Recognition of the health worker crisis in Africa has stimulated debate on what works to deploy and retain health workers in critical levels of African health systems. Most east and southern African (ESA) countries suffer a critical shortage of health workers with fewer than 2.5 skilled health workers per 1000 population, less than the level needed for the most necessary health interventions. The shortfall contributes to the persistence of high disease burdens and poorly developed health systems. These factors together with poor management systems and lack of appreciation of health workers drive further losses of health workers in a vicious cycle. With a Malawian woman having a probability of dying during childbirth that is 130 times greater than that of her American counterpart and faltering progress towards achieving millennium development goals in the region, acting on this health worker crisis has become a matter of global concern. While many policies and strategies are being proposed, answering the question what makes health workers stay in African health systems provides one direction for action.
Many factors responsible for health worker shortages, especially those related to global migration of health workers, are beyond the control of individual countries in ESA and call for wider international action. However there are important ways in which ESA countries can act to deploy and retain health workers in the health systems in the region, and there is learning to exchange from the combination of financial and non-financial incentives being used with varying degrees of success to retain available staff.
As an immediate measure many countries are using financial incentives like salary increases and allowances to send an early signal to attract or stem losses of health workers. To stabilize and sustain these, including in more inflationary environments, a range of non-financial incentives are also being used, such as training and career path-related opportunities, housing, transport, childcare facilities, free food, employee support centres, improvements in working conditions, better facilities and workplace security and improvements in management and human resource information systems.
Recognising the specific contexts affecting the approaches used in countries, there is scope for learning from the impact of measures being used in the region.
The Malawian health worker retention strategy, for example, is a combination of financial and non-financial incentives through a six-year, $272 million emergency human resources programme with budget support from the Government of Malawi, the Department for International Development (DFID) and The Global Fund for AIDS, Tuberculosis and Malaria. Blending these significant sources of budget support, the measures have (at least in the short term) managed to overcome the massive absolute shortfall across the system as a whole and to attract and retain health workers in Malawi. Some incentives address the factors that push workers out of the health system more directly. Swaziland responded for example to the high HIV and AIDS burden among the health workforce through the establishment of a wellness centre for health workers in collaboration with the Swaziland Nursing Association and the International Council of Nurses (ICN). Some countries have reduced the bureaucracy slowing the recruitment of health workers. Tanzania and Kenya have for example involved partners from the private sector to implement more easily administered emergency hiring plans for hard-to-staff areas.
Many countries face issues of internal migration and use incentives to more effectively retain workers in remote or underserved areas. Zambia, has for example, been able to attract staff to rural areas using a comprehensive package of financial and non-financial incentives, originally for doctors but currently extended to other health workers. Uganda made government service more attractive than the private sector through salary enhancement and non-financial incentives like training opportunities, support for research and a Yellow Star Award programme that recognises facilities that have consistently excellent performance. South Africa has used financial incentives in the form of rural and scarce skills allowances for under-served areas, in addition to compulsory community service.
Implementing these incentives and monitoring their impact calls for improved strategic management skills with greater flexibility to respond to rapidly changing conditions. A number of countries have set up autonomous health service boards and commissions to address health worker needs independently of the public service commissions to provide flexibility. This has had mixed results, depending on the resources and power that these boards have. The Zambian Health Service Board had a difficult beginning largely because most of the powers remained with the central public service commission. The Uganda Health Service Commission and the Health Board in Zimbabwe have been reported to function more effectively although their impact on health worker outcomes are not yet well assessed. Approaches that have evolved through consultation with all stakeholders, including the health workers and development partners, that are linked to strategic plans and funded from national budget or pooled funds, instead of vertical schemes, have tended to be more successful. Vertical schemes have suffered from lack of continuity and sustainability.
While experience is growing in the region around incentives for retention, assessing and sharing what works and what doesn’t work is constrained by lack of systematic documentation and limited monitoring and evaluation mechanisms. Success stories and success factors are thus not always well recognized locally or accessible to other countries. Weaknesses in monitoring and review systems also slow the response to unanticipated negative outcomes of schemes. For instance, in both Uganda and Tanzania, introduction of better pay for public sector health workers was accompanied by a net movement of health workers from faith-based facilities to government services, leaving many areas where only faith-based services were available to poor communities underserved. Recognising this, national and regional organizations in EQUINET are documenting experience and impacts in selected countries in the region.
There are good reasons for investing in retention incentives and for more effectively managing this aspect of health systems. Firstly, training health workers is costly and takes long; and without measures for retention there is no guarantee that the trainees will stay after completion of their studies. The loss of public sector training investments is an area of high cost of outmigration to the public health systems of Africa. Secondly, failure to retain staff has direct and knock-on costs, such loss of institutional memory, loss of morale and increased workload for the remaining workers and higher costs to the community to seek care at higher levels. In contrast retention strategies send an affirmative message to health workers that they are valued and this sends positive signals to attract more health workers. Further, measures for retention of health workers have positive implications for equity as they direct resources towards hard-to-staff facilities in rural, remote areas or those serving poor populations who have limited capacity to pay for private health care.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. EQUINET Theme work on health worker retention is co-ordinated at Unversity of Namibia and is being implemented in co-operation with the ECSA Health Community. For further information and publications on this issue please visit www.equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
Call Closes On December 7, 2007!
