There is no question that a large-scale global expansion of health services is needed to reach the internationally agreed Millennium Development Goals for health. But how this massive scale up is to be achieved is the subject of considerable debate.
What exactly is the best way to reduce the number of women dying in pregnancy and childbirth and the number of children killed everyday by pneumonia and diarrhoea? How can we best ensure that, for those living with HIV and AIDS, anti-retroviral medicines are widely available?
For many international organisations and donors, an expansion of private sector health care delivery is considered the key to scaling up health care systems in poor countries. As a result, a growing number of influential organisations are pushing for increased funding of private sector health care, fostering the idea that those who can afford it should pay for their own private health care, and that governments should contract private providers to serve those who cannot.
The World Bank is one such body, advocating private sector involvement in health care while decrying the failure of public health systems in poor countries.
But are institutions that promote the increased role of the private sector in health using reliable evidence to inform their policy decisions? What does the evidence of other countries tell us; countries that have successfully managed to achieve universal access to health care?
Recent research has found that worldwide, publicly financed and delivered services continue to dominate in higher performing and more redistributive health care systems. Studies suggest that no low or middle-income country in Asia has achieved universal or near-universal access to health care without relying solely or predominantly on tax-funded public delivery.
The country level evidence speaks for itself: in just ten years, Botswana, Sri Lanka, South Korea, Malaysia, Barbados, Costa Rica, Cuba and the India State of Kerala were all able to cut child deaths by between 40 and 70 per cent – thanks to committed action by governments in organising and providing health services.
At the same time, the evidence in favour of private sector solutions is far from strong. On the contrary, there is considerable and increasing evidence that there are serious failings inherent in private provision, which makes it a very risky and costly path to take.
In China the rapid proliferation in number of private health facilities since the 1980s has led to significant declines in productivity, rising prices and reduced utilisation. Lebanon has one of the most privatised health systems in the developing world, it spends more than twice as much as Sri Lanka on health care yet its infant and maternal mortality rates are two and a half and three times higher respectively. And due to wide scale private sector participation in Chile’s health care system it has one of the world’s highest rates of birth by Caesarean section – a more costly and profitable procedure than natural delivery and often unnecessary.
So why do so many influential institutions persist in pushing the role of the private sector?
A major part of the answer lies in a number of common assumptions that are made in favour of for-profit private health-care provision, and which tend to persist unchallenged in the debate.
Firstly many argue that the private sector is already the majority provider in poor countries and it is therefore ‘common sense’ to put it at the heart of scaling up health services. But closer analysis of the data in Africa reveals that nearly 40% of so-called ‘private providers’ are in fact unqualified shopkeepers selling drugs of unknown quality. The same data shows that across 15 sub-Saharan African countries only 3 per cent of the poorest fifth of the population who sought care when sick actually saw a private doctor. And even when the private sector is a significant provider it doesn’t mean overall health care access has improved – over half of the poorest children in Africa have no health care at all. As a Senior Civil Servant from the Ministry of Health in Malawi has stated, ‘When poor people cannot get free services they do not go to private clinics, they go to the bush first and look for herbs.’
Another assumption is that the private sector can provide additional investment to public health systems that need it, but South Africa is one example that demonstrates that to attract private providers to low-income risky health markets significant public subsidy is often required, meaning governments have less money to spend on public health care.
Thirdly it is often claimed that the private sector can achieve better results at lower costs, yet private participation in health care is associated with higher, rather than lower, expenditure. The US commercialised health system costs 15.2 per cent of GDP, while across the border the Canadian national health system costs only 9.7 per cent of GDP. Canada has lower infant and child mortality rates and 46 million Americans have no health care at all.
A fourth claim often made is that the private sector provides superior quality health care, yet the World Bank itself reports that the private sector generally performs worse on technical quality than the public sector. And poor quality in the unregulated informal private health care sector puts millions of lives at risk every day.
A fifth argument made in favour of private sector health care is that it can help reduce inequity and reach the poor, but evidence finds this is not the case. For example market reforms of public health systems in both China and Viet Nam have coincided with a substantial increase in rural people reporting illness but not using any health services.
The last assumption is that the private sector can approve accountability, yet there is no evidence that private health care providers are any more responsive or any less corrupt than the public sector, and when the private sector provides health services on behalf of the state it can make it more difficult for citizens to hold their government to account.
Oxfam’s new briefing paper, ‘Blind Optimism: Challenging the myths about private health care in poor countries,’ released on 11 February, examines these six arguments made in support of the private sector, and looks at the evidence, or lack of it, behind them. It demonstrates that there is an urgent need to reassess the arguments used in favour of scaling up private sector health care provision in poor countries, concluding that prioritising the private sector in health care delivery is extremely unlikely to deliver health for poor people.
Further information on Oxfam and the issues raised in this briefing please visit www.oxfam.org/en/campaigns/health-education/health and email
amarriott@oxfam.org.uk or email the EQUINET secretariat at admin@equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
Have non-financial incentives been successful in retaining health workers in Swaziland? This study reviewed health policy and programme documents in Swaziland relevant to health workers and found that only one that mentioned non-financial incentives, suggesting that the value of these incentives is under-rated in policy. In contrast, a field study interviewing health workers at different levels of the health system revealed that most workers in Swaziland consider non-financial incentives to be more important than salary in determining whether or not they will remain in their jobs or join the 'medical brain drain' overseas.
