The way we finance health and health care makes a significant difference to the coverage and accessibility of our health care systems. It has thus been an issue capturing increasing attention from the international community, including from United Nations Children’s Fund (UNICEF), the European Union, the High Level Taskforce on International Innovative Financing for Health Systems who have all held consultations on this in the first quarter of 2009. The UNICEF meeting reviewed the evidence base on the imposition of a ‘price’ for use of health care services - user fees – and considered options and support for feasible health financing mechanisms. UNICEF itself was questioning the necessity and value of user fees in resource constrained settings, particularly given the opportunity costs, transaction costs and barriers posed to utilisation. The EU meeting sought input to its policy on health care financing for developing countries. The meeting reviewed a draft policy that was oriented towards support for general tax financing for public health care systems augmented by Social Health Insurance as a feasible next best alternative modality for long term sustainable health care financing.
There seems to be wide agreement on the question of maintaining tax revenue as the core of health financing, and on the introduction of SHI as the major source of additional domestic funds for health. The debates are more about how to implement these mechanisms in low resource settings.
The simplest mechanism is that of financing through tax revenue. There is evidence that systems that are more dependant on tax revenue have less inequality (measured through the Gini co-efficient) with regard to resource distribution and therefore a higher level of equity within the system. Recognition was made of the need to have with this a systematic resource allocation mechanism as well as a package of care that general tax revenue will purchase, to support a rationale priority setting process and to ensure fairness. It was noted that tax funded systems are more suited to achieving this. Yet increasing these tax revenues cannot simply depend on overall economic growth, as there appears to be little evidence so far that economic growth has translated into immediate gains for resourcing the health sector. There is thus need for evidence and dialogue on the options for strengthening tax revenue sources, including the role of sector wide approaches, of budget support to the health sector and of overall budget support.
Although Social Health Insurance (SHI) is often raised as an equitable option for financing universal coverage, there is limited or zero revenue generation from social security schemes in the African region. In countries such as Ghana, Tanzania and Rwanda, SHI schemes are substantially financed through taxation or support from external resources (such as the Global Fund). They therefore appear to be more hybrid tax based systems with additional transaction costs that may be generating inefficiencies in resource use and allocation. In the same countries coverage of social and private health insurance schemes is extremely limited, raising serious concerns about equity in revenue generation and in service provision and consumption. In other countries, such as South Africa, where private health insurance exists along side some social security mechanisms, the private insurance is limited in terms of coverage and yet consumes a relatively high share of total health expenditures – demonstrating again potential inefficiencies and inequality. We thus need to further analyse and evaluate equity issues in the implementation of social health insurance to inform whether and how to implement these schemes.
So there are clear areas for further work to advance progressive, equitable health financing in Africa.
It is therefore worrying that we are still locked into endless debates on user fees. These debates generate diverse opinion. In health systems in which user fees have been removed at a broad level (South Africa, Uganda, Zambia) as well as those where the user fee exemptions have been targeted at specific vulnerable groups such as child and pregnant women (in support of child, maternal and reproductive health) the evidence of increased utilisation is clear. The evidence also shows that the transaction costs of user fee administration negates any positive contribution of user fees themselves in additional revenue or value terms. The contribution of user fees to health revenues remains low. Some institutions and country representatives strongly support community financing, such as through mutual funds, as well as user fees in public sector facilities. Yet some institutions and country representatives strongly support community financing, such as through mutual funds, and user fees in public sector facilities.
This draws attention from more substantial issues, such as the fact that government commitments to improved health sector funding remains low. Countries have been slow to increase their health sector budgets, let alone reach the 15% of government budget for health set in the 2001 Abuja heads of state commitment and the Southern African Development Community commitments for the Maputo targets. Making these promised increases to the health sector budget would exceed any resources that could be raised through user fees.
One problem is that the debate on health financing is fed by a mix of evidence, values and anecdotes. Relevant evidence is not always available for health sector financing decisions, and ethical and value considerations affect the design of and preferences in health care financing. The case for user fees (alongside community financing initiatives) is often made without evidence and based on institutional interests, rather than on the basis of health system development and improvement of population health. Disappointingly at the UNICEF meeting earlier this year, no consensus was reached and further consultative processes were proposed.
Given the weight of evidence showing the negative balance in the impact of user fees on health systems and population health, I would argue that there is, however, sufficient evidence to put this issue to rest. Rather than continuing the debate on user fees, we should shift to debates on more substantive approaches to resource mobilisation, including:
* How to achieve increased health sector budgets
* How to strengthen tax revenue sources and funding for sector wide and budget support
* How to assess the equity issues in the implementation of social health insurance to inform policy decisions whether and how to introduce SHI
* How to promote accountability and transparency in the way health systems use their funds
Meanwhile as we need to move on in Africa to focus debates and build coherence on these wider financing policies, we also note the proliferation of different donor meetings on this issue. The situation is calling for a harmonised approach among donors and international agencies, if not in terms of harmonised funding, at least in terms of a common position that external funders can adopt on financing options that strengthen the health system. This would be in line with the Paris Declaration on Aid Effectiveness and Harmonisation, so perhaps the World Health Organisation should take some leadership in co-ordinating this?