This call invites applicants to participate and share experiences in a Regional Training Workshop for east and southern African countries on Participatory Methods for research and training for a people centred health system being held on February 27 to March 1st 2008.
The training aims to support work at national, district and local level with health systems and communities in health, with a major focus on the interactions at primary health care level. The 2008 training will focus on overcoming community and health systems barriers in accessing comprehensive prevention and treatment for HIV and AIDS and strengthening equitable primary health care responses to HIV and AIDS.
This study reviews the Zambian deprivation-based health resource allocation formula and assesses how the deprivation-based resource allocation formula has been implemented in terms of achieving the initial desired goals of resource – re-distribution. It further considers the extent of converge or divergence in the equity goals relating to resource re-distribution through the allocation of funding to the districts.
The workshop took participants through the writing process from developing a key message, planning the structure of writing, to writing the specific sections of scientific papers such as the title, abstract, keywords, executive summary, introduction, methodology, results and discussion, conclusions and references; on various aspects of peer-reviewed publishing and on issues of authorship, copyright and plagiarism.
3. Equity in Health
Income inequality is widely assumed to be a major contributor to poorer health at national and subnational levels. According to this assumption, the most appropriate policy strategy to improve equity in health is income redistribution. This paper considers reasons why tackling income inequality alone could be an inadequate approach to reducing differences in health across social classes and other population subgroups, and makes the case that universal social programs are critical to reducing inequities in health. A health system oriented around a strong primary care base is an example of such a strategy.
MHEN held a National Forum on 22nd and 23rd November 2007 at Lilongwe Hotel. It brought together a network of policy makers and practitioners who work in the field of health services delivery. The forum explored the challenges in health services delivery in a non-industrialised country with limited resources.
Visualizing inequalities in health at the world scale is not easily achieved from tables of mortality rates. Maps that show rates using a colour scale often are less informative than many map-readers realize. For instance, a country with a very small land area receives less attention, whereas a large, sparsely populated area on a map is more obvious. Furthermore, unlike our visual ability to compare the lengths of bars in a chart, we do not have a natural aptitude for translating different colours or shades to the magnitudes they represent. Here we introduce another approach to mapping the world that can be useful for illustrating inequalities in health. This article looks at various ways of mapping and visualising global health statistics.
The relationship between AIDS and poverty has more to do with inequality than poverty per se. The relationship between socioeconomic status and HIV varies considerably from country to country, reflecting differences in culture and traditions. Effective actions to tackle AIDS must directly address these specific factors—the inequalities—that drive HIV transmission in different contexts, and must overcome the obstacles to accessing treatment in different groups. It is crucial to place AIDS squarely at the centre of all socio-economic development, and provide long-term, high-level domestic and international investment in HIV prevention and treatment in the world's poorest countries.
4. Values, Policies and Rights
This abbreviated version of the Policy on Quality in Health Care for South Africa follows on the original that became national policy in 2001. It comes at a time when the public health care system is in dire need of again refocusing its collective efforts towards improving the quality of care provided in public health facilities and communities. Knowing that quality is never an accident, always the result of high intention, sincere effort, intelligent direction and skilfull execution, and that it represents the wise choice of many alternatives, this abbreviated version attempts to provide to all public health officials in a nutshell and in a more reader friendly language, the strategic direction health facilities and officials need to follow to assure quality in health care and continuous improvement in the care that is being provided. Health care personnel are encouraged to use this copy of the Policy to focus their intentions and guide their efforts.
This document describes the priorities for the National Health Department.
The Act is intended to provide a framework for a structured uniform health system within the Republic, taking into account the obligations imposed by the Constitution and other laws on the national, provincial and local governments with regard to health services; and to provide for matters connected therewith
The Department of Health conducted a review of the period 1999-2004 to determine what work is outstanding and what new work is needed to provide the necessary stewardship of the South African health system.This process has resulted in the adoption of a new set of priorities described in this document.
5. Health equity in economic and trade policies
The struggle to make medicines affordable to the world’s poor, especially in Africa, is raging on at the highest levels. Last week the European Commission took a landmark decision on generic drugs and next week a high-level intergovernmental meeting will look at ways to prevent patents from blocking access to drugs.
Two proposals to change the current patent system are causing a new diplomatic battle at the World Health Organisation in November. One concerns the launch of new medicines and the other seeks to make existing drugs available at low prices in developing countries. A coalition of developing countries, amongst them Brazil, and non-governmental organisations are defending a “patent pool” to combine intellectual property rights on existing medicines, and a “prize fund” to reward and stimulate discovery of new medicines for so-called neglected diseases. The two initiatives are receiving strong opposition from some rich countries and the pharmaceutical industry. They have also caused a split between the two major Latin American countries. Mexico is moving away from Brazil’s position and is making alliance with the US, alleging that it has commitments in the trade agreement with Washington.