Training and Research Support Centre offer a one day workshop on September 26 2009 for 30 people at the EQUINET Conference in September 2009. The workshop draws on experiences from TARSC and other partners in the field of Youth Reproductive Health, with a particular emphasis on the relationship between youth and health workers. In exploring ways to strengthen the gap between the two, this workshop will offer insight and adaptable strategies that can be used to facilitate dialogue, using participatory approaches including use of the ‘Auntie Stella’ toolkit. Deliberations will include:
• The importance of health worker and youth relations in building a more people-centred health system
• A discussion on the barriers to youth-health worker relations
• How these barriers can be overcome, with a particular focus on participatory approaches
• Discussion on how the interactive toolkit, ‘Auntie Stella’: Teenagers talk about sex, life and relationships can be used and adapted to strengthen youth-health worker understanding and communication (See www.tarsc.org/auntiestella for more information about ‘Auntie Stella’.)
The workshop will be interactive and will introduce a number of participatory tools that participants can use in their work with youth. At the end of the workshop we will also share with the participants follow up activities To register fill in the registration form available on the EQUINET conference site at www.equinetafrica.org/conference2009/index.php giving the name of the workshop and email us on admin@equinetafrica.org
The University of Cape Town is offering a pre conference workshop on September 22 2009 at the EQUINET Conference September 2009 to:
* Reflect on health policy analysis and its role in health system development
* Share experience in the use of health policy analysis to support policy development and implementation
* Share experience in teaching health policy analysis (in short course, post-graduate programmes etc)
* Develop shared ideas of how to strengthen this field of work in Africa.
This workshop is relevant to you if you seek to influence and shape health policy agendas; analyse or support the processes of health policy-making and implementation at any level of the health system; work as a health leader and want to develop your ideas about how to strengthen the implementation of policy, or teach others about health policy analysis.
The workshop will be interactive and based on the experience that those attending it wish to share. To register fill in the registration form available at http://www.equinetafrica.org/conference2009/index.php giving the name of the workshop and email it to admin@equinetafrica.org
3. Equity in Health
Africa is confronted by a heavy burden of communicable and non-communicable diseases. Cost-effective interventions that can prevent the disease burden exist but coverage is too low due to health systems weaknesses. This editorial reviews the challenges related to leadership and governance; health workforce; medical products, vaccines and technologies; information; financing; and services delivery. It also provides an overview of the orientations provided by the WHO Regional Committee for Africa for overcoming those challenges. It cautions that it might not be possible to adequately implement those orientations without a concerted fight against corruption, sustained domestic and external investment in social sectors, and enabling macroeconomic and political (i.e. internally secure) environment.
Health security must be addressed with great urgency, and health-system strengthening is one of the surest routes to health security. The world is not secure when the difference in life expectancy between the poorest and the richest countries exceeds 40 years, or when annual governmental expenditure on health ranges from US$20 per person to well over $6000. It is not secure when more than 40% of the population in sub-Saharan Africa is living on less than a dollar a day. We will not be able to reach the health-related MDGs unless we return to the values, principles, and approaches of primary health care. There are striking inequities in health outcomes, access to care, and what people pay for care. Many health systems have lost their focus on fair access to care, their ability to invest resources wisely, and their capacity to meet people's needs and expectations.
The objectives of this document were to: build awareness of the ways in which an economic downturn may affect health spending, health services, health-seeking behaviour and health outcomes; make the case for sustaining investments in health; and to identify actions – including monitoring of early warning signs – that can help to mitigate the negative impact of economic downturns. Leaders in health must be prepared to speak out – unequivocally and on the basis of sound evidence – to make the case for health at times of crisis. Country-specific analysis is essential to guide policy and assess the potential impact on different populations and institutions. Counter-cyclical public spending provides a means of reviving economies. Aid will play a key role in providing a boost that many low-income countries cannot finance alone. The challenge is to ensure that spending is genuinely pro-poor and that, where possible, it has a positive impact on health. Primary health care provides an overarching approach to policy at a time of financial crisis. Its continuing relevance lies in its value base – stressing the importance of equity, solidarity and gender; through inclusiveness – and the objective of working towards universal coverage and pooling of risk; through a multisectoral approach to achieving better outcomes; and through utilising the assets of all health actors in the private, voluntary and nongovernment sectors.
Progress in basic social indicators slowed down last year all over the world. at the present rate it does not allow for the internationally agreed poverty reduction goals to be met by 2015, unless substantial changes occur, according to the 2008 Basic Capabilities Index (BCI), calculated by Social Watch. Out of 176 countries for which a BCI figure can be computed, only 21 register noticeable progress in social indicators relative to 2000. another 55 countries show some progress, but at a slow rate, while 77 countries showed stagnation or decline in social indicators. Information is insufficient to show trends for the remaining 23. As the impact of the food crisis that started in 2006 begins to be registered in the statistics coming in, indicators are likely to deteriorate in the coming months. Contrary to frequent claims that poverty is diminishing in the world, the index computed by Social Watch shows a persistent shortfall in basic needs even in conditions of economic growth.
4. Values, Policies and Rights
In Part 1 of this three-part study, the authors undertook a multi-method study in three phases – a survey, interviews and case descriptions that drew on site visits – and in each of the second and third phases they focused on a purposive sample of those involved in the previous phase. Seven recommendations emerged for those involved in establishing or leading organisations that support the use of research evidence in developing health policy: collaborate with other organisations; establish strong links with policymakers and involve stakeholders in the work; be independent and manage conflicts of interest among those involved in the work; build capacity among those working in the organisation; use good methods and be transparent in the work; start small, have a clear audience and scope, and address important questions; and be attentive to implementation considerations, even if implementation is not a remit.