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on health financing issues please visit the EQUINET website- www.equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
This paper aims to provide a detailed analysis of the options for protecting universal comprehensive and equitable health services within the framework of the EU-ESA EPA and other EPAs in the region through the services negotiations. The paper notes a number of commitments that the ESA-EU countries have already made in relation to public health. It proposes issues for negotiators in the services negotiations in the EPA to take into account to protect health in these agreements.
Parliaments can play a key role in promoting health and health equity through their representative, legislative and oversight roles, including budget oversight. To better understand and support the practical implementation of these roles, EQUINET (through University of Cape Town (UCT) and its secretariat at Training and Research Support Centre (TARSC) with SEAPACOH implemented a questionnaire survey in September 2008 to explore and document the work and experiences of parliamentary committees on health. This report presents the findings on the general progress on parliament work on health. The survey highlighted a number of areas of current focus of parliament work in health, the potential and experience of positive outcomes, and the limits and constraints to address to support further work. In the budget process parliaments have generally played a role in advocating and engaging on the Abuja commitment, with increasing budget shares to health in a majority of countries, although the target has only been met in two of those included in the survey. Legislative activity is less common, and areas that are of public health concern, such as incorporating TRIPS flexibilities or international commitments into national law are still not well known by parliaments or acted on. Oversight and representative roles are the most frequently reported area of committee action, and parliaments have played an important role in raising debate on and profile of health issues. It appears from the evidence that parliaments can support progress in health equity by enhancing funding for prioritised areas in the budget process, by raising awareness of health issues through parliament debates, by raising public attention to prioritised concerns through media liaison, by gathering evidence and views from communities and communicating issues to communities through constituency visits, and by raising very specific questions to the executive to address.
This study explored the challenges experienced by HIV infected pregnant women and the coping strategies used by those who disclose or do not disclose, to inform community and health workers roles in supporting pregnant women around disclosure. It aimed to explore dimensions of (and impediments to delivery of) Primary Health Care responses to HIV and AIDS in Namibia. The work was implemented at Katutura state hospital, an intermediate hospital in Windhoek, at the Centre for Disease Control, antenatal care and PMTCT services within the hospital complex. The work was done with a small sample (20) due to the criteria of voluntary participation and follow through of a more intensive longitudinal participatory process with the women. The use of participatory methods, while demanding, proved effective even over short time periods to build the empowerment and communication needed to for the changes found. Nursing students proposed that future PRA projects run throughout the year for effective learning and include more students. PHC responses to AIDS start and end in the community, involving households, networks of affected groups, educational, religious and social institutions and supported by primary care services. The study indicates features of this for testing and counselling. Namibia needs to provide high levels of knowledge of services for prevention, testing, health promotion in positive people, partner notification and treatment options to people in the community from an early age onwards. It can also create an enabling social environment encouraging support of PLWHA, openness and reinforcing information on the positive implications of testing and disclosure, including to partners and family members. Another factor is ensuring that testing, counselling and information supporting disclosure, including on positive prevention, is provided at every ANC and PMTCT contact. In addition, it's important to support health worker communication on testing and disclosure with inputs from support groups and expert patients at facilities, and build a health sector response that addresses community as well as health service dimensions of intervention.
A regional meeting was convened on 25-27 February 2009 in Windhoek Namibia by EQUINET and ECSA HC, hosted by the University of Namibia in co-operation with TARSC and University of Limpopo to: review the findings from this body of work and to explore the implications for policies and measures aimed at valuing and retaining health workers in ESA; develop proposals and guidelines for policy and action relevant to health worker deployment and retention; and identify knowledge gaps for follow up work. The meeting also reviewed work implemented within other EQUINET themes to explore the impact of migration on health systems in Kenya (carried out in co-operation with IOM and ECSA-HC), to explore the impact of AIDS financing on health worker retention (carried out in co-operation with WHO and ECSA-HC), and to examine the relationship between health workers and communities at primary care level (in a programme of work co-ordinated by TARSC and Ifakara Health Institute). The meeting, held at the Safari Hotel in Windhoek, brought together country partners, researchers, regional and national institutions involved with health workers. A set of recommendations were produced, particularly focusing on health worker retention.
3. Equity in Health
Developing countries need to deepen their ownership of the development process by engaging local governments, civil society, and parliaments – what could be called 'the basic body of democratic responsibility'. If they identify areas where their capacity is weak, they can develop plans to address those areas. Leadership is required in managing the development process, working out a sensible division of labour among the donors that are active in their countries. They need to improve their ability to gather and use statistical information, so that they know – and can report to their citizens – what results they are achieving. Donors should also make sure that the aid they give is properly managed and that it reaches those who need it most, namely the poor and underserved.
