An EQUINET partner, the Centre for Health Policy at Wits University, has released a report examining policies in the SADC region on the retention of human resources for health. This report has been prepared for the Health Systems Trust (HST), South Africa and the Regional Network for Equity in Health in Southern Africa (EQUINET). It presents a review of issues in the regional policy context that are of relevance to the retention of human resources for the health sector (HRH) within the region, based on a rapid appraisal in selected countries and at regional level.
This work specifically focussed on the actions needed to stem the flow of international migration by encouraging the retention of health staff within countries. A particular concern raised across countries is staff retention in the public and rural services that preferentially serve the poorest populations. Importantly, policy documents and national respondents see the problems of retaining staff in these locations (the push factors underlying migration) as linked to the factors that undermine motivation and productivity. Policies to address retention issues (and so encourage health workers to stick and stay in country settings) are, thus, also likely to address poor motivation and weak productivity. In addition, these three sets of problems often go hand in hand with poor health worker attitudes and behaviours towards patients. So tackling these problems may have double benefits for health system performance – contributing to adequate availability of competent staff, as well as enhanced staff responsiveness to patients.
The report presents the findings of this work in sections 3-5 covering:
- Review of current international and regional HRH policy initiatives of relevance to the Eastern and Southern Africa region;
- Review of national level policy environments, with specific consideration of Malawi, South Africa and Tanzania;
- Implications for the future role of EQUINET in supporting implementation of HRH policy initiatives within the region.
In summary, the report notes that:
- encouraging HRH retention requires a complex package of actions/ /working through different entry points, rather than single policy actions;
- implementation of any HRH retention policy package is challenging because of the need to coordinate efforts across a wide range of governmental actors as well as get the support of a range of external actors;
- regional co-operation to support country level action to encourage retention appears to be, as yet, little developed, although recent discussions within the African Union and SADC, provide possible bases for such co-operation;
- current international initiatives may provide regional opportunities for addressing HRH problems (as a core constraint on health system development), but also hold the danger of over-burdening health systems, and in particular leadership and management within them.
In supporting initiatives to promote HRH retention within the region we suggest that EQUINET could, in broad terms, engage with others in providing a focal point for regional networking in support of HRH policy action. Such networking could, more specifically, focus on two sets of activities (see section 5 for details).
First, analytical work could fill current gaps by supporting cross-country analysis of the implementation of financial incentives, developing ideas and proposals around how to strengthen non-financial incentives and monitoring the impact at country level of externally driven initiatives on HR issues or initiatives (such as those for HIV/AIDS) likely to have impact on HR.
Second, dialogue and engagement with key actors (such as parliamentarians, senior health and other civil servants, professional groupings) could be supported by the development of policy briefs on key issues and collaboration with WHO AFRO, SADC, NEPAD and the AU.
* The report, which is available from http://www.equinetafrica.org/bibl/page.php?record=594, was presented at a "Policy and research meeting on equity in the distribution of health personnel in southern Africa" in August. The meeting:
- provided an update and recap on major policy issues and positions on HRH in east and southern Africa at the country and regional level;
- presented brief summaries of the work that has been done under auspices of EQUINET;
- identified policy positions and issues that require further research;
- explored capacity building and policy intervention within the region;
- identified priority issues in order to deliver clear agendas for action; and
- identified some key collaborations to assist in taking the work forward effectively.
The meeting report will be available on the EQUINET website at the end of September.
1. Editorial
2. Latest Equinet Updates
The Health Economics Unit at the University of Cape Town is offering a 5-day short course addressing the changing role of health insurance in low- and middle-income countries. The course focuses on the financial management of risk pools in diverse settings covering a broad spectrum of insurance arrangements including community-based health insurance, private voluntary insurance for the formal sector and social or national health insurance.
This briefing describes the programme of student research grants in EQUINET and invites applicants for the third round of grants. The Regional Network for Equity in Health in Southern Africa (EQUINET) promotes policies for equity in health across a range of priority theme areas (See www.equinetafrica.org) EQUINET has over the years, organized its work in various theme areas, including: economic and trade policy and health; human rights, governance and participation, equity in health sector responses to HIV/AIDS, human resources for health; monitoring and surveillance and others. Within these areas of work EQUINET aims to identify, recruit and build capacity and analysis. After a successful pilot initiative in 2003 in co-operation with the Malawi Health Equity Network member in the EQUINET steering committee, EQUINET has now launched a programme of student research support that provides small research grants for students at college or university in various programmes in east and southern Africa.