In Part 2, the authors drew on many people and organisations around the world, including their project reference group, to generate a list of organisations to survey. They sent the questionnaire by email to 176 organisations and followed up periodically with non-responders by email and telephone. They received completed questionnaires from 152 (86%) organisations. More than one-half of the organisations (and particularly HTA agencies) reported that examples from other countries were helpful in establishing their organisation. The findings confirm that the principles of evidence-based medicine dominate current guideline programmes and underline the importance of collaborating with other organisations. The survey also provides a description of the history, structure, processes, outputs, and perceived strengths and weaknesses of existing organisations from which those establishing or leading similar organisations can draw.
In Part 3, the authors purposively sampled organisations from among those who completed a questionnaire in the first phase of the study, developed and piloted a semi-structured interview guide, and conducted the interviews by telephone, audio-taped them, and took notes simultaneously. They interviewed the director (or his or her nominee) in 25 organisations, of which 12 were GSUs. Using rigorous methods that are systematic and transparent (sometimes shortened to 'being evidence-based') was the most commonly cited strength among all organisations. GSUs more consistently described their close links with policymakers as a strength, whereas organisations producing CPGs, HTAs, or both had conflicting viewpoints about such close links. With few exceptions, all types of organisations tended to focus largely on weaknesses in implementation, rather than strengths.
Zimbabwe is a party to the International Covenant on Economic, Social and Cultural Rights, the Convention on the Rights of the Child, the Convention on the Elimination of All Forms of Discrimination against Women and the African Charter on Human and Peoples’ Rights. It has a legally binding obligation to respect, protect and fulfill these rights for all people within its jurisdiction. The report argues that a causal chain runs from Mugabe’s economic policies, to Zimbabwe’s economic collapse, food insecurity and malnutrition, and the current outbreaks of infectious disease. The determinants of health, such as broken sewerage systems, chronic food insecurity and widespread starvation, underlie disease epidemics such as cholera and anthrax and a deterioration of maternal health care. The authors recommend that the international community needs to resolve the political impasse, launch an emergency health response with services controlled by a United Nations-designated agency or consortium, refer the situation to the International Criminal Court for Crimes against Humanity, convene an emergency summit on HIV, AIDS and TB and prevent further deterioration of household food supply.
In this paper, some of the right-to-health features of health systems are identified, such as a comprehensive national health plan, and 72 indicators are proposed that reflect some of these features. Globally processed data on these indicators was collected for 194 countries. Globally processed data was not available for 18 indicators for any country, suggesting that organisations that obtain such data give insufficient attention to the right-to-health features of health systems. Where available, indicators show where health systems need to be improved to better realise the right to health. The paper provides recommendations for governments, international bodies, civil-society organisations, and other institutions and suggests that these indicators and data, although not perfect, provide a basis for the monitoring of health systems and the progressive realisation of the right to health. Right-to-health features are obligations under human rights law.
The People’s Health Movement ((PHM) has significantly advanced in the campaign's expansion since its last update in May 2008. India, Ecuador, Zimbabwe and South Africa are involved in the campaign without receiving funding. New PHM circles have been formed in the last three months in Mali, Kenya, Morocco and Uganda and they will be submitting campaign proposals shortly. The countries that have almost completed the assessment are now eligible for a small additional funding to hold a national workshop in which to present the results to the government, UN agencies, international and national NGOs and the media. Any country not mentioned here is welcome to inquire with PHM how they can get a PHM circle going so as to launch the campaign.
Benchmarking exercises have become increasingly popular within the sphere of regional policy-making. This paper analyses the concept of regional benchmarking and its links with regional policy-making processes. It develops a typology of regional benchmarking exercises and benchmarkers, and critically reviews the literature. It is argued that critics of regional benchmarking fail to take account of the variety and development of regional benchmarking systems. It is suggested that while benchmarking exercises are informing policy adaptation and innovation, they have been constrained by political and financial factors. It is concluded that regional benchmarking is facilitating the heightened regional interaction necessitated by globalisation.
Cancer is causing a lot of suffering and death in Africa but is not considered a major health problem in Africa. This needs to change. Cancer should be given equal emphasis to HIV/AIDS, tuberculosis (TB) and malaria. A national cancer policy is required in Malawi to develop and improve evidence-based cancer prevention, early diagnosis, curative and palliative therapy. A national cancer policy is crucial to ensure a priotised, clear, coordinated and sustained fight against cancer. When no policy exists, events are likely to be random, stakeholders and practitioners in the fight against cancer may not agree on how to proceed, may duplicate efforts or may neglect areas that would have greater nationwide impact resulting in poor quality activities and haphazard development.
Few empirical studies of research utilisation have been conducted in low- and middle-income countries. This paper explores how research information, in particular findings from randomised controlled trials and systematic reviews, informed policy making and clinical guideline development for the use of magnesium sulphate in the treatment of eclampsia and pre-eclampsia in South Africa. A qualitative case-study approach was used to examine the policy process, which included a literature review, a policy document review, a timeline of key events and the collection and analysis of 15 interviews with policy makers and academic clinicians The paper concludes that networks of researchers were important not only in using research information to shape policy but also in placing issues on the policy agenda. A policy context that creates a window of opportunity for new research-informed policy development is crucial.
