The EQUINET regional meeting on Human Resources for Health August 19-20 2005 in Johannesburg South Africa discussed and debated Human Resources for Health (HRH) research and policy with a view to improving the equitable distribution of HRH within southern Africa. By the end of the deliberations, the delegates from government, non government, health worker, national, regional and international level at the meeting highlighted key areas of shared perspective on HRH.
The delegates noted an HRH crisis in east and southern Africa that has become more marked with the inadequate resourcing of the health sectors under economic reforms. The migration of HRH from the region to high income countries and the outflows of health workers from primary and district levels of health systems and from the public to private sectors leaves many low income communities with high health need with inadequate personnel for their health care services. This is a perverse outflow of public resources that undermines equity and the health system response to the major public health challenges in the region.
The multisectoral nature of policy implementation on HRH within government, and the international pull factors for migration of HRH were noted. Following the example of some countries in the region it was proposed that HRH be taken up as an issue for government as a whole and not just for the health sector, led by the highest level of government. At the same time Ministries of Health need the institutional latitude to facilitate training and strengthen retention of health workers. Constructing an appropriate policy framework given diverse contextual imperatives implies building a portfolio of policy measures and building policy implementation capacities.
Acting on HRH requires new resources, and, as raised by the African Ministers at the World Health Assembly in 2004 and again in 2005, delegates proposed international action and global transfers to address migration of and reinvestment in HRH.
It was proposed that HRH issues be addressed within the context of building and strengthening the public health sectors in the region. Towards this three areas of focus were identified for action:
- Valuing health workers so that they are retained within national health systems. This includes reviewing and implementing policies on non-financial incentives for HRH such as career paths, housing, working conditions, management systems and communication. To support this delegates proposed greater investment in training in HRH supervision, in management and communication systems, HIS and HRH, and measures to support health workers own health.
- Promoting relevant production of HRH, particularly in terms of the health personnel for district and primary care levels, and drawing on experience in the region on training of auxiliaries. For equitable distribution and retention the delegates noted the importance of appropriate selection of students and the need to locate training within career paths and incentives that recognise the HRH trained within the public health sector.
- Responding to migration, which requires closing the evidence gap with respect to migration (levels, flows and causes), financial flows, costs (benefits, losses) and return intentions and mapping the effectiveness of current policies. Delegates noted that migration represents a perverse subsidy calling for international policy responses that provide for reparation.
* This is the consensus statement from a report of a regional meeting on 'Equity in the Distribution of Health Personnel in southern Africa', held 18 to 20 August 2005, Johannesburg, South Africa. For the full report please visit http://www.equinetafrica.org/bibl/docs/REP082005hres.pdf
1. Editorial
2. Latest Equinet Updates
The EQUINET regional meeting on Human Resources for Health August 19-20 2005 in Johannesburg South Africa discussed and debated Human Resources for Health (HRH) research and policy with a view to improving the equitable distribution of HRH within southern Africa. By the end of the deliberations, the delegates from government, non government, health worker, national, regional and international level at the meeting highlighted key areas of shared perspective on HRH.
A regional meeting (hosted by EQUINET/Oxfam working with SADC in February 2004) identified the need to monitor equity in access and health systems issues as critical to supporting visibility, policy dialogue and programme planning on these issues of equity and health system strengthening. EQUINET, through Training and Research Support Centre, carried out work to assess the existing monitoring taking place in relation to expanding ART coverage and contracted the Equi-TB Knowledge Programme – now REACH Trust - Malawi, to write a paper on the area of monitoring equity and health systems impacts of ART expansion at subnational and national level, with recommendations for regional level monitoring.
Health civil society groups in Zimbabwe and east and southern Africa, met on 13 October 2005 to discuss struggles for health and agreed on the resolutions available through clicking on the web link provided, to be presented at the Southern African Social Forum on 14 October 2005.
3. Equity in Health
Scientists have called for a more balanced approach in distributing the billions of pounds available for controlling tropical diseases. In a paper published recently, they said that a focus by governments and charities on the big three tropical diseases - HIV, malaria and tuberculosis - had left millions of the poorest people in Africa without treatment for a range of illnesses.
The neglected diseases, which include schistosomiasis, river blindness, ascariasis, elephantiasis and trachoma, affect more than 750 million people and kill at least 500,000 every year.
