In 2007, the International Finance Corporation (IFC) of the World Bank Group released a report that observed that over half of health care funding in Africa comes from private sources and that there is considerable spending on private health care providers. It proposed that, if rapid economic growth in Africa is expanding the middle-class, it is also increasing the demand for private health care. The report encouraged investment in the private health sector as one of the top five areas for investment in Africa. Subsequently, the World Bank introduced the “Africa Health Fund”, supported by the IFC and the Gates Foundation, amongst others, to fund efforts to expand the private health sector in Africa.
Should development aid be used to support the growth of for-profit private providers and private health insurance, as the IFC suggests? Should African governments encourage growth of private for-profit health services? Is this as healthy a partnership as the World Bank and IFC would suggest?
These questions need to be answered in all countries in East and Southern Africa, as the private sector already exists, or is growing, in all. While the not-for-profit private sector, such as faith based services, has had a long presence and co-operation with governments in the region, growth in the private-for-profit sector appears to be a new trend.
There are many examples. In the hospital sector, the Indian hospital group, Fortis Healthcare, and African Medical Investments (which is based in the Isle of Wight in the UK) have initiated investments in high-end ‘boutique’ hospitals that target the high-income domestic, expatriate, diplomatic and medical tourism markets in Kenya, Mauritius, Mozambique and Tanzania, while South African private hospital groups are expanding into other African countries. The US-based hedge fund Harbinger Capital Partners has bought a controlling stake in African Medical Investments which aims to become a leading operator of high-end hospitals.
An alliance between two pharmaceutical manufacturers, the South African company, Aspen Pharmacare, and the multinational, GlaxoSmithKline, is leading expansion into many countries in the region. Private health funders are also spreading. The Tanzanian private health insurer, Strategis, is set to expand rapidly with the sponsorship of the “Health Insurance Fund”, supported by the Dutch Ministry of Development Cooperation. This fund provides a mix of public, donor and private funding to stimulate private health insurance companies as a critical step in creating demand for private health care provision. PharmAccess, a Dutch NGO appointed to manage the Fund, is developing models and contracts to facilitate private health insurance elsewhere in Africa. The “Investment Fund for Health in Africa” established in 2007, also from the Netherlands and with Pfizer amongst its shareholders, provides private equity to invest in private health care providers. In 2010, it purchased a 20% stake in a private insurance scheme, AAR East Africa, that is based in Kenya but operates in many other countries in the region.
Such initiatives bring immediate investment resources to the region, and provide services to some of the population However, the experience of South Africa, the country with the longest and most extensive experience of the formal private sector in the region, raises questions about the impact these sorts of activity have on the equity and sustainability of the wider health system.
In South Africa, after de-regulation of the private health sector in the late 1980s, there was the same growth of private health insurers and providers now being proposed in other parts of Africa. As McIntyre shows in EQUINET Discussion paper 84, this was accompanied by increasing costs of health insurance, rising fees charged by private providers (especially hospitals) and low and shrinking coverage of the population. In 1981 an average household with only one member working in the formal sector devoted just over 7% of its wages to medical scheme contributions for the family. By 2007 this stood at almost 30% of average wages. Monopolies emerged, as the same company involved in private hospitals would also buy into ambulance services and a range of other health care activities. Private beds consolidated over the years within three large private hospital groups. This limited the competition that was supposed to reduce costs and decreased, rather than increased, consumer choice. While this expansion was taking place the private sector also received various public subsidies. At the same time it attracted skilled health professionals trained at considerable public cost away from the public sector.
These trends have proved very difficult to reverse in the 2000s in South Africa, despite considerable efforts by government to re-regulate the sector. It has made it more difficult to develop policies to achieve universal coverage. The experience is a warning signal for other countries in the region of the political and economic costs of a private-for-profit health sector expanding in a relatively unregulated environment.
Governments and communities cannot be mere spectactors of these developments. They, together with external funders, should be asking questions before they open the door to such trends elsewhere in the region: Who will benefit from the expansion of the private for-profit sector? What consequences will the expansion have on health service prices, resources, services and coverage? Will it support national health policy goals? What regulations and capacities exist in the state to manage this process?
There is at present inadequate evidence to provide clear answers to these questions, not least because it is difficult to obtain financial and other information from the private sector. Given their duty to protect the health of the whole population, Ministries of Health should thus remain cautious about fostering the expansion of the for-profit private sector and entering into public-private partnerships without getting clear information about the effects on the equity and sustainability of the wider health system.
While arguments are being put forward about the investment and profit potential of the private health sector, Ministries of Health need to make clear to their government colleagues not only the advantages, but also the potential pitfalls of encouraging for-profit private sector expansion as part of their economic growth policies. The opportunity costs of supporting the for-private health sector as opposed to developing the public health system need to be made visible. If private investments in the health sector are proposed, it is a duty of the state to require prior independent health impact assessments, especially where public subsidies from government or development aid funds are involved. The assessments should cover issues such as the impact on health care coverage for low income groups, projections of costs and affordability, impacts on public sector resources, the viability of the entire health system, and so on.
Ministries of Health and the public cannot allow private sector expansion to take place in a vacuum. Government needs to develop comprehensive policies and a robust regulatory framework for the private sector that protects against the development of monopolies and unethical business practices and aligns investments to national policies and core social objectives, particularly for improving the coverage of appropriate, good quality services in rural areas and low-income populations. Health ministries need to ensure that they have departments and capacities to engage with the private sector and to carry out the basic functions of ‘due diligence,’ including co-ordination, monitoring, regulation, management, inspection and enforcement of sanctions.
And as a bottom line, if governments are to gain support for their efforts to manage the for-profit private sector in line with national goals, they must inject resources into the public health system so that it can provide an equitable, effective and good quality alternative to private care.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please read EQUINET Discussion paper 87 and other materials on the EQUINET website at www.equinetafrica.org and visit the Health Economics Unit website at http://heu-uct.org.za/
1. Editorial
2. Latest Equinet Updates
This review was commission by EQUINET to explore the implications of expansion of the private for profit health sector for equitable health systems in East and Southern Africa. It summarises the rationale behind the IFC’s recommendations. It then explores whether there are signs of increasing for-profit private sector activity in the region, along the lines suggested by the IFC. The report then identifies issues of concern on private for profit activity in the health sector. It is an initial scoping exercise based on a desk review of predominantly grey literature. It suggests from the evidence presented that Ministries of Health need to highlight both benefits and pitfalls of encouraging for-profit private sector provisioning in economic growth policies and assess the opportunity costs of supporting the for-profit private health sector as opposed to developing the public health system. Comprehensive policies on the private sector need to be developed, together with a robust regulations and state capacities to monitor private sector activity and enforce regulations and sanctions.
Anti-counterfeiting laws and actions have raised concern about such laws and actions not undermining the flexibilities in the World Trade Organisation TRIPS agreement to protect access to affordable and generic medicines. At the same time, importing countries need measures to protect against substandard imported drugs. The 2011 World Health Assembly resolved that a working group review World Health Organisation (WHO) policy on counterfeit, falsified and substandard medicines, and WHOs relationship with IMPACT. This policy brief defines counterfeit, substandard and falsified medicines. It points to the separate measures and mandates needed to combat each: for dealing with fraudulent trade mark and intellectual property (IP) infringement in counterfeit medicines by IP authorities, for ensuring that any anti-counterfeit measures protect TRIPS flexibilities, including for access to generic medicines; and for national drug regulatory authorities to ensure that substandard and falsified medicines do not compromise health.