5. Health equity in economic and trade policies
Kenya, the third-biggest African market for Indian medicines, is planning a new legislation against ‘counterfeiting’ that could seriously jeopardise India’s medicine exports to that country. Domestic industry fears that other African nations may follow suit. The Anti-Counterfeit Bill, 2008, placed before the Kenyan parliament recently, indicates that copies or generic versions of all products having patent protection in Kenya or elsewhere can be considered ‘counterfeit’ in case of an intellectual property dispute. Since a majority of medicines manufactured by Indian companies are under patent protection in some country or the other (though they do not enjoy patent protection in India or Kenya), the definition, in its current form, can be misused to delay or prevent supply of low-cost generic medicines to Kenya, industry experts fear.
6. Poverty and health
The aim of this study was to describe current infant growth patterns using WHO Child Growth Standards and to determine the extent to which these patterns are associated with infant feeding practices, equity dimensions, morbidity and use of primary health care for the infants. A cross-sectional survey of infant feeding practices, socio-economic characteristics and anthropometric measurements was conducted in Mbale District, Eastern Uganda in 2003; 723 mother-infant (0-11 months) pairs were analysed. The adjusted analysis for stunting showed stunting was more prevalent among boys (58.7% versus 41.3%). Having brothers and/or sisters was a protective factor against stunting, but replacement or mixed feeding was not. Lowest household wealth was the most prominent factor associated with stunting with a more than three-fold increase in odds ratio. In conclusion, stunting is related to sub-optimal infant feeding practices after birth, poor household wealth, age, gender and family size.
Using a cross-country data, drawn from sub-Saharan Africa and a multiple regression analysis, this paper examines the extent to which low nutrient intake has impacted on infant mortality rate in sub-Saharan Africa. The results indicate that low nutrient intake has a significant influence on infant mortality rate, thus fulfilling the a-priori expectation that the lower the nutrient intake, the higher the rate of infant mortality rate in sub-Saharan Africa. Given this, measures such as, increase in food availability, macro-economic stability (especially, a reduction in inflation rate and exchange rate stability), improved nutrition through micro-nutrients fortification and supplementation, ensuring good governance and combating ethnic/religious/ civil conflicts and HIV/AIDS are suggested as possible solutions to improving nutrient intake in sub-Saharan Africa.
Pimbert’s book covers a range of topics related to food sovereignty. He looks at local food systems, livelihoods and environments, and the ecological basis of food systems before explaining how the current multiple crises in food, agriculture and environment arose, in terms of the social and environmental costs of modern food systems. The book concludes with the author’s vision of a way forward: He presents food sovereignty as an alternative paradigm for food and agriculture and discusses how to promote national policies and legislation and global multilateralism and policies that promote food sovereignty.
Cholera can rapidly lead to severe dehydration and death if left untreated. Oral rehydration salts (ORS) can successfully treat 80% of cholera patients - both adults and children –and should be given early at home to avert delays in rehydration and improve survival. WHO outlines in the report that it does not see any contradiction in making ORS packages available to households and non-medical personnel outside health care facilities. In contrast, making ORS available at household and community levels can avert unnecessary deaths and contributes to diminishing case fatality rates, particularly in resource-poor settings. Providing nutritious food as well as continuing breastfeeding for infants and young children should continue simultaneously with administering appropriate fluids or ORS.
During his three-day visit from 16-19 December 2008, Dr Sambo held discussions with national authorities and partners on ways and means of bringing an end to the spread of the cholera epidemic. Dr Sambo advised that beyond cholera, other specific health problems may become worse if the key social and economic determinants of health are not urgently improved. He highlighted the importance of inter-sectoral approach in the prevention of cholera and reached agreement with the Minister of Health to establish the Cholera Command and Control Centre, jointly operated by WHO and the Ministry of Health of Zimbabwe, to coordinate and boost the country’s capacity to manage the response particularly in the areas of disease surveillance, case management, water and sanitation, social mobilisation and logistics.
7. Equitable health services
This paper reports on a cross-sectional study conducted between May and August,2007 in Wakiso district. A total of 762 women (442 adolescents and 320 adult)were interviewed using a structured questionnaire. The study calculated odds ratios with their 95% CI for antenatal and postnatal health care seeking, stigmatisation and violence experienced from parents comparing adolescents to adult first time mothers. It found that adolescent mothers showed poorer health care seeking behaviour for themselves and their children, and experienced increased community stigmatisation and violence, suggesting bigger challenges to the adolescent mothers in terms of social support. The authors propose that adolescent-friendly interventions such as pregnancy groups targeting to empower pregnant adolescents providing information on pregnancy, delivery and early childhood care need to be introduced and implemented.
This report from the Global Alliance for Vaccines and Immunisation (GAVI) Alliance looks at how failing or inadequate health systems are one of the main obstacles to scaling up effective distribution of life-saving interventions such as drugs, vaccines and other preventative treatments. The report describes health system strengthening (HSS) as improving governance and leadership, health financing, human resources management, information and knowledge strategies, service delivery and technology and infrastructure. All GAVI-eligible countries (those with a gross national income per capita of less than US$ 1000 in 2003) can apply for health system strengthening funds. Applications for these funds should be coordinated by the national health sector coordination committee (which should involve health sector stakeholders including civil society) and must be approved by ministries of health and finance.