Immunization at the global level has progressed very well during the past 25 years, but further increases in coverage would save the lives of millions more who do not yet benefit from this protection, said a group of immunization partners at the World Vaccine Congress in Lyon, France. This conclusion was drawn after an analysis of the latest immunization global data. The World Health Organization (WHO) and UNICEF, with financial support from the United States Centers for Disease Control and Prevention, conduct world-wide monitoring and work closely with Ministries of Health to produce estimates of immunization coverage each year.
The SADC Ministerial Sub-Committee on Traditional Medicine met at Sheraton Hotel in Harare on 16 September 2005. With regard to legislation the Ministers agreed to encourage member states to start with the development of appropriate legislation on Traditional Medicine and that the legislation will cover amongst others, establishment of councils for Traditional Medicine, protection of practitioners and consumers including the issue of licensing Traditional Medical Practitioners.
The H5N1 strain of avian influenza, or bird flu, remains a global threat, but while Southern Africa should prepare for its emergence, the region needed to bear in mind that the disease has yet to mutate into a deadly human strain, a World Health Organisation (WHO) expert told IRIN. News reports suggesting that least one case of bird flu in humans had been identified in the Indian Ocean island of Reunion raised concern this week, but these reports proved inaccurate after medical tests were conducted by French authorities.
UN Special Envoy for HIV/AIDS in Africa Stephen Lewis on Sunday criticized rich nations for failing to deliver adequate aid to Africa, CBC News reports. Lewis also recently launched a book titled "Race Against Time." In the book, Lewis criticizes musician Bob Geldof for using the "hype" surrounding the Live 8 concerts in July to allow the leaders of the Group of Eight industrialized nations to promote a "wholly inadequate" aid package for Africa as a "major triumph of international consensus and generosity," the Ottawa Citizen reports.
The report, 'The Promise of Equality: Gender Equity, Reproductive Health and the Millennium Development Goals', explores the degree to which the global community has fulfilled pledges made to the world’s most impoverished and marginalized peoples. It tracks progress, exposes shortfalls and examines the links between poverty, gender equality, human rights, reproductive health, conflict and violence against women and girls. It also examines the relationship between gender discrimination and the scourge of HIV/AIDS.
4. Values, Policies and Rights
In this paper, the Swedish International Development Co-operation Agency (Sida) sets out its policy on sexual and reproductive health and rights (SRHR). It argues that violations of the right to sexual and reproductive health both cause and are caused by poverty. Therefore, realising SRHR is not only a goal in itself, but a means to fight poverty, underpinning all the Millennium Development Goals (MDGs). The paper considers sexual and reproductive health from the perspective of human rights and of the poor, emphasising the need to address power structures and their impacts.
5. Health equity in economic and trade policies
"Major changes in international trade, intellectual property (IP) protections and drug registration requirements are substantially affecting pharmaceutical markets, with significant implications for access to medicines by poor people. Within this framework, and drawing on legal, regulatory, economic and pharmaceutical industry expertise, the UK's Department for International Development (DFID) has commissioned a series of seven studies. The studies, summarised in this paper, examine the policy implications of these trends for emerging producers of generic medicines such as India and China, and for poor people in developing countries.A key question is how strengthened intellectual property protections and heightened registration standards may or may not improve access to medicines in these currently under-served markets."
Tony Blair is running out of time on achieving the third and most controversial part of the 'Marshall Plan for Africa' he promised earlier this year: trade justice. With just weeks to go before critical World Trade Organisation talks in Hong Kong, Europe and the US are in deadlock over how far they should open up their markets to farmers from poor countries - and what they will demand from the rest of the world in return.
This report traces the trends and patterns in economic and non-economic aspects of inequality and examines their causes and consequences across and within regions and countries. It focuses on the gaps between the formal and informal economies and between skilled and unskilled workers, the growing disparities in health, education and opportunities for social, economic and political participation as well as analysing the impact of structural adjustment, market reforms, globalisation and privatisation on economic and social indicators.
The World Bank's annual World Development Report this year focuses on equity, arguing that inequality of opportunity is holding back prosperity and economic growth. This article from the Institute for Development Studies argues that the report fails to get to grips with what inequality really means: "The World Development Report for 2006 on Equity and Development (WDR 2006) has been described by Sanjay Reddy from Columbia University as reflecting the most progressive face of the World Bank. This is because it argues strongly on ethical and efficiency grounds for the need to tackle the gross disparities in opportunity for children born in different parts of the world. Reddy also finds that the theoretical construction of the report is 'rather clunky and appears to be the product of political compromise…but is workable'."