The sharing by countries of influenza virus samples is important for vaccine development, and for understanding how viruses are mutating. Developing countries have thus freely provided samples to the World Health Organisation (WHO). But when private pharmaceutical companies use the samples to develop and patent vaccines which the same developing countries cannot afford, this is unjust and exposes thousands of people in developing countries to preventable deaths. This policy brief outlines the opportunities that African countries have to negotiate for equitable benefit sharing in the use of viral resources, through international treaties. The United Nations Convention on Biological Diversity (CBD) and the Nagoya Protocol on Access to Genetic Resources provide for fair and equitable sharing of benefits from the use of biological resources. The brief provides information on their enabling clauses and outlines the options that African countries may consider in their negotiations for an equitable system.
3. Equity in Health
Preparations for the United Nations High-level Meeting on Non-communicable Diseases in September 2011 have already begun through regional consultations in all six World Health Organisation (WHO) regions. These consultations have resulted in declarations or outcome documents that identify priorities for action against NCDs and outline the expectations of Member States. Based on the regional consultations, some of these expectations include: a greater commitment from policy-makers to NCD prevention; more effective mechanisms and monitoring of intersectoral action; greater accountability of non-health sectors; and scaling-up of WHO’s Action Plan. Despite repeated external funding commitments such as the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action, NCDs receive less than 3% of development assistance for health even though they cause more than one-third of all premature deaths. Ultimately the outcomes of the high-level meeting will depend on the expressed priorities of Member States, the authors of this article argue. At the very least, they conclude, the meeting should increase awareness of NCDs among policy-makers and achieve higher levels of political commitment.
In this study, researchers assessed whether the global target of halving tuberculosis (TB) mortality between 1990 and 2015 can be achieved and estimated the number of lives saved globally by the DOTS/Stop TB Strategy of the World Health Organisation (WHO). Mortality from TB since 1990 was estimated for 213 countries using established methods endorsed by WHO. The researchers found that TB mortality among HIV-negative (HIV−) people fell by 36% between 1990 and 2009 and they predict it could be halved by 2015. The overall decline (when including HIV-positive people, who comprise 12% of all TB cases) was 19%. Between 1995 and 2009, 49 million TB patients were treated under the DOTS/Stop TB Strategy, saving 4.6–6.3 million lives, with a further 1 million lives that could be saved annually by 2015. The researchers conclude that their findings indicate that the global target of halving TB deaths by 2015 relative to 1990 is possible. Intensified efforts to reduce deaths among HIV+ TB cases are still needed, especially in sub-Saharan Africa.
According to this fact sheet measuring progress towards achieving the health-related Millennium Development Goals, annual global deaths of children under five years of age fell to 8.1 million in 2009 from 12.4 million in 1990. Fewer children are underweight. The percentage of underweight children under five years old is estimated to have dropped from 25% in 1990 to 16% in 2010. More women get skilled help during childbirth. The proportion of births attended by a skilled health worker has increased globally, however, in the WHO Africa and South-East Asia regions fewer than 50% of all births were attended. Fewer people are contracting HIV. New HIV infections have declined by 17% globally from 2001–2009. Tuberculosis treatment is more successful. Existing cases of TB are declining, along with deaths among HIV-negative TB cases. More people have safe drinking-water, but not enough have toilets. The world is on track to achieve the MDG target on access to safe drinking-water but more needs to be done to achieve the sanitation target.
The common starting point of many studies scrutinising the factors underlying health inequalities is that material, cultural-behavioural, and psycho-social factors affect the distribution of health systematically through income, education, occupation, wealth or similar indicators of socioeconomic structure. However, little is known regarding if and to what extent these factors can assert systematic influence on the distribution of health of a population independent of the effects channelled through income, education, or wealth. In their analysis, the authors of this paper suggest that three main factors persistently contribute to variance in health: the capability score, cultural-behavioural variables and to a lower extent, the materialist approach. Of the three, the capability score illustrates the explanatory power of interaction and compound effects as it captures the individual's socioeconomic, social, and psychological resources in relation to his/her exposure to life challenges. Models that take a reductionist perspective and do not allow for the possibility that health inequalities are generated by factors over and above their effect on the variation in health channelled through one of the socioeconomic measures are underspecified and may fail to capture the determinants of health inequalities, the authors conclude.
Non-communicable diseases (NCDs), principally heart disease, stroke, cancer, diabetes and chronic respiratory diseases, are a global crisis and require a global response, according to the authors of this report. Yet, despite the threat to human development, and the availability of affordable, cost-effective and feasible interventions, most countries, development agencies and foundations are neglecting the crisis. The authors call on the United Nations, which will gather for its High-Level Meeting on NCDs in September 2011, to launch a coordinated global response to NCDs that is commensurate with their health and economic burdens. The report aims to answer four questions: is there really a global crisis of NCDs? How is NCD a development issue? Are affordable and cost-effective interventions available? And do we really need high-level leadership and accountability? Action against NCDs will support other global health and development priorities, the authors argue, concluding that long-term success will require inspired and committed national and international leadership.
This is the first-ever World Report on Disability (WRD) and it comes at a critical time, now that 150 countries have signed the UN Convention on the Rights of Persons with Disabilities (CRPD). One billion people in the world are experiencing disability – one in seven of the world’s population – and the numbers are rising. The report provides strong evidence of the need to equalise rights and opportunities for persons with disabilities in all aspects of life. The authors highlight the barriers and hardships faced by persons with disabilities, especially in low- and middle-income countries, such as increased unemployment (one in two men and four in five women with disabilities are unemployed globally), increased poverty (higher rates of food insecurity, poor housing, lack of access to safe water and sanitation, and inadequate access to health care), poor educational attainment, poor health outcomes and a higher risk of exposure to violence.
4. Values, Policies and Rights
While neoliberal globalisation is associated with increasing inequalities, global integration has simultaneously strengthened the dissemination of human rights discourse across the world. This paper explores the seeming contradiction that globalisation is conceived as disempowering nations states’ ability to act in their population’s interests, yet implementation of human rights obligations requires effective states to deliver socio-economic entitlements, such as health. Central to the actions required of the state to build a health system based on a human rights approach is the notion of accountability. Two case studies are used to explore the constraints on states meeting their human rights obligations regarding health, the first drawing on data from interviews with parliamentarians responsible for health in East and Southern Africa, and the second reflecting on the response to the HIV/AIDS epidemic in South Africa. The case studies illustrate the importance of a human rights paradigm in strengthening parliamentary oversight over the executive in ways that prioritise pro-poor protections and in increasing leverage for resources for the health sector within parliamentary processes. Further, a rights framework creates the space for civil society action to engage with the legislature to hold public officials accountable and confirms the importance of rights as enabling civil society mobilization, reinforcing community agency to advance health rights for poor communities. In this context, critical assessment of state incapacity to meet claims to health rights raises questions as to the diffusion of accountability rife under modern international aid systems. Such diffusion of accountability opens the door to ‘cunning’ states to deflect rights claims of their populations. We argue that human rights, as both a normative framework for legal challenges and as a means to create room for active civil society engagement provide a means to contest both the real and the purported constraints imposed by globalisation.
Women suffering domestic abuse who are financially dependent on their abusers can now report the crime with the assurance that they will be able to get financial and medical support from the state, thanks to Angola’s new law on domestic violence. Women’s campaigners have welcomed the introduction of the new law, which was signed into the statue books on 8 July 2011, and which criminalises domestic violence and offers protection to victims and their families. Until now domestic violence had not been illegal in Angola – and on the rare occasions it reached court, it was prosecuted under rape, assault and battery laws. The new law guarantees support to victims, through safe houses, medical treatment and financial and legal help. In addition, violence has been designated as a ‘public crime’, which means anyone can report it to the police, not just the victim. However, no details have yet been given about how much money will be made available to victims.