This paper takes a critical look at South Africa's prospects for meeting the Millennium Development targets for child survival. It asks the question: is a return to comprehensive primary health care (PHC) needed right now, as many have been saying? The time is long overdue for energetically translating the rhetorically rich promises of the PHC approach to reality, turning dormant policies into action. The main actions should centre around the development of comprehensive, well-managed programmes involving the health sector, other sectors and communities. The process needs to be structured into functioning district systems. In most countries these need to be considerably strengthened, particularly at the household, community and primary care levels.
A bleak picture has been painted in the Situational Analysis of Children in South Africa 2007–2008, a report compiled by the UN Children’s Fund that looks at the standard of living of children in South Africa. It shows that poverty and crime continue to wreak havoc in the lives of this country’s children. It confirmed the view that South Africa will most likely not reach its Global Millennium Goal of reducing child mortality by two-thirds by 2015. Of every 1,000 children born in KwaZulu-Natal, 99 die before they reach the age of five. Gauteng’s mortality rate is still at about 63 deaths per 1,000 births; in Western Cape the ratio is 40 per 1,000.
The Millennium Declaration is a statement of principles about the kind of future that world governments seek; a future that they envisage to be more equitable and more responsive to the socially most vulnerable. The Millennium Development Goals represent the operational targets by which we may judge their actions. The reduction of the U5MR by two-thirds by 2015 is one of the Millennium Development Goals (MDG4). The reduction in U5MR can, however, be achieved through a diversity of policy interventions, some of which could leave the children of the poor worse off. A celebrated MDG4 success can, thus, be a Millennium Declaration failure. Health policy informed by composite outcome measures that take account of both the U5MR and the distribution of the burden of mortality across social groups would help to overcome this.
4. Values, Policies and Rights
The Women’s Working Group on Financing for Development (WWG on FfD), recognize that the financial and economic crisis represents a critical political opportunity to make significant structural changes in the global development macroeconomic and financial architecture that reflect rights-based and equitable principles. This statement reflects on the actions to respond to the current crisis with alternative policy approaches that harmonize with international standards and commitments to gender equality, women’s rights and human rights and empowerment.
This pack assesses how it might be possible to move towards a world that recognises and values the importance of different forms of care, but without reinforcing care work as something that only women can or should do. Drawing on diverse examples of initiatives taking place in countries across the world, it considers what strategies offer the best prospects for change. It recommends that donors should fund capacity building of grassroots care-givers, women’s organisations and networks, and organisations and networks of people living with HIV and AIDS, to enable care givers to advocate for their rights and represent themselves in local, national and international decision-making forums. Governments should ensure that gender-sensitive care provision is an integral and budgeted aspect of HIV and AIDS policies and programmes.
This report discusses the University of Pennsylvania African Human Genetic Diversity Project, and the filing of patent claims in October 2007 over genetic material collected from communities in Africa. It questions the staking of legal claims over the natural genetic resources of Africans. Such patents not only allow exclusive rights to such resources, but also enable profit from future medical applications. the report notes that the patent is possible, because US patent law extends patent protection to life forms. This new trend has enabled research institutions and corporations to secure patents for almost 5% of the entire human genome. The report seeks to contribute to stopping the exploitation of African genetic resources.
The mountain kingdom of Lesotho faces a number of unique hurdles with regard to HIV and AIDS. The country is landlocked within South Africa, the epicentre of the pandemic and, because of limited job opportunities and high unemployment rates within Lesotho, many of its citizens work as migrant labourers in South Africa. In addition, Lesotho has a particularly weak public health infrastructure due to rural isolation, lack of skilled health workers and high poverty rates. Migrant labourers, particularly all those working in South African mines, are a huge concern because they pose a high risk of having multiple concurrent partnerships and of taking HIV infections across the border. The health departments of Lesotho and South Africa should come up with cross-border health policies to deal with this public health problem.
Government is responsible for the failures in South Africa's public healthcare system, and needs to address them so that every citizen's right to access healthcare services is realised, the South African Human Rights Commission has said. The Commission released its report on an inquiry into the country's public healthcare services, based on visits to about 100 facilities across the country and submissions from the public during May 2007. It identified poverty as a major barrier to accessing healthcare services in South Africa. As of 2007, 88% of South Africans are dependant on public healthcare services. The poor make up the majority of this figure, but the report found that their access to these services is severely constrained by transport costs and unacceptably long waiting times at clinics or hospitals. 'These constraints amount to a denial of the right to access healthcare,' said the Committee's deputy chairperson.