This paper discusses some of the approaches to technical support for health systems strengthening taken to date, and looks at problems and possible solutions. It finds that the growing resources available for health system strengthening are not accompanied by resources and commitment to providing technical support. Furthermore, the global market for technical support is complex: multiple agencies use different approaches for providing support, and a number of issues, including institutional roles, affect the supply and demand for high quality technical assistance. The paper concludes that the provision of technical support for health systems strengthening needs to be scaled up considerably, but in ways that best fit country realities on the ground. Technical support approaches need to take into account the complexity of a country’s national health system and the context within which it operates.
In 2000, WHO published its first attempt to assess the performance of the world’s health systems in The World Health Report 2000. This report generated enormous interest but, in many ways, the scientific progress was overshadowed by the political debate related to the estimates of country-level performance and the associated league tables. Since then, the WHO European and Eastern Mediterranean Regional Offices have maintained health system observatories, with detailed descriptions of country systems. The considerable interest in measuring the performance of health systems worldwide is illustrated by the recent European Ministerial Conference on Health Systems, which culminated in the Tallinn Charter entitled Health systems for health and wealth. In developed countries, primary concerns include costs, quality of care, aging and chronic diseases. In developing countries, health system constraints have restricted progress towards the UN Millennium Development Goals.
The aim of this study was to describe the implementation process of a national anti-tuberculosis drug resistance survey in Tanzania, in relation to the study protocol and standard operating procedures. Factors contributing positively to the implementation of the survey were a continuous commitment of the key stakeholders, the existence of a well-organised National Tuberculosis Programme, and a detailed design of cluster-specific arrangements for rapid sputum transportation. Factors contributing negatively to the implementation were a long delay between training and actual survey activities, limited monitoring of activities, and an unclear design of the data capture forms leading to difficulties in form-filling. Careful preparation of the survey, timing of planned activities, a strong emphasis on data capture tools and data management, and timely supervision are essential.
Delivery of two doses of intermittent preventive treatment of malaria during pregnancy (IPTp) is a key strategy to reduce the burden of malaria in pregnancy in sub-Saharan Africa. This investigation measured coverage of IPTp at national level in Tanzania and examined the role of individual, facility, and policy level influences on achieved coverage. Three national household and linked reproductive and child health (RCH) facility surveys were conducted July-August 2005, 2006, and 2007 in 21 randomly selected districts. National IPTp coverage had declined over the survey period being 71% for first dose in 2005 falling to 65% in 2007 and 38% for second dose in 2005 but 30% in 2007. There is scope to improve IPTp first and second dose coverage at national scale within existing systems by improving stock at RCH, and by revising the existing guidelines to recommend delivery of IPTp after quickening, rather than at a pre-defined antenatal visit.
Primary care internationally is approaching a new paradigm. The change agenda implicit in this threatens to destabilise and challenge established general practice and primary care. The Primary Care Amplification Model offers a means to harness the change agenda by 'amplifying' the strengths of established general practices around a 'beacon' practice. This 'beacon' practices can provide a mustering point for an expanded scope of practice for primary care, by offering integrated primary/secondary service delivery, interprofessional learning, relevant local clinical research and a focus on local service innovation, enhancing rather than fragmenting the collective capacity of existing primary care.
8. Human Resources
The aim of this paper is to give an overview of the development process of a computer-based job task analysis instrument for real-time observations to quantify the job tasks performed by physicians working in different medical settings. First, lists comprising tasks performed by physicians in different care settings were classified. Then, content validity of task lists was proved. After establishing the final task categories, computer software was programmed and implemented in a mobile personal computer. Finally, inter-observer reliability was evaluated. Content validity of the task lists was confirmed by observations and experienced specialists of each medical area. Development process of the job task analysis instrument was completed successfully. Simultaneous records showed adequate interrater reliability. Based on results using this method, possible improvements for health professionals' work organisation can be identified.
Drawing on IntraHealth International's lessons learned in designing reproductive health and HIV/AIDS training and performance improvement programmes, this commentary discusses promising practices for strengthening human resources for health through more efficient and effective training and learning programmes that avoid the same old traps. These promising practices include the following: assessing performance gaps and opportunities before designing a training initiative; addressing performance factors other than skills and knowledge that health workers need to perform well; applying a ‘learning for performance’ approach; standardising curricula throughout a country; linking pre-service education, in-service training and professional associations; enhancing traditional education; strengthening human resources information systems to improve workforce planning, policies and management; and applying technology to meet training needs.
This study aimed to determine the prevalence and associated factors of psychological distress among attendees of traditional healing practices in two districts in Uganda. Face-to-face interviews with the Lusoga version of the self-reporting questionnaire (SRQ-20) were carried out with 400 patients over the age of 18 years attending traditional healing in Iganga and Jinja districts in Eastern Uganda. Three hundred and eighty-seven questionnaire responses were analysed. The study found that a substantial proportion of attendees (61%) of traditional healing practices suffered from psychological distress. Among the socioeconomic indicators, lack of food and having debts were significantly associated with psychological distress. These findings may be useful for policy makers and biomedical health workers for engagement with traditional healers.
In this article, the authors describe health care workers (HCWs') experiences and perceptions of meeting clients exposed to intimate partner violence. Qualitative content analysis of in-depth interviews from 16 informants resulted in four main themes. The first, Internalising women's suffering and powerlessness’, describes HCWs' perceptions of violence, relating it to gender relations. The second, ’Caught between encouraging disclosure and lack of support tools, refers to views on possibilities for transparency and openness. The third, ’Why bother? A struggle to manage with limited resources’, illustrates the consequences of a heavy workload. Last, ‘Striving to make a difference’, emphasises a desire to improve abilities to support clients and advocate for prevention.
