full swing: government forces delivering glittering generalities; actors and ex-presidents discussing their "outrage" while eating five-course dinners in Bangkok hotel penthouses.
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11. Governance and participation in health
Communities are no longer seen as passive recipients of healthcare. But what does this shift in emphasis mean? What kind of relationship between communities, service providers and managers is best? A workshop held at the Institute of Development Studies in 1999 asked three questions: What does accountability mean? How can health service providers be accountable to their users? What sorts of partnership will improve accountability and effectiveness? Studies from eleven countries illustrated experiences with participatory approaches and partnerships in enhancing accountability in the health sector.
This paper examines the way that a range of development actors view and engage with the arena of trade policy, focusing in particular on the challenges encountered by civil society actors participating in that arena. The dynamics of civil society participation in the trade arena – what might be achieved, and how – are very different from those that shape civil society participation in processes labelled poverty reduction; this paper explores the differences.
12. Monitoring equity and research policy
This paper examines some recent yardsticks used to sort the evidential sheep from the research goats by questioning why, how and when such research standards should be brought to bear. It concludes that the drive to cast standards as formal checklists of quality indicators is premature, and that appraising quality is not and cannot be a technical preliminary to research synthesis. Open and critical debate on the interpretation of research findings remains the surest way to establish and maintain investigatory standards.
The use of international comparisons is an essential element of modern, professional policy making. Looking abroad to see what other governments have done can point us towards a new understanding of shared problems; towards new solutions to those problems; or to new mechanisms for implementing policy and improving the delivery of public services. This toolkit pack is intended to provide help and guidance in the use of international comparisons in policy making.
13. Useful Resources
You can now download selected content from the latest issue of The Lancet to read at your leisure on your mobile device - PDA, wireless PDA or smartphone.
The Science and Development Network (SciDev.Net) has launched two new online 'spotlights' on the science of HIV/AIDS, dealing specifically with the topics of microbicides and vaccines. The spotlights provide an overview of the issues in relation to developing countries through the latest news, summaries of key reports and links.
* Vaccines:
http://www.scidev.net/hiv/vaccines
* Microbicides
http://www.scidev.net/hiv/microbicides
IRHMedEd is a new forum for people actively working in preservice medical and health education in international reproductive health (IRH). IRHMedEd aims to strengthen the growing community of experts in this field by facilitating a global dialogue and creating an environment for exchanging lessons learned, sharing resources and ideas, solving individual and common problems, and advancing the field of IRH Medical Education.
14. Jobs and Announcements
Organised by the South African Health Informatics Association, in conjunction with the Computer Society of Southern Africa, the theme of the conference is: "Health Informatics - Southern Africa" Tracks within the conference include discussions on open source initiatives, monitoring of ARV rollout, standards and electronic interchange.
This is an established course directed by Professor Gavin Mooney, a leading international educator in health economics and designed for health care professionals seeking a professional edge. It is open to fee paying international and Australian students.
AIDS researchers from institutes in developing countries now have a new peer-reviewed outlet in which to publish their findings, with this week's launch (7 July) of the e-Journal of the International AIDS Society (eJIAS). eJIAS is the collaborative joint product of the International AIDS Society (IAS) and Medscape, an online provider of medical news.
PLoS Medicine, is a new journal from the Public Library of Science (PLoS). As an open access journal, articles in PLoS Medicine will be immediately and always freely available online from our website and from PubMed Central. Publication is monthly, with a first issue in Autumn, 2004, and submissions are now being accepted.
The World Health Organization is recruiting young health professionals to a two-year work and training programme, specifically aimed at strengthening the knowledge and skills essential for leadership roles in public health at all levels - international, national and local. The global effort to combat poverty, inequities, disease and epidemics calls for dynamic and capable leaders. These future leaders need to start their careers today, and they need continually to build their competences as their responsibilities increase.
Published for the Network for Equity in Health in Southern Africa by
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