In the run up to the UN summit on non-communicable diseases, there are fears that industry interests might be trumping evidence based public health interventions. Will anything valuable be agreed? With only weeks to go before the summit, years of negotiations seem to be stalling. Discussions have stopped on the document that forms the spine of the summit, and charities are concerned that governments are trying to wriggle out of commitments. For example food is proving to be a sticking point again. Changes to language in the latest version of the draft document are subtle but clearly important. While the so called G77 group of lower income states—including India, China, Kenya, and Brazil—argue that saturated fat should be reduced in processed products, as well as sugar and salt, that recommendation is being resisted by the US, Canada, Australia, and the EU. Other areas of industry interest are proving contentious.
Because there has been so little research into the rape of men during war, it's not possible to say with any certainty why it happens or even how common it is, according to this article. Ugandan activists report a veil of secrecy surrounding male rape - the organisations working on sexual and gender-based violence don't talk about it and it’s systematically silenced, even in reports, the author notes. To fill the gap in data, the Refugee Law Project (RLP) in Uganda produced a documentary in 2010 called Gender Against Men, but the producer of the film alleges attempts were made to stop him by well-known international aid agencies. RLP further alleges that one of its funders refused to provide any more funding unless RLP promised that 70% of their client base was female, despite a critical shortage of health and support programmes for vulnerable men in Uganda. RLP calls on African governments, international and local aid agencies and human rights defenders at the United Nations to acknowledge male rape as humanitarian and medical crisis needing urgent attention.
According to this article, it is common in Uganda to hear arguments that men rape women because women wear indecent clothing or invite men into their homes or drink late into the night with men or accept a ride home. Much less discussion focuses on the male’s responsibility. The author of the article examines an incident ofalleged rape reported in July 2011 in Uganda’s national media. The media and the public condemned the complainant as a reckless and oversexed con-woman, the author of this article notes. Ensuing debates and responses in the media since the story broke have implied that even as rape victims, women bear sole responsibility for protecting themselves. With regard to sexual violence against women in Uganda, the author concludes it is time men started seeing women as human beings and not sexualised objects.
The authors of this article warn that new vaccines are likely to be more complex and expensive than those that have been used so effectively in the past, and they could have a multifaceted effect on the disease that they are designed to prevent, as has already been seen with pneumococcal conjugate vaccines. Deciding which new vaccines a country should invest in therefore requires not only sound advice from international organisations such as the world Health Organisation (WHO) but also a well-informed national immunisation advisory committee with access to appropriate data for local disease burden. The authors discuss how the introduction of vaccines might need modification of immunisation schedules and delivery procedures and they outline progressive methods to finance new vaccines in low-income countries.
5. Health equity in economic and trade policies
The Society for International Development (SID)'s triennial World Congress, which concluded on 31 July 2011 in Washington, United States, drew over 1,000 attendees. According to the United Nations Development Programme, which attended the event, the emergence of new paths to development has grown along with the rise of middle- and low-income countries. However much of this growth has not been inclusive. A spokesperson for the UN Development Programme noted at the meeting that the empowerment of women was essential to the solid development of global international economies, a sentiment echoed by many others at the congress. Although 40% of participants were from the global South, one of the speakers, Sanjay Reddy expressed disappointment that the meeting was dominated by Northern development professionals, in particular those who appear to be engaged in for- profit contracting to execute development projects on behalf of organisations such as USAID. Reddy added that, if genuine grassroots development were to take place, SID should return to its original role of facilitating discussions between diverse groups, including voices that call for radically alternative methods to the current neoliberal agenda.
Members of the African, Caribbean and Pacific (ACP) Group and the European Union (EU) met on 31 May 2011 in Brussels, Belgium to continue ongoing negotiations on Economic Partnership Agreements (EPA). The ACP Ministers re-iterated their request for more flexibility on the part of the EU, including trade in medicines, and called for the reinforcement of the development components of EPAs. They also called for regional integration initiatives to be given precedence and for the preferential market access currently being provided under the EU’s EPA Market Access Regulation to be maintained and extended to other ACP countries until negotiations are concluded. In contrast, the EU Commissioner warned that the market access provided since 2007 to ACP countries that concluded EPA negotiations is temporary and predicated upon implementation of EPAs by ACP countries. He also announced that, owing to prolonged delays and stalemates in the negotiations, by the end of 2011 both parties will have to assess whether concluding negotiations is actually feasible within a realistic timeframe.
India and the European Union (EU) have signed an agreement that puts more stringent conditions on EU customs authorities that consider stopping shipments of generic pharmaceuticals passing through Europe. The EU has committed to change the regulation that led to seizures in 2008 of legitimate generics from India passing through the Netherlands and other European countries on their way to South America and Africa. The seizures had been initiated by European patent holders even though the shipments were in transit and not destined for European markets. A key element of the agreement is the core principle that ‘the mere fact that medicines are in transit through EU territory, and that there is a patent title applicable to such medicines in EU territory, does not in itself constitute enough grounds for customs authorities in any Member State to suspect that the medicines at stake infringe patent rights’. Only if there is adequate evidence of a likely diversion of medicines into the EU market, then can EU authorities have grounds for suspicion of infringement of intellectual property rights.
On his trip to South Africa on 18 July 2011, British Prime Minister, David Cameron, talked of the need to go beyond debt cancellation and aid and instead promote free trade with Africa. But ‘free trade’ on inequitable terms has been and will be of no benefit to Africa, the author of this article argues. Africa has much to learn from South Korea, the model to which Cameron refers as a successful example of free-market liberalisation. What Cameron failed to point out, the author notes, is that South Korea used a range of government interventions that are not accepted in free trade practice and are being denied to African governments. The author argues that African prosperity relies on a wholesale rejection of the western free trade model, which means protecting industries, developing alternative and complementary means of trading, control of food production and banking, progressive tax structures, controlled use of savings, and strong regulation to ensure trade and investment really benefits people.
6. Poverty and health
Arguments about the most effective and equitable approach to distributing insecticide-treated nets (ITNs) centre around whether to provide ITNs free of charge or continue with existing social marketing strategies. In this study, researchers in Tanzania examined the equity implications of ownership and use of ITNs in households from different socioeconomic quintiles in a district with free ITNs (Mpanda) and a district without free ITN distribution (Kisarawe). They found that ownership of ITNs increased from 29% in the 2007/08 national survey to 90% after the roll out of free ITNs in Mpanda, and use increased from 13% to 77%. Inequality was considerably lower in Mpanda. In Kisarawe, ownership of ITNs increased from 48% in the 2007/08 national survey to 53%, with marked inequality. The results suggest that inequality in ownership and use of ITNs may be addressed through the provision of free ITNs to all.
Exclusive breastfeeding (EBF) is reported to be a life-saving intervention in low-income settings. In this study, researchers evaluated the effectiveness of breastfeeding counselling by peer counsellors in Africa. Twenty-four communities in Burkina Faso, 24 in Uganda and 34 in South Africa were included in the study. Of the 2,579 mother-infant pairs assigned to the intervention or control clusters in the three countries, EBF prevalences were recorded along with prevalence of diarrhea. The researchers found that, although it does not affect diarrhoea prevalence, low-intensity individual breastfeeding peer counselling is an achievable target and they urge governments in low-income countries in sub-Saharan Africa to scale up EBF counseling to increase the prevalence of EBF.