The Ministers of the African, Caribbean and Pacific (ACP) group of countries have issued their most comprehensive policy statement on the Economic Partnership Agreements (EPAs) at the end of a meeting they held in Brussels on 8-9 November. From the "Conclusions of the meeting" that they issued, it is clear that the Ministers recognised that the six ACP regional groupings are at different stages of negotiations with the European Commission on their respective EPAs, and that there are also differences between the regions on the issues that the EPAs would cover and on whether the negotiations will end by the official 31 December deadline. The Ministers welcomed the results obtained and stressed the need to do everything possible to ensure that the list submitted by the ACP Group regarding the preference erosion is rationalised to render it more credible.
The aim of this Report is to provide a rigorous analysis on how employment relations affect different population groups, and how this knowledge may help identify and promote worldwide effective policies and institutional changes to reduce health inequalities derived from these employment relations. Consequently, the report incorporates the political, cultural, and economic context to provide a comprehensive account of the current international situation of labour markets and types of employment conditions. Thus, through regulating employment relations, main political actors can not only redistribute resources affecting social stratification, but also have an impact on the life experiences of different social groups including opportunities for well-being, exposure to hazards leading to disease, and access to health care.
The Southern African civil society organisations campaigning on the Economic Partnership Agreements (EPAs), met in Gaborone, Botswana, from 20-22 November 2007, to review the EPA negotiations. This here forms a statement compiled by these organisations to re-affirm their opposition to these self-serving Free Trade Agreements that the European Union (EU) seeks to impose on African, Caribbean and Pacific (ACP) countries. The respective civil society organisations condemned the interim arrangement put in place to address market access to the EU at the expiration of the Cotonou preferences on December 31, and describe the treacherous framework as designed for bulldozing Africa into signing a comprehensive EPA/FTA.
Ministers from the Eastern and Southern Africa region (ESA) and Commissioners from the European Union met in Brussels on 12 November 2007. The ESA delegation was led by Honourable Felix Mutati, Minister of Commerce, Trade and Industry of Zambia, and included Ministers from countries in the region. The main purpose of the meeting was to take stock of EPA negotiations in view of impending expiry of the trade regime set out in the Cotonou Partnership Agreement and to provide political guidance for the next steps in the negotiation process. The Parties reaffirmed their commitment to conclude a comprehensive EPA as tool for sustainable development and the promotion of regional integration.
Following a meeting with trade ministers from the African, Caribbean and Pacific countries with the European Union (EU) in Brussels Wednesday, the European Commission said existing modalities supporting trade preferences would no longer be in force from January 1, 2008.
This statement on EPAs was compiled by the Platform of Central African Non State Actors (PANEAC) representing the following countries: Cameroon, Congo, Equatorial Guinea, Sao Tome and Principe, Gabon, Central Africa Republic, the Democratic Republic of Congo and Chad.
This article provides a detailed analysis of the Rwanda-Canada use of the system created under the August 2003 Decision for the import/export of pharmaceutical products manufactured under compulsory license. It will describe the various procedures that the importing country, the generic pharmaceutical company and the exporting country have to go through, identifying lessons from the experience. The precedent that may be established is critical to the continued utility and functionality of the system under the August 2003 Decision.
A dramatic rise in international patent applications related to influenza is underway. This includes patent applications covering the virus itself, vaccines, treatments, and diagnostics. As recently as 1993, years passed with little or no such patent activity. In 2006, however, more than 30 international (Patent Cooperation Treaty) patent applications were filed on influenza vaccines alone, making it the largest year on record - but not for long. World Intellectual Property Organization (WIPO) data indicates that during the first half of 2007 as many influenza vaccine patent claims have been filed as in the entirety of 2006, meaning that this year is on track to at least double the record set in 2006. Together, these developments are resulting in a much more complex and limiting field of intellectual property claims than has ever before existed for influenza vaccine. And it is going to get worse.
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6. Poverty and health
School-based health and nutrition interventions in developing countries aim at improving children’s nutrition and learning ability. In addition to the food and health inputs, children need access to education that is relevant to their lives, of good quality, and effective in its approach. Based on evidence from the Zambia Nutrition Education in Basic Schools (NEBS) project, this article examines whether and to what extent school-based health and nutrition education can contribute directly to improving the health and nutrition behaviors of school children. Initial results suggest that gains in awareness, knowledge and behavior can be achieved among children and their families with an actively implemented classroom program backed by teacher training and parent involvement, even in the absence of school-based nutrition and health services.
Urbanisation can and should be beneficial for health. In general, nations that have high life expectancies and low infant mortality rates are also those where city government leaders and policies address the key social determinants of health. Within developing countries, the best local governance can help produce 75 years or more of life expectancy; with bad urban governance, life expectancy can be as low as 35 years. Better housing and living conditions, access to safe water and good sanitation, efficient waste management systems, safer working environments and neighborhoods, food security, and access to services like education, health, welfare, public transportation and child care are examples of social determinants of health that can be addressed through good urban governance. Failure of governance in today’s cities has resulted in the growth of informal settlements and slums that constitute an unhealthy living and working environment for a billion people. National government institutions need to equip local governments with the mandate, powers, jurisdiction, responsibilities, resources and capacity to undertake “healthy urban governance”. A credible health agenda is one that benefits all people in cities, especially the urban poor who live in informal settlements.