6. Poverty and health
There is a growing concern within the international development community that policies aimed at reducing the number of people living below the poverty line could leave the most disadvantaged groups behind. In line with these concerns, this Eldis dossier looks at different strategies for reaching the very poor within the health sector, and at the institutional challenges associated with scaling up health-related interventions to cover broader segments of the population.
7. Human Resources
"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."
A qualitative study was conducted in Malawi to describe the perceptions of medical students, recent medical graduates, faculty members of the Malawi College of Medicine and private general practitioners (GPs) towards a proposed utilization of GPs in the teaching of undergraduate medical students. General Practitioners welcomed these proposed changes whilst the majority of students, recent graduates and faculty were opposed to this idea. General practitioners were perceived not to be able to adapt to the culture of public teaching hospitals.
"There has been substantial immigration of physicians to developed countries, much of it coming from lower-income countries...International medical graduates constitute between 23 and 28 percent of physicians in the United States, the United Kingdom, Canada, and Australia, and lower-income countries supply between 40 and 75 percent of these international medical graduates. The United Kingdom, Canada, and Australia draw a substantial number of physicians from South Africa, and the United States draws very heavily from the Philippines. Nine of the 20 countries with the highest emigration factors are in sub-Saharan Africa or the Caribbean."
Migration has long been an important part of labour markets and livelihoods across Africa. It is estimated that there are between 20 and 50 million African migrants today. Migration flows have implications for meeting the Millennium Development Goals, but their effects are poorly understood. Most African governments, however, are concerned with the migration of educated professionals abroad, or the 'brain drain'. It is estimated that US$4 billion is spent on replacing African professionals with expatriates, mostly through aid programmes.
8. Public-Private Mix
The Department of Health’s recently released Draft Charter of the Public and Private Health Sectors (CPPHS) aims to address the legacy of apartheid restraint on access to health care for all South Africans. It commits public and private sectors to create “a health care system that is coherent, cost-effective and quality driven … for the benefit of the entire population” and to work together “to improve the scope, accessibility and quality of care at all levels”. For these laudable goals we give our wholehearted support. The CPPHS specifies four “key areas” of transformation: access to health services, equity in health services, quality of health services, and Black Economic Empowerment (BEE). The first three – access to, equity in, and quality of health care services, are essential (though not enough) to meet the goal of health for all South Africans. The fourth area is problematic.
"The privatization of state-owned enterprises has been among the most controversial of market reforms. This new edited volume brings together a comprehensive set of country studies on the effects of privatization on people-and answers the overarching question: who are the winners and losers of the wave of privatizations that swept across the developing world in the 1980s and 1990s? The studies are sophisticated and careful, and address the big questions: Are the poorest households paying more for water, power, and other basic services? Did those who lost jobs suffer permanent declines in income? Were state assets sold at prices that were too low, and who benefited from the resulting windfalls? Was the process, in laypersons' terms, fair?"
9. Resource allocation and health financing
Many African health ministries face insufficient and unpredictable funding from development partners and others, and have limited resources to devote to even important tasks such as long-term planning in developing their health work forces. PHR is calling on African Union ministers of health, who meet in Botswana in mid-October, to commit to developing targets, plans, and budgets for health workforces and systems to meet the Millennium Development Goals by 2015, as well as other health aims. The challenges to developing these plans are real, but the potential benefits to them are immense.
This paper is based on a detailed and critical review of the literature relating to health care financing in the African context. The objectives are to: * Provide an overview of the equity challenges, particularly in relation to poverty concerns, of current health care financing mechanisms in Africa; * Provide a brief critical review of major recent developments in health care financing in Africa; and * Identify key issues in promoting equitable and poverty-reducing health care financing options in the African context. It is important to stress that health care financing mechanisms differ in each African country and that there are no ‘one-size-fits-all’ solutions.