This guide is intended to aid civil society actors in becoming more involved in the work of the UN Special Rapporteur on the right to health, with a specific focus on the valuable role that health workers can play. The appointment of the first Special Rapporteur on the right to health in 2002 and the resulting body of work on the right to health has proven to be a valuable catalyst for further action within the health and human rights movement. At the same time there remains much unawareness and misconception concerning the work of the Special Rapporteur and the ways in which civil society actors can be involved. The guide provides general information on the Special Rapporteur, and presents possibilities for contribution and follow-up to the three main areas of his work. It offers concrete assistance on how the annual reports, country missions, and the individual complaints mechanism of the Special Rapporteur can be used by civil society.
In a strongly worded letter to the president of Zambia, the country's Catholic bishops called on the government not to ratify an African Union protocol with articles that would threaten the sacredness of life and the sanctity of marriage. They demand amendments to Article 7 on separation, divorce and the annulment of marriage and to Article 14 on the protection of reproductive rights of women by authorising medical abortion in cases of assault, rape and incest. The bishops said the Catholic Church holds in high esteem the sanctity of marriage and the sacredness of human life from birth to death. 'It is in this light we find it immoral, unjust and out of context to sign this protocol without making changes to the two articles to agree with the divine and natural law,' they said. The government has not yet reacted to the bishops' appeal.
5. Health equity in economic and trade policies
Is there a link between the financial crisis dominating the front pages of newspapers and the health stories on the inside? The Commission on Social Determinants of Health certainly believed so. Its starting point was that the economic and social features of society are closely linked to the distribution of health within and between countries. The social determinants of health are the conditions of daily life and its structural drivers will be influenced by the financial crisis. As social determinants are affected by the financial crunch, so will health outcomes be affected as well.
This paper is an unprecedented collaboration between a wide spectrum of civil society organisations in the United Kingdom (UK). the civil society organisations in the UK called on the UK government to initiate an economic system that that seeks to work for people and for the planet. The civil society statement makes recommendations to world leaders to chart a path out of recession in a way that builds an equitable global economy. It prioritises tax reforms to end poverty, accountable and transparent processes for the international finance system and calls for reforms to be implemented through the United Nations in consultation with governments, trade unions and civil society organisations.
The auhtor argues that there are several issues that the G20 Summit failed to resolve, besides the biggest omission – failure to reform IMF policies. First, it failed to produce anything tangible on a coordinated fiscal stimulus policy. Secondly, it did not come up with a plan of action to clean up the crisis-hit banking systems. Thirdly, there was no plan for regulating cross-border activities of financial institutions or cross-border financial flows, nor an acknowledgement that a framework should be created that facilitates developing countries’ ability to regulate the flow of cross-border funds. Fourthly, there was no move to assist developing countries to avoid wrenching debt crises. Without this, they would be deprived of the kinds of schemes by which banks or companies in trouble pay back only a portion of their loans whose market values would have fallen.
This compilation consists of short essays from a broad range of experts to provide proposals on immediate trade priorities in the context of the economic crisis and provide a forward-looking agenda for global trade governance. The essays focus special attention on the needs of developing countries and sustainable development considerations. Some conclusions drawn from the compilation include the recommendation to establish a working group of experts to propose WTO reforms. Immediate action should be taken to implement those areas of the Doha Development Agenda where agreement exists. The World Trade Organisation's capacity needs to be expanded and a trade-and-development ombudsman should be appointed at the WTO to whom third-party complaints about trade impacts can be brought.
The draft G20 Communiqué recognises explicitly in its opening paragraph, that 'a global crisis requires a global solution'. But at no point does it recognise any need for a global process to decide what that global solution should be. The G20 members appear determined that they, and they alone, should determine the future course of the global economy – and that it should be designed to protect their financial interests, with only token efforts to limit the damage to the rest of the world. They are trying to seize control of the global economy but, in doing so, the author argues that they are amply demonstrating why they must not be allowed to succeed.
The author argues for a new financial system that is transparent and accountable to all. The G20's task is to expose all that has gone wrong, including the role the African leaders have played in the crisis, through the externalisation of billions of pounds intended for the development of their countries. These activities, Nabudere notes, have helped position Africa as a net creditor to the world, with the external assets of 40 African countries outstripping their external liabilities over the period from 1970–2004. In other words, he says, despite the widely held view that Africa was 'decoupled' from the global economy, African leaders have contributed to the activities of ‘shadow banks’ being used to create ‘toxic debt’, their wealth contributing to the global economic turmoil.
6. Poverty and health
The Moving Out of Poverty study, carried out in 15 countries, is one of the few large-scale comparative research attempts to analyse mobility out of poverty rather than poverty alone. This book is about local realities and the urgent need to develop poverty-reducing strategies informed by the lives and experiences of millions of poor people in communities around the world. The report notes the diversity of experience across households in their movement in and out of poverty within countries. It points to the need to examine the local realities of communities rather than countries and to move beyond assumptions and beliefs about poor people to identify the underlying causes of poverty and to inform development plans, policies and actions that address poverty.