The famine spreading across the Horn of Africa is not principally the result of drought, but due to political and social circumstances that urgently need to be addressed, the author of this article argues. Global media reports attribute the main cause for the famine to successive seasons of failed rains, yet the author notes here that there has been only one failed rainy season in the Horn so far. The primary cause of the famine is war, the author argues, which has disrupted farmers in Somalia from their normal routines. In the past, a single rainy season failure was easily augmented by relying on stored food from surplus harvests, or from importing food from further south, but violence and fighting has kept farmers from their fields, even if the rains are good, as they were this year. And while there is surplus food, it isn’t getting to the famine area due to lack of infrastructure and local disruption of services. Tanzania, which has had a bumper harvest so far this year, has also banned agricultural sales to the north, for fear it will deplete its own surpluses.
In this paper, the authors investigated the relationship between maternal depression and child growth in developing countries through a systematic literature review and meta-analysis. Seventeen studies were included, with a total of 13,923 mother-and-child pairs from 11 countries. The authors found that children of mothers with depression or depressive symptoms were more likely to be underweight or stunted. The selected studies indicated that if the infant population were entirely unexposed to maternal depressive symptoms, 23% to 29% fewer children would be underweight or stunted. The authors call for rigorous prospective studies to identify mechanisms and causes. Early identification, treatment and prevention of maternal depression may help reduce child stunting and underweight in developing countries.
7. Equitable health services
Despite the availability of many treatment options, depressive disorders remain a global public health problem, according to this study. In developing countries, the World Health Organisation estimates that less than 10% of those suffering from depression receive proper care due to poverty, stigma and lack of governmental mental health resources and providers. Positive activity interventions (PAIs) are a type of low-cost intervention that teaches individuals ways to increase their positive thinking, positive emotions and positive behaviours. In this article, the authors review the relevant literature on the effectiveness of various types of PAIs, draw on social psychology, affective neuroscience and psychophamacology research to propose neural models for how PAIs might relieve depression, and discuss the steps needed to translate the potential promise of PAIs as clinical treatments for individuals with major and minor depressive disorders.
In 2009, as part of a strategic planning process, Makerere University College undertook a qualitative study to examine care and service provision at Mulago National Referral Hospital (MNRH), identify challenges, gaps, and solutions, and explore how the University could contribute to improving care and service delivery at MNRH. Twenty-three key informant interviews and seven focus group discussions were conducted with nurses, doctors, administrators, clinical officers and other key stakeholders. Participants identified a number of challenges to care and service delivery at MNRH, including resource constraints, staff inadequacies, overcrowding, a poorly functioning referral system, limited quality assurance, and a cumbersome procurement system. They also pointed to insufficiencies in the teaching of professionalism and communication skills to students, and patient care challenges that included lack of access to specialised services, risk of infections, and inappropriate medications. The authors recommend addressing these barriers by strengthening the relationship between the hospital and Makerere. Strategic partnerships and creative use of existing resources, both human and financial, could improve quality of care and service delivery.
The objective of this study was to determine whether community-based health workers in a rural region of Ethiopia can provide injectable contraceptives to women with similar levels of safety, effectiveness and acceptability as health extension workers. The researchers examined the provision of injectable contraceptives by community-based reproductive health agents (CBRHAs). A total of 1,062 women participated in the study. Compared with health post clients, the clients of CBRHAs were, on average, slightly older, less likely to be married and less educated, and they had significantly more living children. Women seeking services from CBRHAs were also significantly more likely to be using injectable contraceptives for the first time; health post clients were more likely to have used them in the past. In addition, clients of CBRHAs were less likely to discontinue using injectable contraceptives over three injection cycles than health post clients. In conclusion, receiving injectable contraceptives from CBRHAs proved as safe and acceptable to this sample of Ethiopian women as receiving them in health posts from health extension workers.
This report on public healthcare provision in South Africa revealed deficiencies in the national health care system, including a shortage of ambulances, clinics, medical personnel and medication. More than 400 community-based and nongovernment organisations, human rights and health organisations and almost every district municipality across the country participated in the assessment. Patients complained of verbal abuse, discrimination and violation of patient rights, especially with regard to confidentiality. The environmental causes of illness, including poor water quality and a lack of proper sanitation was commonly noted, putting pressure on the health system. Deep concern was also expressed that those suffering from chronic illnesses needed access to social and financial support as well as medical treatment. The consultations exposed an absence of effective monitoring and evaluation systems. There are no central points where complaints can be lodged, the report notes. The report has been released ahead of the scheduled parliamentary debates on the proposed National Health Insurance (NHI) scheme.
8. Human Resources
Using a policy analysis framework, the authors of this study analysed the implementation and perceived effectiveness of a rural allowance policy and its influence on the motivation and retention of health professionals in rural hospitals in the North West province of South Africa. They conducted 40 in-depth interviews with policy-makers, hospital managers, nurses, and doctors at five rural hospitals and found weaknesses in policy design and implementation. These weaknesses included: lack of evidence to guide policy formulation; restricting eligibility for the allowance to doctors and professional nurses; lack of clarity on the definition of rural areas; weak communication; and the absence of a monitoring and evaluation framework. Although the rural allowance was partially effective in the recruitment of health professionals, it has had unintended negative consequences of perceived divisiveness and staff dissatisfaction. The authors recommend that government should take more account of contextual and process factors in policy formulation and implementation so that policies have the intended impact.
In this study, researchers surveyed the alumni of Community-Based Education and Service (COBE) programmes at Makerere University, Uganda, to obtain their perceptions of the management and administration of COBE and whether COBE had helped develop their confidence as health workers, competence in primary health care and willingness and ability to work in rural communities. A total of 150 alumni were contacted, of which 24 (13 females and 11 males) were selected for focus group discussions. The alumni almost unanimously agree that the initial three years of COBES were very successful in terms of administration and coordination. COBES was credited for contributing to development of confidence as health workers, team work, communication skills, competence in primary health care and willingness to work in rural areas. The alumni also identified various challenges associated with administration and coordination of COBES at Makerere. The authors conclude that health planners should take advantage of the long-term positive impact of COBES and provide the programmes with more support.
This study was undertaken to assess the scope and nature of community-based education (CBE) for various health worker cadres in Uganda. Curricula and other materials on CBE programmes in Uganda were reviewed to assess nature, purpose, intended outcomes and evaluation methods used by CBE programmes. In-depth and key informant interviews were conducted with people involved in managing CBE in twenty-two selected training institutions, as well as stakeholders from the community, Ministry of Health, Ministry of Education, civil society organisations and local government. The researchers found that CBE curriculum is implemented in most health training institutions in Uganda and is a core course in most health disciplines at various levels. The CBE curriculum is systematically planned and implemented with major similarities among institutions. Organisation, delivery, managerial strategies, and evaluation methods are also largely similar. Strengths recognised included providing hands-on experience, knowledge and skills generation and the linking learners to the communities. Almost all CBE implementing institutions cited human resource, financial, and material constraints. It is still uncertain whether this approach is increasing the number graduates seeking careers in rural health service, one of the stated programme goals.
Have AIDS external funders harmed or strengthened health workforce development in countries with severe shortages? This research led to six key findings. First, to staff AIDS programmes, external funders have relied on training existing workers and taskshifting, not on training new health workers. Second, AIDS external funders have swamped countries with in-service training programmes for HIV/AIDS-specific skills. Third, PEPFAR and the Global Fund have relied on task-shifting to lower level health workers without assuring adequate resources or support. Fourth, community health workers are employed as a quick fix without considering their long -term role. Fifth, the incentives that AIDS external funders offer health workers to achieve HIV and AIDS programme targets distort allocations of time and resources to the detriment of other health sector objectives. Finally, AIDS external funders pay health workers through short-term special arrangements without addressing long-term constraints on the public and private health workforce.