10. Equity and HIV/AIDS
Where have the billions of dollars poured into Africa to fight AIDS gone? A lot of this money is channelled through non-governmental organisations (NGOs) mainly to pay for life-prolonging drugs and education campaigns on a continent where many national healthcare systems are broke and in tatters. Donors increasingly prefer to fund NGOs rather than African governments, many of which are seen as corrupt. But because the NGOs number in the thousands, it is unclear how much money they have received or how it was used.
This technical note from the Food and Nutrition Technical Assistance (FANTA) Project provides information and guidance about the food and nutrition implications of antiretroviral therapy (ART) in resource limited settings. It discusses the effects of food on medication efficacy, the effects of medication on nutrient utilisation, the effects of medication side effects on food consumption, and unhealthy side effects caused by medication and certain foods. It also outlines ways to manage the effects of these drug-food interactions, with a particular focus on food security constraints in resource limited settings.
How is the HIV/AIDS pandemic affecting food security in Lesotho, Malawi and Mozambique? How can humanitarian agencies speed up their response to hunger crisis in Africa? These are just two of many questions emerging from an independent evaluation of the 2002-2003 Disasters Emergency Committee Southern Africa Crisis Appeal. In 2001, abnormal rains led to flooding and water logging, substantially reducing maize production. Unable to store maize, farmers were forced to sell at low prices early in the season, and buy back at inflated prices later. The food crisis situation in Malawi - combined with chronic poverty, HIV/AIDS, poor governance, political instability, and misguided market reforms of neighboring countries – led to catastrophe throughout the region.
11. Monitoring equity and research policy
Ultimately any policy or health system change, whether generated from within or outside national environments, has to work through those responsible for service delivery, and their interactions with the intended beneficiaries of those changes. Yet we continue to know too little about the experiences of these groups, including how their words, actions and beliefs shape the practice of implementation. This paper used policy analysis to understand these implementation gaps.
This provisional framework provides a practical and transparent method for deriving grades of recommendation for public health interventions, based on a synthesis of all relevant supporting evidence from research.
12. Useful Resources
In the run up to the WTO’s 6th Ministerial Conference in December 2005 in Hong Kong, this trade union action guide provides background information as well as a number of tools with which to exert pressure on national governments and trade negotiators to ensure that the concerns trade unionists share globally about the latest round of negotiations are dealt with.
GlobalHealthReporting.org helps journalists, researchers, policy makers and NGOs efficiently sort through the latest and most accurate information on HIV/AIDS, tuberculosis and malaria.
13. Jobs and Announcements
The Global Health Research Initiative (GHRI), a partnership among the Canadian International Development Agency (CIDA), Canadian Institutes of Health Research (CIHR), Health Canada (HC) and the International Development Research Centre (IDRC), invites letters of intent from teams composed of Canadian and low and middle-income country (LMIC) researchers and research users (e.g. policy makers, practitioners, civil society organizations and community members), interested in developing innovative multi-year programs that combine applied research, knowledge translation and capacity building to solve pressing health problems in LMICs.
The Knowledge Management for Development (KM4Dev) community of practice (www.km4dev.org) publishes a peer-reviewed, open access e-journal in the field of knowledge sharing for development, the 'Knowledge Management for Development Journal' (KM4D Journal) at www.km4dev.org/journal The first issue of the second volume (2006) will deal with 'Effective knowledge sharing for development in Africa.' Guest editors comprise Dina El Halaby, Reine Djuidje Kouam, Kingo Mchombu and Alice Mungwa, working with Chief Editor, Julie Ferguson.
"We would like to invite you to participate at the e-conference to be hosted by the Quality Network for Rational Drug Management, or QU4RAD Network, at www.qu4rad.net on 28 October to 5 November 2005. Entitled “Health, Human Rights and Health Professionals -What is the role of health professionals in promoting the peoples’ rights to adequate, affordable and effective treatment of illnesses?"."
Plans for the Global Health Watch 2007-2008 (GHW2) are underway which include a move of the secretariat to the Global Equity Gauge Alliance (GEGA) office at the Health Systems Trust in South Africa in October. The secretariat will be led by Antionette Ntuli and Bridget Lloyd of GEGA with the support of David Sanders from the University of the Western Cape. Thanks to Medact for hosting the GHW1 secretariat for the last two years. The GHW2 will be coordinated by a coalition of GEGA, Medact and the People's Health Movement (PHM) together with a new partner - the Health Research and Consultancy Centre (CEAS) based in Quito, Ecuador.
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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