The WHO Secretariat held a global, web-based public hearing between 1 September and 3 October 2008 to obtain inputs on the first draft of the WHO code of practice from as wide a group of stakeholders as possible. Member States, national institutions, health professional organisations, nongovernmental organisations, academic institutions, international organisations and other stakeholders submitted more than 90 contributions to the public hearings. Some expressed the view that Article 4 should be revised to provide greater emphasis on the legal responsibilities of health personnel to source and destination countries, such as those to protect the public health interest. Others felt that Article 4 should recommend that states prohibit all active recruitment of health personnel from countries experiencing a health workforce crisis.
9. Public-Private Mix
This study, from the National Bureau of Economic Research, examines the distribution of such spending according to income and type of health care in order to assess whether it would be possible to supply voluntary private health insurance to reduce variation in spending. Using data from the World Health Survey for 14 developing countries, the report finds that out variations in out-of-pocket spending depend on income. The authors use estimates of the variance of total spending, hospital spending, physician spending and outpatient drug spending tends to generate estimates of the amounts of money risk averse consumers might pay for insurance coverage. For hospital spending and total spending, these amounts are larger than the authors consider reasonable, suggesting that voluntary insurance might be feasible. However, the strong relationship between spending and income suggests that insurance markets may need to be segmented by income.
The event ‘Public private partnerships against HIV: How can we together turn the tide?’ was organised by UNAIDS and explored the benefits and challenges of public-private partnerships in the global response to AIDS. Participants agreed that attention should be paid to ensure wide participation and representation across the private sector including from the labour unions, employers’ federations, small and medium enterprises and the informal sector. There is still a lot to do to improve participation by small and medium enterprises and the informal sector which employ most of the labour force in Africa. The group identified four factors as critical in creating and sustaining successful PPPs: clear definition of partners’ roles and responsibilities, transparency and respect for ethical standards, coordination between partners, and periodic assessments of the partnership.
10. Resource allocation and health financing
To address the gap between health investments and financial flows worldwide, the authors identified the patterns in allocation of funds by the four largest donors — i.e. the World Bank, Bill and Melinda Gates Foundation (BMGF), the US Government, and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria — in 2005. They created a disbursement database with information gathered from the annual reports and budgets. Funding per death varied widely according to type of disease. The World Bank, US Government, and Global Fund provided more than 98% of their funds to service delivery, whereas BMGF gave most of its funds to private research organisations, universities and civil societies in rich countries and the US Government and Global Fund primarily disbursed grants to sub-Saharan Africa. Continued attention is needed to develop country ownership, particularly in planning and priority setting.
This study looked at the monitoring and evaluation (M&E) methods used to measure the equity, efficiency and sustainability of the Tanzania National Voucher Scheme (TNVS), which is used to deliver subsidised insecticide-treated mosquito nets (ITNs) to pregnant women and infants in Tanzania. The M&E focused on five key domains: ITN ownership and use among target groups, provision and use of reproductive and child health services, “leakage” of vouchers (use of vouchers by people not meant to benefit from the programme or use of vouchers to buy other things), availability of nets in the commercial ITN market and cost and cost-effectiveness of the scheme. The authors identify several successful features of this approach, namely, independence, breadth of scope, timely reporting with regular feedback, and sustainability - monitoring outcomes over time helps to identify lasting change.
11. Equity and HIV/AIDS
The objective of this paper was to assess the awareness, attitude and perceptions on HIV AND AIDS vaccine trials among students at the University of Dar es Salaam, Tanzania. This was a descriptive cross-sectional study. A total of 384 students were recruited in the study. Out of these, 41.7% reported that HIV vaccine can not prevent the spread of HIV. One hundred-and-four (26.8%) were of the opinion that an HIV vaccine can cause infection to the person vaccinated. The perceptions and attitudes of University of Dar es Salaam students towards HIV vaccine trials were generally positive. However misconceptions were common. The community should be educated more on HIV vaccine trials, and more socio-behavioral studies need to be done among different social groups on HIV vaccine trials.
This study of six countries, including Zimbabwe, Kenya and Uganda, indicates that new investment in AIDS services has exposed existing fragilities in health systems. In some cases it has placed increasing burdens on these systems by expanding demand and stretchied already overextended human resources. The report, which provides some of the first on-the-ground research documenting the impacts of the AIDS service scale up, shows that the AIDS response has attracted the biggest share of health financing, increased the number of trained medical personnel, improved the management of people living with the virus, and supported the establishment of HIV clinics that treat TB and other opportunistic infections.
This study compared risks of perinatal HIV transmission between multiparous women who had previously received a dose of single-dose nevirapine (SDNVP) (exposed) and those that had not (unexposed) and who were given SDNVP for the index pregnancy within a prevention of mother-to-child HIV transmission (PMTCT) clinical study. We also compared transmission risks among exposed and unexposed women who had two consecutive pregnancies within the trial. Transmission risks did not differ between 59 SDNVP-exposed and 782 unexposed women in unadjusted analysis or after adjustment for viral load and disease stage. Transmission risks for women who had two consecutive pregnancies were 7% at both the first (unexposed) and second (exposed) delivery, suggesting that the efficacy of SDNVP may not be diminished when reused in subsequent pregnancies.