9. Public-Private Mix
Policy makers in developing countries need to assess how public health programmes function across both public and private sectors. The authors of this paper propose an evaluation framework to assist in simultaneously tracking performance on efficiency, quality and access by the poor in family planning services. They applied this framework to field data from family planning programmes in Ethiopia and Pakistan, comparing independent private sector providers; social franchises of private providers; non-government organisation (NGO) providers; and government providers on these three factors. They found that franchised private clinics have higher quality than non-franchised private clinics in both countries. In Pakistan, the costs per client and the proportion of poorest clients showed no differences between franchised and non-franchised private clinics, whereas in Ethiopia, franchised clinics had higher costs and fewer clients from the poorest quintile. These results suggest that there are trade-offs between access, cost and quality of care that must be balanced as competing priorities. The relative programme performance of various service arrangements on each metric will be context specific, the authors conclude.
The author of this paper examined the functioning of the informal transport markets in facilitating access to maternal health care in Eastern Uganda, to demonstrate the role that higher institutions of learning can play in designing projects that can increase the utilisation of maternal health services. Data were collected through qualitative and quantitative methods that included focus group interviews and a review of project documents and facility-level data. There was a marked increase in attendance of antenatal, and delivery care services, with the contracted transporters playing a leading role in mobilising mothers to attend services, the authors found. The project also had economic spill-over effects to the transport providers, their families and community generally. However, some challenges were faced including difficulty in setting prices for paying transporters, and poor enforcement of existing traffic regulations. The findings indicate that locally existing resources such as motorcycle riders can be used innovatively to reduce challenges caused by geographical inaccessibility and a poor transport network with resultant increases in the utilisation of maternal health services. However, care must be taken to mobilise the resources needed and to ensure that there is enforcement of laws that will ensure the safety of clients and the transport providers themselves.
The authors of this paper reviewed and synthesised findings from eight independent evaluations of Global Health Partnerships (GHPs) as well as research projects they had conducted themselves. They present the major drivers of the current GHP trend, briefly review the significant contributions of GHPs to global health and set out common findings from evaluations of these global health governance instruments. The paper answers the question of how to improve GHP performance with reference to a series of lessons emerging from the past ten years of experience. These lessons cover the following areas: value-added and niche orientation; adequate resourcing of secretariats; management practices; governance practices; ensuring divergent interests are met; systems strengthening; and continuous self-improvement. The authors argue in favour of sustained critical reflection and independent evaluation of GHPs so as to ensure optimal results, given the high level of resources that collaboration demands. They call for the opening up of spaces for public debate so that the findings from evaluation can be frankly discussed, as well as highlight the need to apply lessons more widely across and within partnerships.
The chairman of South Africa’s Parliament’s health portfolio committee, Bevan Goqwana, is lobbying for a new, statutory body to oversee private hospitals. Members of his committee grilled the Hospital Association of SA (Hasa) on the prices charged by its members, which include more than 95% of private hospitals. The Council for Medical Schemes said a lack of competition was partly to blame for rising private hospital fees. They said that, in 1996 half the hospitals in metropolitan areas were independent but by 2006 this figure had fallen to 12,3%, due to market concentration in the hands of a few private health care providers, resulting in an oligarchy of providers. Private hospitals and healthcare professionals have faced constant criticism from the Health Minister, Aaron Motsoaledi, for the role he perceives them to be playing in driving up the cost of healthcare. In their defence, Hasa claims that the real cause of high hospital costs in the private sector is the cost of inputs and the expense of increasing hospital capacity with the purchase of expensive specialist equipment.
For human vaccines to be available on a global scale, complex production methods, meticulous quality control and reliable distribution channels are needed to ensure that the products are potent and effective at the point of use, the authors of this article argue. The technologies used to manufacture different types of vaccines can strongly affect vaccine cost, ease of industrial scale-up, stability and, ultimately, worldwide availability. The complexity of manufacturing is compounded by the need for different formulations in different countries and age-groups. Reliable vaccine production in appropriate quantities and at affordable prices is the cornerstone of developing global vaccination policies, the author argue. However, they emphasise that to ensure optimum access and uptake, strong partnerships are needed between private manufacturers, regulatory authorities, and national and international public health services. For vaccines whose supply is insufficient to meet demand, prioritisation of target groups can increase the effect of these vaccines.
10. Resource allocation and health financing
The financial sector is traditionally under-taxed relative to the rest of the economy, so it is ideally suited as a source of taxes that can be used for global health, according to this brief. Taxes on the sector are also predominantly progressive, falling on the richest institutions and individuals. Harm Reduction International (HRI) proposes a financial transaction tax (FTT) that collects a tiny percentage (between 0.5% and 0.005%) of the value of each financial product that is traded. An average tax of just 0.05% on transactions (such as bond and share sales) could raise as much as US$409 billion a year, HRI notes, significant funding for disease responses and health system strengthening in poorer countries. HRI cautions that the FTT would be in addition to - not instead of - government commitments to overseas development assistance, so it could help bridge the resource gap that currently exists to achieve the Millennium Development Goals.
Low-income countries bear over 60% of the HIV disease burden, but ActionAid argue that their total annual resources for HIV went down from 2009 to 2010. This raises a gap between resources available and needed. To close this gap by 2015, UNAIDS estimate that the international community needs to raise an additional US$6 billion annually, with a parallel increase in commitments for the period 2011-2020. Proposed potential sources of funding include innovative financing mechanisms, indirect taxation (airline tickets, mobile phone usage, exchange rate transactions), front-loading mechanisms (IFF-Im) and advance market commitments. The author urges pharmaceutical companies to enter into negotiations with the Patented Medicines Pool and to ensure that the geographic scope of these licensing agreements includes low- and middle-income countries.
From 9 to 13 July 2011, members of the Future Health Systems consortium gathered in Toronto, Canada, to participate in the 8th World Congress on Health Economics (iHEA 2011). Following a keynote address that considered the risks of a polarised debate between private or public health care, a presentation considered the future of working with health markets. The focus of the Congress was how to deliver quality health services. Participants argued that ensuring quality in inequitable contexts requires the skillful combination of commodities with knowledge. With this in mind, two panels were convened to look at how both supply side and demand side factors can be altered to improve quality of health care, in terms of both ethics and economics.
In the run-up to the fourth High-level Forum on Aid Effectiveness in Busan, South Korea, in November 2011, analysts are warning that aid measurements cannot be "dumbed down", particularly in fragile states. The UK Overseas Development Institute (ODI) has condemned the much-praised British campaign, Make Poverty History, which suggests that all that is required to solve poverty is for rich nations to give money to poor ones. In contrast, the ODI argued that development processes tend to be complex and time-consuming, especially in fragile states and states emerging from conflict. While politicians, press and voters in donor countries often demand greater transparency and less corruption as part of their aid effectiveness criteria, citizens in recipient countries may prioritise other issues like job creation or better health services. This gap in priorities needs to be addressed, the ODI concludes. The World Bank said the Busan meeting should present new funding opportunities, as increasingly important `non-traditional' development funders, such as China, India and the Arab states, will be present, and they will demand effectiveness criteria that are different from those of traditional external funders like the European Union and the United States.