7. Equitable health services
Health systems cannot properly diagnose, treat, or contain the co-epidemic of HIV and tuberculosis (TB) because not enough is known about how the two diseases interact. A report by leading global health experts warned that the largely “unnoticed collision” of the global epidemics of HIV and TB has exploded to create a deadly co-epidemic that is rapidly spreading in sub-Saharan Africa. About one-third of the world’s 40 million people with HIV/AIDS are co-infected with TB, and the mortality rate for HIV-TB co-infection is five-fold higher than that for tuberculosis alone.
This article reviews literature on cancer statistics in sub-Saharan Africa, and assesses the need for population-based cancer registries to enhance cancer care and prevention within the region. The article finds that there are few cancer registries in sub-Saharan Africa and most of these are hospital based. This is partly because in many countries cancer is a low priority as more emphasis is placed on the control of communicable diseases and improving environmental sanitation.
This study examines the role of Community Home-Based Care in Botswana for people with HIV/AIDS and those with other terminal illnesses. Kerkhoven and Jackson (1995) attribute the popularity of Community Home-Based Care (CHBC) programmes in the developing countries to high rates of HIV/AIDS. Botswana has adult HIV/AIDS prevalence rate of 37 per cent and over 350,000 people living with HIV/AIDS. Rapid rise in incidences of HIV/AIDS has hence resulted in increasing need for CHBC and thus many CHBC services have been established through disorganized and fragmented manners. This paper is an extended literature review. It identifies and discusses challenges facing CHBC programmes in Botswana. The findings indicate that poverty, high cost of community care, inadequate medical facilities, poor infrastructures and socio-cultural issues have threatened the sustainability of CHBC programmes in Botswana. Recommendations and policy options are discussed.
This paper discusses the burden of cancer in developing countries and examines which types of cancers can be prevented and treated affordably in low-resource settings and which interventions can be used to control them. The paper concludes that to guide policymakers on the most effective cancer control strategies in developing countries, more work is needed in: clinical evaluations of cancer control interventions, health services research, and country specific economic evaluations. It recommends that since current knowledge about cancer control is incomplete, developing countries should start in small areas and gain knowledge from well-documented pilot programmes. Starting small might entail focusing on individuals with certain high-risk characteristics or in a limited geographic area, and scaling up should occur only after pilot programmes have been shown to perform well.
Ten per cent of individuals infected with TB develop the active disease but this is greatly increased in those whose immune systems have been weakened by HIV. This report highlights the difficulty in managing the co-epidemic of HIV and TB and identifies priority areas in need of further research: better population-based data on the incidence of drug-resistant TB is required, increased laboratory capacity is needed to make the currently difficult diagnosis of co-infection of HIV-TB accessible to a larger proportion of Africans, more child-specific research is needed especially on paediatric drug formulations. The low uptake of drugs that treat co-infection remains a real problem, with concerns over drug efficacy and the creation of drug resistant strains of TB cited as the main reasons. The report concludes that strategies for dealing with TB and HIV currently exist in isolation, often reinforced by vertical programme financing. Efforts must be made to integrate these disease treatment programmes which will involve stakeholders working together within an evidence based collaborative framework.
Malaria remains a leading global health problem that requires the improved use of existing interventions and the accelerated development of new control methods. In this editorial we reflect on the possibility of eradicating malaria in infants in Africa with the introduction of the malaria vaccine RTS,S/AS02D.
The purpose of this declaration is to raise awareness of the magnitude of the cancer burden in Africa and to call for immediate action to bring comprehensive care to African countries. The establishment of cancer care programmes in African countries requires the integration of clinical and public health systems. A comprehensive cancer control strategy must bring together prevention, early detection and diagnosis, treatment and palliative care. More investment is needed to deliver these services in terms of trained staff, equipment, relevant drugs and information systems, as well as public education.
This report presents a draft of the proposed Essential Heath Package (EHP) and its costing for Malawi. It is intended to stimulate comment and debate, and to move the process to a final stage whereby the contents can be incorporated into a broader implementation plan for the Ministry of Health and Population (MOHP) and partners. By MOHP, we mean the various departments at headquarters, the technical programmes, and the districts who will ultimately deliver the EHP services.
Based on this scientific information and WHO recommendations of changing to combination therapy, the Ministry of Health has adopted the use of Artemesinin based Combination Therapy (ACT) as 1st line treatment of uncomplicated malaria. There is therefore need to implement a new antimalarial treatment policy using ACTs. The Ministry of Health has developed these guidelines for malaria diagnosis, treatment and prevention with an aim of improving malaria case management by health workers and having a harmonized approach in efforts aimed at the reduction of morbidity and mortality due to malaria.