Limited information about symptom prevalence exists about HIV infected persons in South Africa, in particular in the context of antiretroviral treatment (ART). The aim of this study was to assess HIV symptoms and demographic, social and disease variables of people living with HIV in South Africa. In 2007, 607 people living with HIV or AIDS (PLWHAs), sampled by all districts in the Eastern Cape Province and recruited through convenience sampling, were interviewed by PLWHAs at health facilities, key informants in the community and support groups. Symptom assessment provided information that may be valuable in evaluating AIDS treatment regimens and defining strategies to improve quality of life. Because of the high levels of symptoms reported (26.1 symptoms out of a possible 64), the results imply an urgent need for effective health care, home- and community-based and self-care symptom management.
Populations at risk for HIV and other sexually transmitted infections (STIs) include those living in rural areas. The authors describe a statewide training programme that targeted rural-based health professionals. This program focused on HIV, STIs, and viral hepatitis and was designed to enhance participants’ ability to conduct sexual histories and risk assessments, educate clients about risk reduction and prevention, screen for and diagnose these infections, clinically manage clients with positive screening test results, access prevention and other educational materials, and conduct other clinical and public health activities. A total of 122 participants reflecting a wide variety of practice settings attended trainings at five sites throughout Minnesota; 74% of participants were nurses and 81% characterised employment settings as rural. Nurses and other health professionals in rural settings are an important training priority and can play an important role in education, prevention, screening, and clinical care for HIV and other STIs.
The Treatment Barometer, a survey by SATAMo on access to AIDS treatment within Southern African Development Community (SADC) countries, calls on regional leaders to keep the promises they made towards the provision of HIV treatment by committing much-needed resources. It’s the first regional treatment monitoring research to be carried out by community-based treatment activists, who noted that more than 80% of SADC governments have not honoured the Abuja Declaration more than seven years after the commitment, barriers to treatment still exist, reports of stigma and discrimination by health care workers remain high, stock-outs of drugs are common in more than 80% of the countries surveyed and most countries are struggling to provide first-line treatment to those who need it, with eight countries in SADC below 35% coverage and only two exceeding 75% coverage.
12. Governance and participation in health
Over the past few years, a flood of new work has emerged challenging the validity of the traditional measurements of corruption and arguing for new and improved tools for national policy makers, civil society and donors alike. This guide suggests ways of measuring corruption promoting a multiple data sourcing approach and a focus on actionable measurements. It is aimed at national stakeholders, donors and international actors involved in corruption measurement and anti-corruption programming. This guide is based on more than thirty interviews with individuals from dozens of countries who are working on corruption and governance reforms. It explains the strengths and limitations of different measurement approaches, and provides practical guidance on how to use the indicators and data generated by corruption measurement tools to identify entry points for anti-corruption programming.
This paper analyses the impact of corruption on the extent of trust in political institutions using data from surveys conducted in eighteen sub-Saharan African countries. The authors test the ‘efficient grease’ hypothesis that corruption can strengthen citizens’ trust since bribe paying and clientelism open the door to otherwise scarce and inaccessible services and subsidies, and that this increases institutional trust. The findings do not support this theoretical argument. The impact of corruption on institutional trust is never positive whatever the evaluation of public service quality. The study shows that the perceived level of corruption has a strong adverse effect on citizens’ trust in political institutions and that the scope of its negative effect increases with the quality of public services, while, in contrast, the negative effect of experienced corruption decreases with the ease of access to public services. These findings call for more detailed and expanded studies.
In many countries, international NGOs have replaced traditional western donors and absentee states' influence by providing services that are traditionally the responsibility of the home governments. The growing trend is for international NGOs wield increasing power and resources in fragile states or so-called ‘failed states’. Western countries prefer to route donor funds through international NGOs rather than national governments, which are perceived as corrupt, bureaucratic or incompetent. The amount of aid flowing through NGOs in Africa rather than governments has more than tripled.
Shah’s book presents the latest thinking of leading development scholars on operationalising a framework of governance to empower citizens to demand accountability from their governments. Focusing on the question of how to institutionalise performance-based accountability, especially in countries that lack good accountability systems, the essays in the book describe how institutions of accountability may be strengthened to combat corruption. In general, the essays in the book highlight the causes of corruption and the use of both internal and external accountability institutions and mechanisms to fight it. It provides advice on how to tailor anticorruption programs to individual country circumstances and how to sequence reform efforts to ensure sustainability. They offer insights into ways policy makers can initiate governance reforms that introduce performance-based accountability in the public sector.
13. Monitoring equity and research policy
This short-term review of the International Health Partnership (IHP+) was commissioned by the IHP+ Scaling-up Reference Group to assess whether programme partners are adhering to their commitments and to review what progress has been made in implementing an IHP+ interagency common work-plan. The review was undertaken between May and August 2008 and is based on the opinions of 100 key informants who represent a cross-section of partner agencies, civil society and national ministries of health in the initial IHP+ countries and at the international level. It found that the relevance of IHP+ is not widely understood, transparency is essential for ensuring accountability (which also depends on the availability of reliable information). If well designed, the planned annual external monitoring and evaluation review of the IHP+ could potentially function as the key global accountability mechanism and it is still too early to assess what impacts or external effects that can be attributed to the IHP+.