According to AFRODAD, tax revenues are, on average, lower in developing countries than in rich countries; the average revenue in African countries was approximately 15% of GDP in 2008. Hence the argument that if developing countries were able to collect sufficient tax revenues, they might be able to increase their independence, the provision of social protection, infrastructure and basic services such as education and health care which are crucial for development. The two reports on Mozambique and Zimbabwe reveal that mobilising domestic resources as a means to financing development has become an important development issue, a shift from the past emphasis on financing development from aid and external borrowing. For a long time mobilising domestic revenue has been neglected, despite being a better long-term option, AFRODAD argues. The reasons for this included the inherent pessimism about raising revenue, a prevalent ‘small-state’ ideology and a preference for foreign aid-led solutions. AFRODAD proposes that progressive taxation should play an important role in shaping the distribution of benefits from higher-income citizens to those most in need in a country. The reports also examine the various complexities surrounding taxation as a development finance mechanism in the two country cases including the current tax framework, the amount and extent of tax evasion and more specifically tax incentives and governance in various sectors of the economy. They conclude with policy and institutional recommendations to the governments of Mozambique and Zimbabwe – and civil society – to refine their tax systems.
11. Equity and HIV/AIDS
Highly Active Antiretroviral Therapy (HAART) has been available free of charge in Tanga, Tanzania since 2005, yet many women referred from prevention of mother-to-child transmission services to the Care and Treatment Clinics (CTC) for HAART never registered at the CTCs. In this study, researchers focused on the motivating and deterring factors to presenting for HAART, particularly in relation to women. A qualitative approach was used, including in-depth interviews and focus group discussions. Researchers found that the main deterrent to presenting for treatment appears to be fear of stigmatisation including fear of ostracism from the community, divorce and financial distress. Participants indicated that individual counselling and interaction with other people living with HIV would encourage women to present for HAART, to do so, and indicated that the entrance to the CTC should be placed to allow discreet access. Necessary steps towards encouraging HIV infected women to seek treatment include reducing self-stigma, assisting them to form empowering relationships and to gain financial independence and emphasising the beneficial effect of treatment for themselves and for their children by example.
In this study, researchers conducted a qualitative study to explore risk situations that can explain the high HIV prevalence among youth in Kisumu town, Kenya. They conducted in-depth interviews with 150 adolescents aged 15 to 20, held four focus group discussions, and made 48 observations at places where youth spend their free time. Porn video shows and local brew dens were identified as popular events where unprotected multipartner, concurrent, coerced and transactional sex occurs between adolescents. Forced sex, gang rape and multiple concurrent relationships characterised the sexual encounters of youth, frequently facilitated by the abuse of alcohol, which is available for minors at low cost in local brew dens. A substantial number of girls and young women engaged in transactional sex, often with much older, wealthier partners. The authors conclude that local brew dens and porn video halls facilitate risky sexual encounters between youth and should be regulated and monitored by the government. Young men should be targeted in prevention activities, to change their attitudes related to power and control in relationships, while girls should be empowered how to negotiate safe sex, and their poverty should be addressed through income-generating activities.
Are Uganda’s health systems are being strengthened to sustain access to antiretroviral therapy (ART)? This study applies systems thinking to assess supply chain management, the role of external support and whether investments create the needed synergies to strengthen health systems. The authors combined data from the literature and key informant interviews with observations at health service delivery level in a study district. Findings indicate that current drug supply chain management in Uganda is characterised by parallel processes and information systems that result in poor quality and inefficiencies. Less than expected health system performance, stock outs and other shortages affect ART and primary care in general. Poor performance of supply chain management is amplified by weak conditions at all levels of the health system, including the areas of financing, governance, human resources and information. Governance issues include the lack to follow up initial policy intentions and a focus on narrow, short-term approaches. In conclusion, the study indicates serious missing system prerequisites. The findings suggest that root causes and capacities across the system have to be addressed synergistically to enable systems that can match and accommodate investments in disease-specific interventions. The multiplicity and complexity of existing challenges require a long-term and systems perspective essentially in contrast to the current short term and programme-specific nature of external assistance.
According to this report, despite a broad awareness of HIV, comprehensive knowledge of HIV and how to prevent it is still low, even in countries that have been most affected by the epidemic. There are encouraging signs that HIV-prevention efforts are resulting in positive change in sexual behaviours, accompanied by declines in HIV prevalence among young people in the most-affected countries. This should not be cause for complacency, UNAIDS warns. Instead, these successful services and programmes should be built upon to further efforts to reverse the epidemic among young people. To effectively advance the response among young people, UNAIDS argues that there is a need to increase investments. However, it also cautions that simply directing more resources will not increase HIV testing and uptake of services among young people. Instead, empowering young people and particularly young women to exercise their rights to sexual and reproductive health, improve programmes for young people and repeal national laws and policies that restrict access to HIV services for young people is required to protect future generations from HIV. The report highlights that young people are a key resource to reverse the global AIDS epidemic and lead the response in decades to come, but it stresses that the legal and policy barriers that prevent young people from accessing HIV services must be addressed, and young people should be engaged more effectively in the response.
The public health response to sexually transmitted infections, particularly HIV, has been and continues to be overwhelmingly focused on risk, disease and negative outcomes of sex, while avoiding discussion of positive motivations for sex like pleasure, desire and love. Recent advocacy efforts have challenged this approach and organisations have promoted the eroticisation of safer sex, especially in the context of HIV prevention.
This paper is a case study of one of these organisations – the Pleasure Project. The authors give a brief background on the public-health approach to sex and sexual health, and recommend an alternative approach that incorporates constructs of pleasure and desire into sexual health interventions. The Pleasure Project’s aims and unorthodox communications strategies are described, as are the response to and impact of its work, lessons learned and ongoing challenges to its approach. Despite the backdrop of sex-negative public health practice, there is anecdotal evidence that safer sex, including condom use, can be eroticised and made pleasurable, based on qualitative research by the Pleasure Project and other like-minded organisations. Yet there is a need for more research on the effectiveness of pleasure components in sexual health interventions, particularly in high-risk contexts, the authors argue. This need has become urgent as practitioners look for new ways to promote sexual health and as new prevention technologies (including female condoms and microbicides) are introduced or disseminated.
Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of ≤350 cells/µl rather than ≤200 cells/µl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. The authors estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs. For Hlabisa subdistrict, KwaZulu-Natal, they predicted the HIV epidemic dynamics, number on ART and programme costs under the new guidelines relative to treating patients at ≤200 cells/µl for the next 30 years. Calculations indicated that during the first five years, the new WHO treatment guidelines will require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years. The findings strengthen the WHO recommendation of starting ART at ≤350 cells/µl for all HIV-infected patients.
12. Governance and participation in health
In this paper, the authors examine the potential role of civil society action in increasing state accountability for development in Sub-Saharan Africa. They build on the analytical framework of the World Development Report 2004 on accountability relationships, to emphasise the underlying political economy drivers of accountability and implications for how civil society is constituted and functions. The main argument is that the most important domain for improving accountability is through the political relations between citizens, civil society and state leadership. The evidence broadly suggests that when higher-level political leadership provides sufficient or appropriate powers for citizen participation in holding within-state agencies or frontline providers accountable, there is frequently positive impact on outcomes. However, the big question remaining for such types of interventions is how to improve the incentives of higher-level leadership to pursue appropriate policy design and implementation. The paper concludes that there is substantial scope for greater efforts in this domain, including through the support of external aid agencies. Such efforts and support should, however, build on existing political and civil society structures (rather than transplanting ‘best practice’ initiatives from elsewhere), and be structured for careful monitoring and assessment of impact.