Dehydration caused by severe diarrhoea is a key cause of infant deaths in Zambia, a country with one of the highest child morality rates in the world, according to a new report by Zambia’s health department. This will not change until government makes a major effort to improve access to clean water and sanitation throughout the country, health experts say. Diarrhoea accounts for one fifth of all deaths among children under five. The symptom makes children more susceptible to other illnesses, such as malnutrition and respiratory infections, which are also among the leading causes of child mortality in Zambia. Diarrhoea can easily be avoided or reduced by improved sanitation. But sanitation remains a major problem in Zambia. According to the Lusaka-based Central Statistical Office (CSO), less than 60% of the population have access to adequate sanitation and safe water.
The Swazi government's slow response to a fast-growing tuberculosis epidemic has eroded the possibility of controlling it, says the National TB Control Programme manager. There has been a nearly ten-fold increase in the last 20 years from about 1,000 TB cases per year in 1987 to over 9,600 cases in 2007, exacerbated by the world's highest HIV prevalence rate – 80% of the TB cases are also co-infected with HIV. The country is falling short of meeting the World Health Organisation's TB treatment rate of 85% with a treatment success rate of 42%. The report points to higher rates of default on treatment when patients feel the TB treatment takes long, when they are also taking antiretroviral drugs and when they take drugs on an empty stomach.
7. Equitable health services
The cholera epidemic in southern Africa continues to abate, but international and local health authorities stress the need to remain vigilant, the United Nations has reported. There were a total of 4,579 new cases between 3 and 17 April in the nine countries – Angola, Botswana, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe – affected by the often fatal disease since August 2008. During the two weeks preceding 3 April, 6,460 new cases were reported. Authorities warn, however, that cholera could re-appear in the coming one to three weeks, when waters from flooding in the region, which has affected more than 1.2 million people, subside and become stagnant.
There were 1.37 million new TB cases in 2007 among HIV-infected people and 456,000 deaths, says a new global TB report by the World Health Organization. One out of four TB deaths is HIV-related, twice as many as previously recognised. Despite an improvement in the quality of the country data, which are now more representative and available from more countries than in previous years, these shocking findings point to an urgent need to find, prevent and treat tuberculosis in people living with HIV. According to Dr Margaret Chan, Director-General of WHO, 'We need to test for HIV in all patients with TB in order to provide prevention, treatment and care. Countries can only do that through stronger collaborative programmes and stronger health systems that address both diseases,' she said.
Haemorrhage is the leading causes of obstetric mortality. Studies show that active management of third stage of labour (AMTSL) reduces post partum haemorrhage. This study describes the practice of AMTSL and barriers to its effective use in Tanzania. Correct practice of AMTSL was observed in only 7% of 251 deliveries. Knowledge and practice of AMTSL is very low and STGs are not updated on correct AMTSL practice. The drugs for AMTSL are available and stored at the right conditions in nearly all facilities. All providers used ergometrine for AMTSL instead of oxytocin as recommended by ICM/FIGO. The study also observed harmful practices during delivery. These findings indicate that there is need for updating the STGs, curricula and training of health providers on AMTSL and monitoring its practice.
The World Health Organization (WHO) announced Thursday that Zambia had achieved a major reduction in malaria mortality through accelerated malaria control activities. Malaria deaths reported from health facilities have declined by 66% in Zambia and this result, along with other data, indicates that Zambia has reached the 2010 Roll Back Malaria target of more than 50% reduction in malaria mortality compared to 2000. WHO said Zambia’s efforts would be promoted as a model for other countries to follow. The decline in Zambia was especially steep after 3.6 million long-lasting insecticide nets were distributed between 2006 and 2008. During this period, malaria deaths declined by 47% and nationwide surveys showed that parasite prevalence declined by 53% from 21.8 to 10.2% and the percentage of children with severe anaemia declined by 68% from 13.3 to 4.3%.
This pilot study in Thailand assessed policies about primary health care (PHC), focusing on how equitably resources are distributed, the adequacy of resources, comprehensiveness of services and co-payment. A questionnaire survey was administered to five policymakers, five academicians and 77 primary care practitioners at a PHC workshop. Responses were consistent: financial resources should be allocated based on different health needs and special efforts must be made to assure PHC to underserved populations. The supply of essential drugs should be adequate, as well, with equitable distribution of services and low out-of-pocket payments. The questionnaire was robust across key stakeholders and feasible for use in transitional or less-developed countries, like those in Africa.
Normally, women have to wait a long time for the results of a pap smear. But, in Uganda, a fast, cheap diagnostic test based on vinegar is invigorating the battle against cervical cancer. Health activists are raising money to put it in a mobile clinic and health officials are eyeing a national rollout. A pilot project in Kampala has begun to demonstrate that cervical cancer screening is possible in small health centres. As part of that project, two clinics began screening women with a fast, innovative test that used acetic acid--or vinegar--as the primary active ingredient. The test, called visual inspection with acetic acid (VIA) is reported to not require a pathologist, refrigeration of samples or a microscope. A nurse, midwife, or gynecologist swabs a patient's cervix with acetic acid and then inspects the tissue visually. The author reports that if the cervix has lesions, the tissue turns white.