Existing school health programmes in Uganda target children above five years for de-worming, oral hygiene and frequent vaccination of girls of reproductive age. This study assessed primary school children's perspectives on common diseases they experience and medicines used in order to suggest reforms for school healthcare programmes and priority setting. Children named and ranked malaria as the most severe and frequently experienced disease. Other diseases mentioned included diarrhoea, skin fungal infections, flu, and typhoid.The symptoms children recognised in case of illness were high body temperature, vomiting, headache, weakness, appetite loss and diarrhoea. Children were either given medicines by the school nurse or they selfmedicated using pharmaceuticals including chloroquine, panadol, flagyl, fansidar, quinine injections, capsules (amoxicillin and ampicillin) obtained from the clinics, drug shops, pharmacies,and other unspecified indigenous medicines from their home and markets.
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8. Human Resources
Speakers at a two-day international conference in Africa on midwifery have called for more incentives to attract young people into the midwifery profession. They said the midwives of today were fast ageing and that unless immediate measures were put in place to attract more young ones into the profession, the fight for the reduction in maternal and infant mortality and morbidity would be a mirage. The speakers made the call at a two-day international conference of midwives on the theme, "African Midwives: Uniting to address the reduction of maternal and infant mortality and morbidity".
Dr Tshabala-Msimang said for Africa to scale up health work-force training, there is a need to mobilise adequate resources. She appealed to the developed world which has largely benefited from this exodus of health workers, to consider financially supporting Africa to train more health workers. Additional resources will also be required to rebuild the health infrastructure in some instances as well as training our lecturers, tutors and researchers.
In responding to the goal of rapidly increasing access to antiretroviral treatment (ART), the government of Botswana undertook a major review of its health systems options to increase access to human resources, one of the major bottlenecks preventing people from receiving treatment. In mid-2004, a team of government and World Health Organization (WHO) staff reviewed the situation and identified a number of public sector scale up options. The team also reviewed the capacity of private practitioners to participate in the provision of ART. Subsequently, the government created a mechanism to include private practitioners in rolling out ART. At the end of 2006, more than 4500 patients had been transferred to the private sector for routine follow up. It is estimated that the cooperation reduced the immediate need for recruiting up to 40 medically qualified staff into the public sector over the coming years, depending on the development of the national standard for the number and duration of patient visits to a doctor per year. Thus welcome relief was brought, while at the same time not exercising a pull factor on human resources for health in the sub-Saharan region.
The School of Medicine at Muhimbili is the main doctor-training institution in the country. It runs a five-year MD programme taking 200 students annually. As for many schools in low-income countries, the majority of teachers have no formal training in educational theory. The learning environment at the school has some strengths that should to be amplified, and numerous weaknesses that need to be corrected in order to make the environment more conducive to teaching and learning.
9. Public-Private Mix
Previous studies in the public sector in Tanzania, have demonstrated major prescribing problems due to poly-pharmacy and irrational use of antibiotics and injections. Little is understood about prescribing in the private sector. This paper measures and compares prescribing practices in public and private dispensaries in Kibaha District Tanzania. Prescribing of antibiotic and injections was significantly higher in private than in public dispensaries (P<0.05). The extent of prescribing in private dispensaries calls for intervention to reduce overuse of antibiotics and injections.
A cross sectional study was conducted in rural areas of Kibaha district within the Coastal region of Tanzania to assess knowledge on dosage, storage, expiry and dispensing practices of antimalarial drugs among households, drug stores and ordinary shops. The majority of drug store (53 %) and ordinary retail shop (75 %) sellers did not dispense correct doses of antimalarials due to low literacy and lack of dosage guidelines or package inserts. In order to reduce incidences of drug poisoning due to over-dosage or drug resistance due to under dosage, there is need to educate both consumers and dispensers on correct dosage regimens through mass media such as radio, health education programs, television, posters, leaflets and newspapers.
This study analyses the economic potential of pharmaceutical production of Anti Retroviral Drugs (ARVs) in Tanzania. This includes an analysis of the pharmaceutical sector in the country and the potential to export ARVs to the region. The study shows that production of pharmaceutical products in Tanzania is on the rise and can become viable in the long term. Even though the overall drug market is rather small, public health related drugs have a significant, largely donor based, market.
The UN health chief urged countries to come up with new ways to make medicine for HIV/AIDS and other diseases more affordable in the world's poorest countries, without stifling innovation among pharmaceutical companies. WHO's 193 member states are looking to forge a global strategy on the highly divisive issues of drug development, patenting and pricing.
10. Resource allocation and health financing
Member states of the African Union pledged at the 2001 Abuja summit to commit at least 15% of national budgets to healthcare but 6 years later have largely failed to do so. This failure amongst others has resulted in the annual loss of an estimated 8 million African lives to preventable, treatable and manageable diseases and health conditions. In other words Africa has lost a staggering estimated 40 million lives since 2001 due to a failure to develop, implement and fund comprehensive Public Health policies alone. African governments are not yet all working collectively or quickly enough to analyse and resolve the long term big picture and real scale of Africa’s health catastrophe. Many appear to be relying mainly on international efforts from wealthy philanthropists, donor countries and facilities such as the Global Fund to resolve Africa’s accumulated Public Health problems. Some are also still focusing on only some specific diseases without long-term perspectives to ensure that Public Health is comprehensively promoted to resolve what are essentially interlinked symptoms of one problem – the lack of a comprehensive long term Public Health policy and planning across Africa.