As the centre of global geo-politics continues to shift, much attention is being focused on the BRICS (Brazil, Russia, India, China, South Africa) group of emerging economies and the IBSA (India, Brazil and South Africa) group of emerging democracies as their power in global political and economic affairs has increased substantially, the author notes in this article. He calls attention to the implications of the growing power of BRICS and IBSA countries both individually and collectively for global civil society and development cooperation. From civil society’s point of view, concerns have been raised about the fact that while aid is offered to other developing countries by BRICS countries, there is an overall lack of information about the basis on which aid is given by them. Civil society is notably absent from BRICS meetings and summits. Additionally, there is the question of BRICS countries’ limited participation in ongoing multi-lateral processes to ensure harmonisation and transparency of aid. Traditionally, external funder countries have been involved in multiple processes and discussions to reduce aid overlap, faulty prioritisation and wastage. The author recommends greater south-south cooperation led by the democratic trio of IBSA countries. Their civil societies are active and also well placed to connect with their peers in the developing world to promote sustainable development underpinned by democratic values. But this will require some key foreign policy shifts for which civil society needs to lobby hard.
In sub-Saharan Africa media coverage of reproductive health issues is poor due to the weak capacity and motivation for reporting these issues by media practitioners, the authors of this paper argue. They describe the experiences of the African Population and Health Research Centre and its partners in cultivating the interest and building the capacity of the media in evidence-based reporting of reproductive health issues in sub-Saharan Africa. The authors note that the Research Centre’s media strategy evolved over the years, including: enhancing journalists’ interest in and motivation for reporting on reproductive health issues through training and competitive grants for outstanding reporting; building the capacity of journalists to report reproductive health research and the capacity of reproductive health researchers to communicate their research to media through training for both parties and providing technical assistance to journalists in obtaining and interpreting evidence; and establishing and maintaining trust and mutual relationships between journalists and researchers through regular informal meetings between journalists and researchers, organising field visits for journalists, and building formal partnerships with professional media associations and individual journalists. The authors conclude that a sustained mix of strategies that motivate, strengthen capacity of, and build relationships between journalists and researchers can be effective in enhancing quality and quantity of media coverage of research.
Kenyan President, Mwai Kibaki, has assured members of the African Peer Review Mechanism (APRM) that his government is committed to undertaking far-reaching reforms in the management of public affairs and entrenchment in constitutionality. President Kibaki affirmed that Kenya’s process of reforming governance would continue and urged the APRM team to share their experiences, particularly positive developments realised in other parts of the world that would be of value to Kenya and other African nations. Prime Minister, Raila Odinga, noted that Kenya was a pioneer in the review mechanism and was keen to evaluate the status of the country’s governance and explore ways of improving weak areas. He added that Kenya was open to scrutiny by peers and looked forward to a full examination and recommendations for appropriate remedy for various challenges facing the nation and its people.
This paper reports the findings of an atypical systematic review of 60 years of literature in order to arrive at a more comprehensive awareness of the constructs of participation for communicable disease control and elimination and provide guidance for the current malaria elimination campaign. Of the 60 papers meeting the selection criteria, only four studies attempted to determine the effect of community participation on disease transmission. The studies showed statistically significant reductions in disease incidence or prevalence using various forms of community participation. The use of locally selected volunteers provided with adequate training, supervision and resources is crucial to the success of the interventions in these studies, the authors argue. After a qualitative synthesis of all 60 papers, they elucidate the complex architecture of community participation for communicable disease control and elimination. The authors stress the importance of ensuring that current global malaria elimination efforts do not derail renewed momentum towards the comprehensive primary health care approach. They recommend that the application of the results of this systematic review be considered for other diseases of poverty in order to harmonise efforts at building 'competent communities' for communicable disease control and optimising health system effectiveness.
The authors of this article argue that governments need to provide civil society organisations with more space and recognition to facilitate a stronger health response with a particular focus on tuberculosis (TB) prevention, care and control. They call on the World health Organisation (WHO) and its international partners to play a brokering and facilitative role to catalyse the process, and they provide a contextual framework to achieve this in the article. In many countries, civil society organisations have been responsible for handling the majority of resources to deliver services to individuals and have played a leading role in developing and implementing sustainable strategies to mitigate the impact of HIV and AIDS. In contrast, TB prevention, care and control activities face numerous challenges. A major problem is that one in three estimated TB cases globally is either not formally reported in the public system or not reached at all by existing services. TB is rarely recognised as a priority by national political authorities, United Nations agencies, development banks, the pharmaceutical industry and philanthropic organisations and often neglected within development, human rights and social justice agendas. Despite some efforts to engage civil society organisations in global TB activities, in many countries they still lack recognition as legitimate partners at national and local level even in established democracies.
13. Monitoring equity and research policy
In 2008, Makerere University began a radical institutional change to bring together four schools under one College of Health Sciences. This paper’s objective is to demonstrate how the University’s leadership in training, research and services has impacted health in Uganda. Data were collected through analysis of key documents; systematic review of MakCHS publications and grants; surveys of patients, students and faculty; and key informant interviews of the College’s major stakeholders. The researchers found that the University inputs to the health sector include more than 600 health professionals graduating per year, many of whom assume leadership positions. University contributions to processes include strengthened approaches to engaging communities, standardised clinical care procedures and evidence-informed policy development. Outputs include the largest number of out-patients and in-patient admissions in Uganda. Outcomes include an expanded knowledge pool, and contributions to coverage of health services and healthy behaviours. Pilot projects have applied innovative demand and supply incentives to create a rapid increase in safe deliveries (three-fold increase after three months), and increased quality and use of HIV services with positive collateral improvements on non-HIV health services at community clinics.
The Ghanaian government’s strategy on orphans and vulnerable children (OVCs) recommends they should be encouraged to live in their home communities rather than in institutions. The paper presents lessons here on efforts to use research to build a response across different agencies to address the problems that communities and families face in caring for these children in their communities. This approach to building consensus on research priorities points to the value of collaboration and dialogue with multiple stakeholders as a means of fostering ownership of a research process and supporting the relevance of research to different groups. The authors argue that if the context within which researchers, policy makers and stakeholders work were better understood, the links between them were improved and research were communicated more effectively, then better policy making which links across different sectors may follow. At the same time, collaboration among these different stakeholders to ensure that research meets social needs, must also satisfy the requirements of scientific rigour.
In this study, researchers conducted a comparative analysis of cotrimoxazole preventive therapy (CPT) in Malawi, Uganda and Zambia. They held 47 in-depth interviews to examine the influence of context, evidence and the links between researcher, policy makers and those seeking to influence the policy process. In relation to context, they found a number of factors to be influential, including government structures and their focus, funder interest and involvement, healthcare infrastructure and other uses of cotrimoxazole and related drugs in the country. In terms of the nature of the evidence, the researchers found that how policy makers perceived the strength of evidence behind international recommendations was crucial (if evidence was considered weak then the recommendations were rejected). Finally, the links between different research and policy actors were considered of critical importance, with overlaps between researcher and policy maker networks crucial to facilitate knowledge transfer. Within these networks, in each country the policy development process relied on a powerful policy entrepreneur who helped get CPT onto the policy agenda.
This qualitative study focuses on the research communication and policy-influencing objectives, strategies and experiences of four research consortia working in sexual and reproductive health, HIV and AIDS in nine countries in sub-Saharan Africa and Asia. The authors carried out 22 in-depth interviews with researchers and communications specialists to identify factors that affect the interaction of research evidence with policy and practice, using an adapted version of the Overseas Development Institute’s RAPID analytical framework. Results indicated that the characteristics of researchers and their institutions, policy context, the multiplicity of actors, and the nature of the research evidence all play a role in policy influencing processes. Research actors perceived a trend towards increasingly intensive and varied communication approaches. Effective influencing strategies include making strategic alliances and coalitions and framing research evidence in ways that are most attractive to particular policy audiences. Tensions include the need to identify and avoid unnecessary communication or unintended impacts, challenges in assessing and attributing impact and the need for adequate resources and skills for communications work. The authors conclude that the adapted RAPID framework can serve as a useful tool for research actors to use in resolving tensions.