8. Human Resources
This study examined the relationship between doctor and nurse concentrations and utilisation rates of six essential health services in developing countries: antenatal care, attended delivery, caesarean section, measles immunisation, tuberculosis case diagnosis and care for acute respiratory infection. It found that nurses were associated with high levels of utilisation of skilled birth attendants and doctors were associated with high measles immunisation rates, but neither were associated with the remaining four services. It is plausible that other health workers, such as clinical officers and community health workers, may be providing a substantial proportion of these health services, which means that the human resources for health research agenda must be expanded to include these other workers.
Through distance education, the School of Public Health of the University of the Western Cape, South Africa has provided access to master's level public health education for health professionals from more than 20 African countries while they remain in post. Since 2000, interest has increased overwhelmingly to a point where four times more applications are received than can be accommodated. This brief paper describes the innovative aspects of the programme, offering some evaluative indications of its impact, and reviews how the delivery of text-led distance learning has helped realise the objectives of public health training. Strategies are proposed for scaling up such a programme to meet the growing need for health professional development in Africa.
This article investigates whether present community health worker programmes for antiretroviral treatment are taking into account the lessons learnt from past experiences with community health worker programmes in primary health care and to what extent they are seizing the new antiretroviral treatment-specific opportunities. It is based on a desk review of multi-purpose community health worker programmes for primary health care and of recent experiences with antiretroviral treatment-related community health workers. The renewed attention to community health workers is very welcome, but the scale-up of community health worker programmes runs a high risk of neglecting the necessary quality criteria if it is not aligned with broader health systems strengthening. To achieve universal access to antiretroviral treatment, this is of paramount importance and should receive urgent attention.
The paper examines trends in inflow of health professionals to the United Kingdom from other countries, using professional registration data and data on applications for work permits. Available data show a considerable reduction in inflow of health professionals, from the peak years up to 2002 (for nurses) and 2004 (for doctors). There are multiple causes for this decline, including declining demand in the United Kingdom. Regulatory and education changes in the United Kingdom in recent years have also made international entry more difficult. Two lessons were learnt: comprehensive data is needed for proper monitoring of the impact of a code and countries with many independent, private-sector health care employers struggle to implement a code. the authors note therefore the significant challenges in implementing and monitoring a global code.
On the occasion of World Health Day 2009, the Global Health Workforce Alliance has underlined the important and critical role played by health workers at times of disaster and emergency. At the heart of making hospitals safer are the people responsible for saving lives - the health workers. And when an emergency strikes - health workers are on the frontline. Often 'first on scene', health workers are tragically also often the first casualties themselves - there are many examples around the work where health workers have been killed in large numbers in the early instances of disaster. Added to this, health workers - like all members of populations in crisis zones - lose family members, friends, colleagues and others close to them.
This paper reports on the first international attempt to investigate the migration intentions of pharmacy students and identify migration factors and their relationships. Nine countries were surveyed, including Zimbabwe. Results showed a significant difference in attitudes towards the professional and sociopolitical environment of the home country and perceptions of opportunities abroad between those who have no intention of migrating and those who intend to migrate on a long-term basis. Given the influence of the country context and environment on migration intentions, research and policy should frame the issue of migration in the context of the wider human resource agenda, thus viewing migration as one form of attrition and a symptom of other root causes. Policy development must take into account both remuneration and professional development to encourage retention.
9. Public-Private Mix
People use a variety of market-based providers of health-related goods and services ranging from highly organised and regulated hospitals and specialist doctors to informal health workers and drug sellers operating outside the legal framework. Many encounters with health workers and suppliers of pharmaceuticals involve a cash payment. The boundary between public and private sectors is often very porous, with people either paying government health workers informally or consulting them outside their official hours. Unregulated markets, in particular, raise problems with safety, efficacy and cost. This editorial of id21 insights explores some of the responses to these problems.
While universal access to reproductive health care – including family planning, maternal health care, and prevention of HIV/AIDS and other sexually transmitted infections – is critical to achieve the United Nation's Millennium Development Goals, it is far from becoming a reality. Governments are often major providers of reproductive health services, but inadequate funding greatly limits the availability and quality of the services. The private sector can help expand access to and quality of reproductive health services through its resources, expertise, and infrastructure. This brief provides an overview of the private sector, highlights the critical role it plays in delivering health services and products in developing countries, and explains how governments and donor agencies can engage this sector to achieve reproductive health goals.
10. Resource allocation and health financing
Over 100 Civil Society Organisations worldwide are united in calling on G20 leaders to introduce a currency transaction levy (CLT). At a time when the financial crisis is endangering the lives of millions in the developing world additional finance is desperately needed to meet the Millennium Development Goals, particularly relating to health. In an open letter, addressed to Gordon Brown as Chair of the G20 and published in The Times newspaper, the message of this growing coalition of organisations is simple: implement a CTL now to meet the aid revenue shortfall and safeguard lives from the worst ravages of the economic storm.