Donor funding for HIV/AIDS has skyrocketed in the last decade: from US$ 300 million in 1996 to US$ 8.9 billion in 2006; yet, little is understood about how these resources are being spent. This paper analyses the policies and practices of the world’s largest AIDS donors as they are applied in Mozambique, Uganda and Zambia. The report offers a number of recommendations for how donors can improve their programmes to increase the effectiveness of aid. Recommendations for all three donors include: jointly coordinate and plan activities to support the National AIDS Plan, assist the government in tracking total national AIDS funds, focus on building and measuring capacity, and develop strategies with host governments and other donors to ensure financial sustainability.
The Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria today approved 73 new grants worth more than US$ 1.1 billion over two years. The Board has also approved US$ 130 million for renewal of five grants that have reached the end of their five year life. More than 80 percent of the approved Round 7 grants are for low-income countries, with the majority of resources (66 percent) for Africa. Asia and the Western Pacific will receive 13 percent of the newly approved funding, Latin America and the Caribbean five percent, Eastern Europe three percent, and the Middle East 13 percent.
The act is intended to consolidate the laws relating to registered medical schemes; to provide for the establishment of the Council for Medical Schemes as a juristic person; to provide for the appointment of the Registrar of Medical Schemes; to make provision for the registration and control of certain activities of medical schemes; to protect the interests of members of medical schemes; to provide for measures for the coordination of medical schemes; and to provide for incidental matters.
11. Equity and HIV/AIDS
The aim of this study was to investigate knowledge of prevention of mother to child HIV transmission (PMTCT) programmes and to describe potential barriers that might affect their acceptability in a resource poor setting in South Africa. Based on interviews with over 1500 pregnant women, their families and five communities around the PMTCT clinic areas, the authors found that there are several major potential barriers in implementing PMTCT programmes in a resource poor setting. The authors suggest that increased access to HIV testing and counselling would be one of the most effective ways of reducing perinatal transmission. They state that this can be achieved by ensuring that expectant mothers receive antenatal care from trained staff throughout their pregnancy and have a skilled professional childbirth attendant.
This evaluation report from the World Bank’s Operation Evaluation Department (OED) assesses the development effectiveness of the Bank’s country-level HIVand AIDS assistance. The report concludes that Bank assistance has persuaded governments to act earlier or in a more focused and cost-effective way. It also finds that whist Bank assistance has helped raise political commitment, these pledges have sometimes been overestimated and need to be constantly addressed in the country context. The authors recommend that the Bank, in order to have a sustainable impact on the HIV/AIDS epidemic, should help governments use human and financial resources more efficiently and effectively. They also recognise the need to strengthen local monitoring and evaluation practices and help improve the local evidence base for making decisions.
Comparative, multi-country research has been underutilised as a means to inform health system development. South-south collaboration has been particularly poor, even though there have been clearly identified benefits of such endeavours. This commentary argues that in a context of HIV/AIDS, the need for regional learning has become even greater. This is because of the regional nature of the problem and the unique challenges that it creates for health systems. We draw on the experience of doing comparative research in South Africa, Tanzania and Zambia, to demonstrate that it can be useful for determining preconditions for the success of health care reforms, for affirming common issues faced by countries in the region, and for developing research capacity. Furthermore, these benefits can be derived by all countries participating in such research, irrespective of differences in capacity or socio-economic development.
The new Epidemic Updates reflects improved and expanded epidemiological data and analyses that present a better understanding of the global epidemic. These new data and advances in methodology have resulted in substantial revisions from previous estimates. While the global prevalence of HIV infection—the percentage of people infected with HIV — has levelled off, the total number of people living with HIV is increasing because of ongoing acquisition of HIV infection, combined with longer survival times, in a continuously growing
general population. Global HIV incidence — the number of new HIV infections per year — is now estimated to have peaked in the late 1990s at over 3 million [2.4 – 5.1 million] new infections per year, and is estimated in 2007 to be 2.5 million [1.8 – 4.1 million] new infections, an average of more than 6 800 new infections each day. This reflects natural trends in the epidemic, as well as the result of HIV prevention efforts.
This paper discusses the issue of equity in the distribution of ARV drugs in the Malawi health system. Malawi is one of the countries most severely affected by HIV/AIDS in southern Africa. It is also one of the poorest countries in the world.ARV drugs are expensive.The Malawi government, with assistance from the Global Fund on Tuberculosis, Malaria and HIV/AIDS, started providing free ARV drugs to eligible HIV-infected people in September 2004.The provision of free drugs brought the hope that everyone who was eligible would access them. Based on data collected through a qualitative research methodology, it was found that achieving equity in provision would face several challenges including policy, operational and socio-economic considerations. Specifically, the existing policy framework, shortage of medical personnel, access to information and inadequacy of effective community support groups are some of the key issues affecting equity.