3. Equity in Health
The World Summit is expected to bring together more than 170 Heads of State and Government: the largest gathering of world leaders in history. It is a once-in-a-generation opportunity to take bold decisions in the areas of development, security, human rights and reform of the United Nations. Proposals in the area of development call for breakthroughs in debt relief and trade liberalization, and increases in aid to revitalize infrastructure and improve health and education services, in order to achieve the Millennium Development Goals (MDGs), including cutting extreme poverty in half by 2015 (www.un.org/millenniumgoals ).
As the prices of first-line anti-AIDS medication continue to fall, newer antiretrovirals (ARVs) can cost up to 12 times more in sub-Saharan Africa, according to a report by Medecines Sans Frontieres (MSF). Paediatric formulations were also more expensive than adult ARV drugs: treating a child for one year could be as much as US $816, while the same triple-drug regimen for adults was only $182.
The report, Health and the Millennium Development Goals, presents data on progress on the health goals and targets and looks beyond the numbers to analyse why improvements in health have been slow and to suggest what must be done to change this. The report points to weak and inequitable health systems as a key obstacle, including particularly a crisis in health personnel and the urgent need for sustainable health financing.
The fifty-fifth session of the WHO Regional Committee for Africa ended August 26 in Maputo, Mozambique, with the adoption of six resolutions, including one declaring tuberculosis (TB) a “regional emergency” and the other, proclaiming 2006 as the “Year for Acceleration of HIV Prevention.” The resolution declaring TB a regional emergency called on Member States to undertake “urgent, extraordinary and intensified actions” to bring the epidemic under control.
Mozambique and South Africa are to sign a health cooperation agreement, allowing the exchange of knowledge on diseases such as HIV/AIDS. Mozambican Health Minister Ivo Garrido and his South African counterpart, Manto Tshabalala-Msimang, met in the Mozambican capital, Maputo, to finalise details of the agreement.
A new Bangkok Charter for Health Promotion has been adopted by participants at the 6th Global Conference on Health Promotion, co-hosted by the World Health Organization (WHO) and the Ministry of Public Health of Thailand. It identifies major challenges, actions and commitments needed to address the determinants of health in a globalized world by engaging the many actors and stakeholders critical to achieving health for all. The Charter highlights the changing context of global health and the challenges faced in achieving its aims, including the growing double burden of communicable and chronic diseases which include heart disease, stroke, cancer and diabetes.
The member countries of the Southern African Development Community (SADC) are to adopt an integrated strategy to fight against malaria. For this the organization counts on the financial support of 30 million US dollars, granted by the African Development Bank (ADB), which will also be used in cross-border interventions for other communicable diseases, including HIV/AIDS and tuberculosis.
4. Values, Policies and Rights
Lynn Freedman argues in the journal Development that achieving the MDGs will require massive new investment in the health sector but also notes that success is not only about money but also the way in which the connection between health and development is constructed. She writes: "This is the hidden opportunity of the MDGs: With health recognized as a central part of a wider development agenda, we have a chance to push past the conventional target-based public health approach and to re-ground health policy in the most critical debates of the day, including globalization, human security, equity, human rights, and poverty reduction."
"One-third of all human lives end in early death from poverty-related causes. Most of these premature deaths are avoidable through global institutional reforms that would eradicate extreme poverty...The rules should be redesigned so that the development of any new drug is rewarded in proportion to its impact on the global disease burden...The existing medical-patent regime (trade-related aspects of intellectual property rights - TRIPS - as supplemented by bilateral agreements) is severely unjust - and its imposition a human-rights violation on account of the avoidable mortality and morbidity it foreseeably produces."
5. Health equity in economic and trade policies
"We deplore the worsening conditions of health experienced by many of the world's people and we denounce their cause - neo- liberalism. Neo-liberal polices imposed by the G8, transfer wealth from the South to the North, from the poor to the rich, and from the public to the private sector. Corporate profits increase while poor people, indigenous peoples and the victims of war and occupation, suffer. Economically and politically generated health inequalities have increased, yet these root causes of avoidable disease and death are not effectively addressed by current policies or programs."
"The General Agreement on Trade in Services (GATS) seeks to expand international trade in a wide range of services ranging from tourism to telecommunications and education. In recent years, it has come under attack from civil society organizations in both the North and the South for having a detrimental impact on poor people's right to basic services. This article explores some of these controversies, using the example of water services. It focuses specifically on the impact of the GATS on poor people's right to water and national governments' ability to safeguard the interests of poor people through regulation."
6. Poverty and health
This article, published in The Lancet, explores what further progress towards the health objectives set out in the United Nations Millennium Development Goals (MDGs) will mean for the poor. The author notes that, unlike the MDGs overall, these health objectives do not focus specifically on poor people. “Rather, they call for improvements in national averages that can be achieved through gains in both advantaged and disadvantaged groups. As a result, any reduction in society-wide average rates of death or illness can provide a wide range of outcomes for poor people.”