This paper assesses the adequacy of the Fund’s toolkit for low-income countries (LICs), with a view to ensuring that it keeps pace with a changing world, particularly as global economic conditions deteriorate and put pressure on countries. It seeks to answer the following key questions: What are the needs of LICs in relation to Fund financing and how have they changed? How have existing instruments met LIC needs, and are there gaps or overlaps? Could changes to access rules, financing terms, or conditionality help the Fund better support LICs? What is the available concessional resource envelope and how will the changing external environment affect possible financing needs through the medium term? What scope is there to make the concessional financing framework more flexible?
Third World Network report a call for a World Social Bank funded by abolishing offshore tax havens. A letter from civil society, sent in advance of the April G20 summit, appeals to United Kingdom Prime Minster Gordon Brown and other world leaders to 'reform international finance in a way that provides a real boost to the growth of the third sector'. About £255bn is said to be lost each year to tax havens, and the funds couold be used for a World Social Bank that could stimulate social investment by developing the infrastructure for an international social investment market, working with private investors to grow this market and encouraging collaboration between different countries.
11. Equity and HIV/AIDS
This article presents the first known systematic review of the research literature on carers of AIDS-orphaned children. Twenty-nine studies of caregivers of AIDS-orphaned children were identified and assessed, mostly in the developing world. Most studies included identifying the individuals who were providing care, assessing the capacity of the extended family to care for AIDS orphans and exploring the process of care placement. Few examined the caregiving experience in any depth, including the challenges of caring for orphans or the effects of caring for these children on the caregivers' health and wellbeing. The article concludes with suggestions for future research to guide policy and programming efforts.
This study has investigated human immunodeficiency virus (HIV) knowledge, attitudes and sexual at-risk behaviours of youths from disadvantaged communities of Dar es Salaam, Tanzania. Participants were 800 youths aged 12-15 years from poorer communities. Participants showed low levels of HIV knowledge, little experience with condom use and low intention to use condoms. Contrary to expectations, there were no significant differences between those in-school and those out-of-school. Gender differences were apparent, in that girls scored consistently lower than boys on all variables. HIV and AIDS education within the schools of Tanzania needs to be re-evaluated and better educational strategies developed.
Nearly 500 delegates from all over the world met at the Rio de Janeiro Global Forum to discuss how men can help improve gender equality, prevent domestic and sexual violence, and improve maternal and reproductive health for themselves and their partners. Gender roles play a major role because they can determine the extent of our vulnerability to the HIV infection. Research in nine Latin American countries found that young men, aged 10 to 24, were far more concerned with achieving and preserving their masculinity than with their health. Another study found that expectations about male behaviour may result in early sexual initiation and more sexual partners, less intimacy in relationships and reluctance to use condoms.
Anecdotal evidence that entrenched cultural beliefs among Swazis actively encourage the spread of HIV/AIDS has been confirmed by a joint government and UN report. The study, called 'The State of the Swaziland Population', echoes warnings by local NGOs that 'AIDS cannot be stopped unless there is a change in people's sexual behaviour.' 'Swazis are very traditional people, and their sexual behaviour is inbred and totally against safe sexual practices, like condom use and monogamous relationships, that limit the spread of HIV,' noted an HIV testing counsellor in Manzini, the country's main commercial city. The report, based on focus groups and surveys, found that maintaining a centuries-old cultural belief in procreation to increase the population size, was having devastating consequences in the age of AIDS.
12. Governance and participation in health
This article discusses the appropriateness of western bioethics in the African setting. It focuses on the decision-making process regarding participation in health research as a contested boundary in international bioethics discourse. An ethnomethodological approach is used to explain African ethics, and African ethic is applied to the decision-making process in the African community. An HIV/AIDS surveillance project is used as a case study to explore the concept of communitarianism. The article argues that what exists in Africa is communal or social autonomy as opposed to individual autonomy in the West. As a result, applying the western concept of autonomy to research involving human subjects in the African context without adequate consideration for the important role of the community is inappropriate. It concludes that lack of adequate consideration for community participation in health research involving human subjects in Africa will prevent proper management and lack truly informed consent.
13. Monitoring equity and research policy
Three years ago, the Society of General Internal Medicine's Evidence-based Medicine Task Force began an inquiry to integrate evidence-based medicine (EBM) and the learning organization (LO), an approach to training from a systems-based perspective, into one model to address the knowing-doing gap problem. The authors of this study searched several databases for relevant LO frameworks and their related concepts by using a broad search strategy. They found seven LO frameworks particularly relevant to evidence-based practice innovations in organisations. These were integrated to form the new Evidence in the Learning Organization (ELO) model, which can be used by health organisations to identify their capacities to learn and share knowledge about evidence-based practice innovations.