This study aimed to explore perceptions of Uganda-based key decision-makers about the past, present and optimal future roles of FBOs in HIV/AIDS work, including actions to promote or dissuade stigma and discrimination. Uganda's program continues to face challenges, including perceptions among the general population that HIV/AIDS is a cause for secrecy. By virtue of their networks and influence, respondents believe that FBOs are well-positioned to contribute to breaking the silence about HIV/AIDS which undermines prevention, care and treatment efforts.
This paper presents findings from a study on the experiences of orphan care among Langi people of Amach sub-county in Lira District, northern Uganda, and discusses their policy implications.The findings revealed that the Langi people have an inherently problematic orphan concept, which contribute toward discriminatory attitudes and practices against orphans.The clan based decision-making to care for orphans, the category of kin a particular orphan ends up living with, the sex and age of the orphan, as well as the cessation of the ‘widow-inheritance' custom emerged as prominent factors which impact on orphan care.Thus there is the need to draw upon such local knowledge in policy making and intervention planning for orphans.
Successful nutritional care and support of PLWHA requires an inferred partnership between those affected and different levels of care providers. A coordinated effort is required from people in many disciplines. The wide dissemination and use of these Guidelines, as well as supportive policies and services to implement the recommendations herein, will help all stakeholders to improve the quality of life of people living with HIV and AIDS.
This report and policy brief summarises the key findings and suggested policy options that emerged from rapporteur reports of conference proceedings including the following themes: (1) Orphans and vulnerable children, (2) Treatment, (3) Prevention, (4) Gender and male involvement, (5) Male circumcision, (6) People living with HIV and AIDS, (7) Food and nutrition, (8) Socioeconomics, and (9) Politics/policy. Policy frameworks which are likely to succeed in combating HIV and AIDS need to be updated to cover issues of access, testing, disclosure and stigma.
This report from UNAIDS assesses the implementation of the Global Task Team (GTT) recommendations in two key areas: technical support provision to the national AIDS response as brokered by the UN system; and harmonisation and alignment of international partners. In the area of technical support, the report concludes that the UN has made significant progress in establishing joint teams on AIDS and recognises that they are beginning to enable the UN to speak and act as “one” on HIV/AIDS issues. However differences in commitment to joint working and in skills and capacity between agencies combined with high work loads are putting pressures on these teams. The harmonisation and alignment agenda needs strong leadership from headquarters about the importance of joint working.
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12. Governance and participation in health
Civil Society Organisations, especially those actively engaged with the health sector, have been largely of the opinion that the Commission constitutes a major opportunity to address key issues in the health sector. This is especially so as the Commission is seen to be engaged in examining and taking forward some of the key fundamentals of the Alma Ata declaration – viz. a Health Systems approach that foregrounds Primary Health Care and locating health in a larger social, economic and political context.
Good public-health decisionmaking is dependent on reliable and timely statistics on births and deaths (including the medical causes of death). All high-income countries, without exception, have national civil registration systems that record these events and generate regular, frequent, and timely vital statistics. By contrast, these statistics are not available in many low-income and lower-middle-income countries, even though it is in such settings that premature mortality is most severe and the need for robust evidence to back decisionmaking most critical. Civil registration also has a range of benefits for individuals in terms of legal status, and the protection of economic, social, and human rights. However, over the past 30 years, the global health and development community has failed to provide the needed technical and financial support to countries to develop civil registration systems. There is no single blueprint for establishing and maintaining such systems and ensuring the availability of sound vital statistics. Each country faces a different set of challenges, and strategies must be tailored accordingly. There are steps that can be taken, however, and we propose an approach that couples the application of methods to generate better vital statistics in the short term with capacity-building for comprehensive civil registration systems in the long run.
13. Monitoring equity and research policy
Most developing countries do not have fully effective civil registration systems to provide necessary information about population health. Interim approaches—both innovative strategies for collection of data, and methods of assessment or estimation of these data—to fill the resulting information gaps have been developed and refined over the past four decades. To respond to the needs for data for births, deaths, and causes of death, data collection systems such as population censuses, sample vital registration systems, demographic surveillance sites, and internationally-coordinated sample survey programmes in combination with enhanced methods of assessment and analysis have been successfully implemented to complement civil registration systems. Methods of assessment and analysis of incomplete information or indirect indicators have also been improved, as have approaches to ascertainment of cause of death by verbal autopsy, disease modelling, and other strategies. Our knowledge of demography and descriptive epidemiology of populations in developing countries has been greatly increased by the widespread use of these interim approaches; although gaps remain, particularly for adult mortality.