7. Human Resources
“In the context of the Millennium Development Goals, human resources represent the most critical constraint in achieving the targets. Therefore, it is important for health planners and decision-makers to identify what are the human resources required to meet those targets. Planning the human resources for health is a complex process. It needs to consider both the technical aspects related to estimating the number, skills and distribution of health personnel for meeting population health needs, and the political implications, values and choices that health policy- and decision-makers need to make within given resources limitations.”
Massive shortages in trained health care professionals in sub-Saharan Africa have led to an examination of substitute health workers as an immediate response to the workforce crisis. For many countries these substitute health workers (SHWs) are not new. They already play various minor roles in health services, especially in rural and deprived areas. In Tanzania, Malawi and Mozambique, assistant medical officers are used as substitutes for doctors. They perform surgery and a variety of other tasks.
The shortage of health workers with the right expertise and experience has reached crisis levels in many developing countries. The human resources (HR) crisis in the health sectors of many developing countries is now firmly on the international policy agenda. The work of the Joint Learning Initiative (JLI) and the High Level Forum on Health has described the magnitude of the HR challenge, identified the key contributory factors, and defined some of the potential solutions.
* Relating Link
The Joint Learning Initiative Report: overcoming the crisis
http://www.id21.org/health/InsightsHealth7art6.html
8. Public-Private Mix
To achieve the health-related Millennium Development Goals, the delivery of health services will need to improve. Contracting with non-state entities, including non-governmental organisations (NGOs), has been proposed as a means for improving health care delivery, and the global experience with such contracts is reviewed here, in this Lancet article. The ten investigated examples indicate that contracting for the delivery of primary care can be very effective and that improvements can be rapid. (requires registration)
The paper first discusses the concept of PuPs and proposes a two-dimensional typology for categorising the various forms of partnership so described. The range of types of PuPs is then discussed with reference to specific sectors (water and healthcare), international associations, and six case studies. The final section draws general conclusions and makes recommendations for future research into the subject.
This issues paper, published by the DFID Health Systems Resource Centre (HSRC), was one of several feeding into Department for International Development (DFID) policy discussions in mid-2004. It examines evidence on the impacts of user fees for primary health care, evaluates the cost implications of abolishing user fees, and considers what line donors should take on the issue. The paper argues that the case for abolishing user fees is strong: they raise little money, rarely meet their stated efficiency and equity goals.
9. Resource allocation and health financing
This is the eighth edition of ‘Untangling the web of price reductions: a pricing guide for the purchase of ARVs for developing countries’. The report was first published by Médecins Sans Frontières (MSF) in October 2001 in response to the lack of transparent and reliable information about prices of pharmaceutical products on the international market, a factor which significantly hampers access to essential medicines in developing countries. The situation is particularly complex in the case of antiretrovirals (ARVs). The purpose of this document is to provide information on prices and suppliers that will help purchasers make informed decisions when buying ARVs. Since the first edition of ‘Untangling’, prices of some first-line ARVs have fallen significantly due to competition between multiple producers. However, not all countries are able to benefit from these lower prices because of patent barriers to accessing generic versions.
10. Equity and HIV/AIDS
Developing countries will be paying less for two anti-AIDS drugs produced by multinational pharmaceutical company, Gilead Sciences. In a statement Gilead said it had dropped the cost of Viread by 31 percent and that of Truvada by 12 percent. Both medications are already sold at no-profit prices in 97 developing countries around the world.
The crucial role played by Community Based Organisations (CBOs) in the fight against HIV/AIDS is far from being recognized, says a report from SIDACTION. Until now, there was neither a record of what these organizations were doing nor any formalized description of the different kinds of activities which help facilitate access to treatment, so as to demonstrate the potential they might represent in terms of ARV access. SIDACTION sent out a concise questionnaire to more than a thousand organizations. Within a few weeks we received more than 300 responses from organizations expressing an interest in HIV care, treatment and support. There were many contrasts among the responses to the Community Access study conducted by SIDACTION: Uganda, Nigeria and Kenya accounted for 60 of the 300 continent-wide organizations that stated that they provide HIV care services.
In an attempt to reduce the psychosocial impact of the AIDS epidemic, Zimbabwean communities have started an innovative community-based counselling initiative across the country. Until recently it was inconceivable for 48 year-old Mildred Mutumwapavi of Zaka District to talk openly about the HIV/AIDS in the community, let alone to regularly visit and counsel people living with and affected by the disease. But her attitude has changed: not only is she a trained community counsellor, she is also active in Zaka district, some 370 km southeast of the capital, Harare.