14. Useful Resources
The new movement, Economic Governance for Health (EG4Health) promises to be a useful resource for health activists. Its launch coincided with protests and campaigns across the world and involving hundreds of thousands of people angry at the evidence of global financial mismanagement, corruption and rising economic inequalities. A 'Put People First' march in London, host of the G20 meeting, was supported by over 150 civil society organisations. EG4Health presents a 12-point plan for democratic economic governance, as well as a more detailed policy paper, included in this edition of the EQUINET newsletter.
Management Sciences for Health (MSH) has published the International Drug Price Indicator Guide since 1986 and updates it annually. The guide contains a spectrum of prices from pharmaceutical suppliers, international development organisations and government agencies. It aims to make price information more widely available in order to improve procurement of medicines of assured quality for the lowest possible price. Comparative price information is important for getting the best price, and this is an essential reference for anyone involved in the procurement of pharmaceuticals. This 2008 version is their latest update and has just been released.
15. Jobs and Announcements
Non-discrimination is perhaps the most fundamental principle underlying all of human rights. Yet, notions of equality and non-discrimination have yet to be fully developed as they apply to health policy and programming. What does equality actually mean in rolling out or scaling up services, or determining resource allocations in health? What dimensions of inequality result in inequity? What are the grounds for advancing substantive equality as it relates to preconditions for health and access to care? How is the concept of non-discrimination related to but distinct from development concepts of social exclusion? A forthcoming issue of Health and Human Rights will cover these issues and is calling for submissions.
Health and Human Rights, an international journal, invites manuscript submissions for its next theme issue on international assistance and cooperation. The ability of poor countries to realize the right to health must be understood within the context of the global political economy. Donor countries assume human rights obligations both directly and as members of international organisations, such as the World Bank, IMF and regional development banks. UN and international agencies, as well as transnational corporations under certain circumstances, may also have human rights obligations relating to health. This issue will critically explore how these international obligations are being defined and discharged, and how to make stakeholders accountable for their human rights obligations.
The Centre for African Family Studies (CAFS) is an African institution dedicated to strengthening the capacities of organisations and individuals working in the field of health, HIV & AIDS, population and development in order to contribute to improving the quality of life of families in sub-Saharan Africa.
To achieve its mission, CAFS conducts courses and provides research and consultancy services from strategically located bases in East and West Africa, with headquarters in Nairobi, Kenya, and a regional office in Lom, Togo. Highly qualified professionals, who form a multi-disciplinary team within the fields of reproductive health, HIV & AIDS and population & development, provide its services. The list of courses is as follows:
o Resource Mobilization & Proposal Writing, 11 - 15 May 2009
o Advocacy for Reproductive Health and HIV & AIDS, 8 -19 June 2009
o Supervising HIV & AIDS Services, 6 - 17 July 2009
o Advances in Behavior Change Communication for HIV & AIDS, TB and Malaria Programmes, 20 - 31 July 2009
o Promoting Gender and Rights in Reproductive Health and HIV&AIDS, 27 July -14 August 2009
o Impact Measurement, Monitoring and Evaluation of HIV & AIDS Programmes, 10 - 21 August 2009
o Developing and Implementing an Effective Knowledge Management Strategy, 21 -25 September 2009
o Leadership and Management of Reproductive Health, and HIV & AIDS Programmes, 5 -16 October 2009
o Strengthening Multi-sectoral Prevention and Response Interventions to Sexual and Gender Based Violence, 9 -20 November 2009
This is a three days non residential course aimed at enhancing the reporting and management of workplace HIV and AIDS interventions. The course programme is anchored in three core modules: Introduction to M&E; Developing M&E work plans, collecting, analyzing and using monitoring & evaluation data for programme reporting and management. The course is designed for those that provide oversight and leadership of workplace interventions, Human Resource Managers, HIV and AIDS Workplace Focal Point Persons, Clinical officers, HIV and AIDS Programme Managers, Peer Educators, and including workplace Union and Labor Representatives.
This course is intended for PhD students and other researchers interested in the quantitative analysis of inequality and inequity in health and health care. The course consists of five days of lectures and tutorials on a number of topics related to the measurement and explanation of inequities/inequalities in health. Apart from providing a general introduction into the range of approaches available to researchers, it will also provide practical experience of computation using Stata. Illustrations will be based on real-world examples drawn from evidence in European and other OECD countries, as well as developing countries. The objectives are to review health economics approaches to the measurement of inequality and inequity, provide detailed guidance on computational procedures using Stata and provide hands-on experience with computation-based exercises.
The Global Health Workforce Alliance announces the launch of its Communities of Practice (CoPs), entitled - Human Resources for Health (HRH ) Exchange. The topic of the moderated on-line discussion will be Task Shifting. This is the 1st in a series of planned CoPs and forms part of our knowledge brokering effort. It will be held from April 28 - May 8, 2009 and supported by facilitators who are expert in the field of Public Health and the issue of Task Shifting.
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).
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