The Mexico City Ministerial Summit in 2004 made the problem of poor knowledge translation (KT) a priority, and a solution imperative. Summiteers called for the increased involvement of the demand side in the research process, emphasising knowledge brokering and other mechanisms for ‘involving the potential users of research in setting research priorities’. Though the declaration was made with enthusiasm – and echoed in many follow-up meetings and papers – there was little guidance on how to actually bring together research and research-users. This guide addresses that gap. It discusses three core KT principles: knowledge, which depends on a robust, accessible and contextualised knowledge base, regular dialogue between all stakeholders and strengthened capacity, where researchers, decision-makers and other research users require a strengthened skill-base to create and respond to KT opportunities.
14. Useful Resources
The attainment of the Millennium Development Goals has been hampered by the lack of skilled and well-informed health care workers in many developing countries. The departure of health care workers from developing countries is one of the most important causes. This handbook is intended to enable institutions to adapt quality assurance principles in accordance with their local resource capacity. The handbook addresses six minimum requirements that a higher education course should incorporate to ensure that it meets internationally recognised standards: recruitment and admissions, course design and delivery, student assessments, approval and review processes, support for students and staff training and welfare. It is hoped that the handbook will contribute to providing a skilled and sustainable health care workforce that would reduce the need for health care workers to travel overseas in search of good higher-education courses. The principles outlined in the handbook should provide a sound regulatory framework for establishing local, quality higher education courses.
This toolkit looks at elements necessary when creating conditions for the participation of people living in extreme poverty. These include: a lack of expectation of the contribution of people living in extreme poverty (the position of individuals and families living in extreme poverty is affected by the way society views them), reaching out, time and flexibility (people living in extreme poverty are often difficult to include in participatory projects), respecting and ensuring everyone's freedom by acknowledging that the very nature of such a project means that the different participants are from the beginning in a situation of inequality, a will to create equal partnerships and involvement at every stage - to succeed in achieving a truly participative approach, the participation of people living in poverty should be an integral part of the process rather than an add-on at any given stage.
15. Jobs and Announcements
The 5th International Conference of the International Society for Equity in Health will be hosted by the Greek School of Public Health in Crete. The meeting will bring together, researchers, policy-makers, practitioners and others concerned with equity in health to develop and international health agenda for governments, universities and organisations all over the world. The Conference will explore the theme ‘Social and Societal Influences on Equity in Health’ through a varied program of plenary sessions, forums, poster sessions and scientific sessions. You are invited to participate in the advancement of knowledge, exchange of experiences and promotion of equity in health.
The Global Forum for Health Research invites all interested parties to contribute their ideas for presentations and also welcomes innovative ideas for discussion topics and for the format of sessions in Forum 2009 in three different categories. First, in ‘Innovative presentations and discussion topics, çontributors may be invited for oral or poster presentations or as a panellist in a discussion session. Second, in ‘Innovative approaches to sessions’, a diverse array of formats will be presented, including panel discussions, workshops and roundtables. These seek to engage the participants in constructive dialogue and debate to identify pathways to solutions for critical health problems. Third, in ‘Other innovative proposals’, proposals may include suggestions for executive meetings, prizes, declarations, action plans, networking events, launches of books and of innovative initiatives and partnerships, among others.
The guest editor seeks contributions to the issue on any topic related to feminist disability studies and bioethics, including (but not limited to):critiques of bioethics by feminist disability theorists from within feminist bioethics, the relevance of feminist disability studies in developing countries, what’s still missing from feminist arguments in the debates about stem cell research and other forms of biotechnology, the importance of perspectives of disabled embodiment in feminist bioethics, how the critiques of bioethics advanced in disability studies are gendered and the integration of political analyses of disability into feminist bioethics. All submissions should be prepared in accordance with the journal’s style guidelines which are posted on the IJFAB website. The deadline for submissions is 30 April 2009.
Equal Treatment, the magazine of the Treatment Action Campaign, is accepting CVs for the position of editor. It is used by communities throughout Southern Africa in treatment literacy and advocacy work. The key areas of responsibility include developing content for each issue of the magazine, liasing with partners to source and verify content, and aiding in the coordination of the magazine’s production. Successful candidates should have a keen interest in working in community-based settings on HIV & TB prevention and care. Excellent writing skills and experience in training and editing are a necessity. A good knowledge of HIV, TB and related health is also required. The candidate must have excellent computer and communication skills and be fluent in English. Interested candidates are asked to email their CVs and a letter of interest.
The Global Health Research Initiative (GHRI) is a partnership formed by five Canadian agencies - the Canadian Institutes of Health Research; the Canadian International Development Agency; Health Canada; the International Development Research Centre; and the Public Health Agency of Canada - to strengthen Canada’s role on the global health research scene. The research component of the 'African Health System Initiative' (AHSI-RES) is a five-year research programme (2008-2013) that forms one component of the African Health System Initiative (AHSI) supported by the Canadian International Development Agency (CIDA). This call for proposals invites teams of researchers and decision-makers to submit research proposals focusing on human resources for health (HRH) and/or health information systems (HIS). Equity is a cross-cutting theme. Registration is due on 13 March 2009. Full application is due on 22 April 2009.
Published by the Regional Network for Equity in Health in east and southern Africa (EQUINET) with technical support from Training and Research Support Centre (TARSC).
Contact EQUINET at admin@equinetafrica.org and visit our website at www.equinetafrica.org
Website: http://www.equinetafrica.org/newsletter
SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to editor@equinetafrica.org Please forward this to others.
SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org or send an email to info@equinetafrica.org
This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact editor@equinetafrica.org immediately regarding any issues arising.