In May 2006, the Ministers of Health of all African countries, at a special session of the African Union, undertook to institutionalise efficiency monitoring within their respective national health information management systems. The specific objectives of this study were: (i) to assess the technical efficiency of National Health Systems (NHSs) of African countries for measuring male and female life expectancies, and (ii) to assess changes in health productivity over time with a view to analysing changes in efficiency and changes in technology. The analysis was based on a five-year panel data (1999-2003) from all 53 countries. Data Envelopment Analysis (DEA) − a non-parametric linear programming approach − was employed to assess the technical efficiency. Malmquist Total Factor Productivity (MTFP) was used to analyse efficiency and productivity change over time among the 53 countries' national health systems. The data consisted of two outputs (male and female life expectancies) and two inputs (per capital total health expenditure and adult literacy). All the 53 countries' national health systems registered improvements in total factor productivity, attributable mainly to technical progress. Over half of the countries' national health systems had a pure efficiency index of less than one, signifying that those countries' NHSs pure efficiency contributed negatively to productivity change.
This report begins by identifying six problems which make developing the evidence base on the social determinants of health potentially difficult. In order to overcome these difficulties a number of principles are described which help move the measurement of the social determinants forward. The report proceeds by describing in detail what the evidence based approach entails including reference to equity proofing. The implications of methodological diversity are also explored. A framework for developing, implementing, monitoring and evaluating policy is outlined. At the centre of the framework is the policy-making process which is described beginning with a consideration of the challenges of policies relating to the social determinants.
14. Useful Resources
This volume aims to provide researchers and analysts with a step-by-step practical guide to the measurement of a variety of aspects of health equity. Each chapter includes worked examples and computer code. This is intended to help build more comprehensive monitoring of trends in health equity, a better understanding of the causes of these inequities, more extensive evaluation of the impacts of development programs on health equity, and more effective policies and programs to reduce inequities in the health sector.
These guidelines focus on the inpatient management of the major causes of childhood mortality such as pneumonia, diarrhoea, malaria, severe malnutrition, meningitis, HIV, neonatal and related conditions. The basis of these guidelines is the WHO IMCI Manual, “The Management of the Child with a Serious Illness or Severe Malnutrition.” This booklet is a result of a workshop in Machakos in February 2004 drawing together experienced paediatricians from the Ministry of Health, Kenyatta National Hospital, KEMRI and the University of Nairobi. It deals with the management of seriously ill children in the first 48 hours.
15. Jobs and Announcements
The theme of the third national conference of peer education, HIV and AIDS, is 'Stigma, lets act now'. The conference will bring together participants from diverse peer education groups in Kenya and the region, and organisations implementing different aspects of HIV and AIDS, treatment, care and support.
A short video is now available on the website of the World Health Organisation (WHO) Global Health Workforce Alliance. In it, Dr Omaswa refers to the first Global Forum on Human Resources for Health, to be held in Kampala , Uganda , on 2-7 March 2008. This conference is a remarkable and unique opportunity to bring together all those who are working to meet the needs of health workers in developing countries - whether our focus is on Skills, Equipment, Information, Structural support, Medicines, Incentives, and/or Communication facilities. Together participants can "plan and build a global movement to ensure that every person in every village everywhere has access to a skilled, motivated and supported health worker". The Forum meshes well with current movements to revitalize primary health care on the 60th anniversary of WHO, 30 years after Alma Ata. It promises to be an exciting and critical next step for achieving global goals and re-energising the global movement for better health in the 21st century. It is also an opportunity for HIFA2015 and CHILD2015 members to meet up.
This new program approaches health outcomes from the demand side through a multisectoral perspective, looking into mechanisms such as Poverty Reduction Strategy Papers (PRSPs), and Sector Wide Approaches (SWAPs). The course underscores the different roles necessary at each different sector for a multisectoral approach, the need for coordination at the central level, and also alignment of donors with national processes - especially budgets - to ensure harmonization. This course will build capacity for developing multisectoral health outcome strategies, emphasizing that better effective interventions, actions and policies exist and that adaptation to the country situation is critical. The application deadline is 22 February 2008.
The seminar series aims to provide a forum where cutting-edge research and ideas on innovation, access to knowledge and intellectual property, from a development perspective, are presented and debated. Speakers are researchers and policy analysts especially from the South who focus their work on key issues for developing countries and the international community more generally. The seminar series plays an important role in linking local/national circumstances and challenges, and the norm-setting activities in various international institutions and process. By engaging negotiators and key players in international processes, the seminars will also contribute to promoting evidence-based norm-setting in key institutions such as the World Intellectual Property Organization (WIPO), the World Health Organization (WHO), the World Trade Organization (WTO), among other organisations and processes.
The Innovation and Access to Knowledge Programme (IAKP) of the South Centre seeks applicants for a 12 month Research Fellowship in Innovation, Public Health and Intellectual Property. Applicants should send their applications indicating their interest and highlighting their relevant qualifications and experience as well as detailed CVs, letter of interest, references, preferably by email, by 18h00 Central European Time (CET) on 14 December 2007 to: Ms. Caroline Ngome Eneme, Administrative Assistant, Innovation and Access to Knowledge Programme, South Centre, Chemin du Champ D’Anier 17, P.O.B. 228, 1211 Genev
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