In 2003, Family Health International (FHI) and its donor and country partners launched antiretroviral therapy (ART) "learning sites" in Ghana, Kenya and Rwanda, hoping to demonstrate that ART services could be provided safely and effectively in resource-constrained settings. At each site, ART was introduced as an integral component of comprehensive care and support for HIV-infected patients and their families. The sites are part of closely linked referral networks within defined geographic areas, such as districts or municipalities. In the two years since the initial sites were launched, FHI and its partners have learned valuable lessons that can guide development and expansion of ART services in Africa and other regions.
Zambia's civil society groups are targeting parliamentarians, urging them to step up efforts to curb the spread of the HIV/AIDS pandemic. Advocacy groups point out that members of parliament (MPs) are in an ideal position to help eradicate stigma and discrimination, as they could influence their constituents.
11. Governance and participation in health
"Advocates of participatory approaches to service delivery see devolution as key to empowering people to take charge of their own affairs. Participation is portrayed as guaranteeing the delivery of services that are in line with user preferences. It is assumed that people are keen to participate in public affairs, that they possess the capacity to do so, and that all they need is opportunities. Using evidence from ethnographic research in Uganda, this article questions these views. It shows that, to succeed in the long term, devolution and participation must take place in the context of a strong state, able to ensure consistent regulation, and a well-informed public backed up by a participatory political culture."
This Agency for Co-operation and Research in Development (Acord) report features two country case studies (Uganda and Burundi) which explored the role of community-based research in responding to HIV stigma and discrimination. The research found that issues of stigma and discrimination reached all spheres of life, including the home, family, the workplace, school, health settings and the larger community. It also identified a number of key factors that contribute to stigma and discrimination. These include ignorance and fear, cultural norms and values, some religious teachings, the lack of legal sanctions, lack of rights awareness, the design of government and other programmes, and inaccurate or irresponsible media coverage.
12. Monitoring equity and research policy
"Inequalities in health are important for overall well-being even in developing countries. But research into this area has lagged behind developed countries partly because of the lack of routine and longitudinal data. Insights from developed countries have highlighted how risk factors are clustered around poor people and the ways in which pathways of poverty and poor health are formed during their lives. This is being overlaid by the process of globalization that seems to be accentuating these processes. The paucity of reliable routine data should encourage public health researchers in developing countries to stretch their methodological imagination to include qualitative insights in order to facilitate a more probing investigation that moves beyond describing inequalities but begins to describe how they are produced and reproduced."
The contemporary public health effort sees much debate about the concepts of “evidence” and “the evidence base”, and the usefulness and relevance of such terms to both policymaking and practice. A key challenge to public health is to better contextualize evidence for more effective policymaking and practice. Theory on the translation of research findings into policy and practice, and on knowledge utilization, offers only part of the solution to this complex task. The policymaking context is highly political and rapidly changing, and depends on a variety of factors, inputs, and relationships.
13. Useful Resources
Presentations from the People's Health Assembly 2, held in Ecuador in July, are now available on a central website. Africa-related presentations include 'Improving Care And Implementing Intersectoral Action Through Participatory Research And Advocacy : An Example From Rural South Africa' by David Sanders, from the School of Public Health at the University of the Western Cape and ' The war of the transnational oil companies against the people' by Nnimmo Bassey from Nigeria.
The Synergy HIV/AIDS http://www.synergyaids.com/resources.asp Online Resource Center contains 3,824 searchable online documents relevant to HIV/AIDS project management, research, and reproductive health issues. Please click on the links, where available, to view the latest additions to the Synergy Resource Center. For questions or inquiries, please mail SynergyInfo@s-3.com
14. Jobs and Announcements
The International Society for Equity in Health, ISEqH, welcomes those interested in promoting equity in health to share experience and expertise at its Fourth International Conference in Adelaide, Australia. The overarching theme for the ISEQH's Fourth International Conference, Creating Healthy Societies through Inclusion and Equity, reflects the central role of social, political, and economic determinants in creating health.
The Centre for Human Rights Studies in the Faculty of Law, University of the Free State, South Africa, invites applications for admission to study for a Masters Degree (LLM) in Human Rights specialising in Reproductive and Sexual Rights. The LLM in Human Rights specialising in Reproductive and Sexual Rights is the first of its kind on the African continent. The LLM was launched in 2005. It is an international programme that is aimed at equipping committed lawyers from the African continent with academic and practical skills for securing the realisation of reproductive and sexual rights at a domestic as well as an international level. The LLM programme is financially supported by the Ford Foundation.
Published for the Network for Equity in Health in Southern Africa by
Fahamu - Networks for Social Justice
http://www.fahamu.org/
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