In this study, researchers analysed the impact of the report ‘Reviewing ‘Emergencies’ for Swaziland: Shifting the Paradigm in a New Era’, which was published in 2007 and built a picture of the HIV and AIDS epidemic as a humanitarian emergency, requiring urgent action from international organisations, external funders and governments. Following a targeted communications effort, the report was believed to have raised the profile of the issue and Swaziland - a success story for HIV and AIDS research. The authors conducted a literature search on the significance of understanding the research-to-policy interface, using the report as a case study. They explored key findings from the assessment, suggesting lessons for future research projects. They demonstrate that, although complex, and not without methodological issues, impact assessment of research can be of real value to researchers in understanding the research-to-policy interface. Only by gaining insight into this process can researchers move forward in delivering effective research, they argue.
The case-studies presented in this paper analyse findings from sexual and reproductive health and HIV research programmes in sub-Saharan Africa, including Ghana, South Africa and Tanzania. The analysis emphasises the relationships and communications involved in using research to influence policy and practice and recognises a distinction whereby practice is not necessarily influenced as a result of policy change – especially in SRH – where there are complex interactions between policy actors. Both frameworks demonstrate how policy networks, partnership and advocacy are critical in shaping the extent to which research is used and the importance of on-going and continuous links between a range of actors to maximise research impact on policy uptake and implementation. The case-studies illustrate the importance of long-term engagement between researchers and policy makers and how to use evidence to develop policies which are sensitive to context: political, cultural and practical.
Assessing the impact that research evidence has on policy is complex, the authors of this paper argue, and they review some of the main conceptualisations of research impact on policy, including generic determinants of research impact identified across a range of settings, as well as the specificities of sexual and reproductive health (SRH) in particular. They identify aspects of the policy landscape and drivers of policy change commonly occurring across multiple sectors and studies to create a framework that researchers can use to examine the influences on research uptake in specific settings, to guide attempts to ensure uptake of their findings. The framework distinguishes between pre-existing factors influencing uptake and the ways in which researchers can actively influence the policy landscape and promote research uptake through their policy engagement actions and strategies. The authors conclude by highlighting the need for continued multi-sectoral work on understanding and measuring research uptake and for prospective approaches to receive greater attention from policy analysts.
14. Useful Resources
The Sub-Saharan African Medical Schools Study (SAMSS) website is a portal for information on medical education in Sub-Saharan Africa. It highlights reports and articles that shed light on the current state of medical education in the region and describes innovations and trends that will shape the future of medical education in Africa. Links to relevant resources are also provided, as well as information about the pioneering work done by the SAMSS team. SAMSS is committed to addressing the extremely low physician to population ratio (13/100,000) in sub-Saharan Africa, arguing that any efforts to stabilise and improve health in the region must address this shortage of physicians. The primary goal of SAMSS is to increase the level of practical knowledge about medical education in Sub-Saharan Africa in order to inform educators, policy makers, and international funders about the challenges and opportunities for increasing the capacity of African medical schools and the retention of their graduates.
This guide sets out the legal responsibilities of South African local government and our rights under the Constitution and in law. It shows how to engage government from inside, by participating in formal processes, and from outside by going public through complaints, petitions, protest action, the media and the courts.
This toolkit is published by the African Women’s Development and Communication Network (FEMNET) with the support of UNESCO. It provides guidance for women’s organisations in Africa on how to organise around freedom of information. It has compiled five case studies from five African countries, namely, Cameroon, Ghana, Kenya, South Africa and Zambia under different scenarios. As women continue to remain one of the most marginalised groups in African countries, the guide can assist NGOs in adopting new tools in ensuring gender rights and equality. The five case studies discussed in the book provide ideas and experiences faced by organisations lobbying for drafting and passing of a law where ordinary citizens have access to governmental information. From countries like Ghana and Cameroon, where no such law has even been drafted to countries like South Africa where such legislation exists. Studying these case stories from different countries can assist organisations to lobby for such a law and if it exists, how it can be used to create awareness within the community, especially for women empowerment. In general, the toolkit aims to mobilise women’s NGOs to take up freedom of information for ensuring rights and justice for women.
The World Health Statistics report is an essential resource for policy-makers and researchers working on the identification and reduction of health inequities. A dedicated section in the 2011 report presents data from 93 countries using three health indicators - percentage of births attended by skilled health personnel, measles immunisation coverage among 1-year-olds, and under-five mortality rate - disaggregated according to urban or rural residence, household wealth and maternal education level. The data presented refer to ratios and differences between the most-advantaged and least-advantaged groups.
15. Jobs and Announcements
The East, Central and Southern Africa Health Community (ECSA-HC), in collaboration with the Ministries of Public Health and Sanitation and Medical Services Republic of Kenya will host the 54th ECSA Health Minister’s Conference from 07 - 11 November 2011 in Mombasa, Republic of Kenya. The Conference, will bring together Ministers of Health, Senior Officials from Ministries of Health, Experts, Health Researchers, Heads of Health Training Institutions from Member States of the ECSA Health Community; diverse Collaborating Partners in the region and beyond with the aim of identifying policy issues and making recommendations to facilitate the implementation of high impact interventions for improved health outcomes. The theme of the 54th ECSA Health Ministers Conference is “Consolidating the gains: Addressing High Impact Interventions for Improved Health Outcomes” Abstracts are being invited for presentation of papers under the ECSA-HC Regional Forum on Best Practices which is held annually in conjunction with the Health Ministers Conference for the East Central and Southern Africa - Health Community (ECSA-HC) You are kindly requested to submit your abstract(s) by 16 September 2011 to admin@ecsa.or.tz.
The BRAC University is calling for applicants for its Masters of Public Heath programme. Since its inception, the School has received 191 diverse students from different corners of the globe such as South Asia, Southeast Asia, Africa, Australia, North and South Americas, and Europe. The graduates move on to work for their respective governments, national and/or international NGOs, or with various donor and UN agencies. Additionally, universities and research organizations also acquire a large number of our MPH students. The MPH curriculum is structured to maximize learning around the health problems faced by communities in Bangladesh, and elsewhere. This includes extensive field-based instructions complemented by interactive classroom based work in teams. The School has a generous scholarship programme that aims to promote global access to the MPH amongst potential students from all over the world based on merit. The admission process includes an application, reference letters, statement of interest in public health, individual and group interviews, as well as written and oral tests.
The Africa Programme for Advanced Research Epidemiology Training(APARET) is an European Union-funded programme whose goal is to support independent research activities by fellows in Africa . The programme will run for four years with three fellow intakes, and each intake will last for two years in selected African research training institutions. During this period, the fellows shall conduct epidemiologic research with their host institutes. A major part of the first year shall be the application for a major research grant. Each fellow shall be supported by a mentor and supervisor and a grant averaging 6,000 Euros to facilitate their research during the fellowship. Fellows will be supervised and trained in planning and conducting independent epidemiological research as well as in the analysis of epidemiological data. Further training will be provided on critically reviewing scientific papers and on the submission of scientific manuscripts to a peer-reviewed journal.
The MRC/DfID African Research Leader scheme is awarded for non-clinical and clinical researchers of exceptional ability. The aim of the scheme is to strengthen research leadership across sub-Saharan Africa by attracting and retaining talented individuals undertaking high quality programmes of research. The ARL scheme will continue to build on existing strong research partnerships between African and UK research organizations by providing support for outstanding non-clinical and clinical researchers, ideally from less resourced, sub-Saharan Africa countries. The scheme is open to all research areas within the Medical Research Council’s remit that address the priority health problems of people in developing countries and where the research is best conducted in sub-Saharan Africa. This includes biomedical and health research (including social sciences and public health research) relevant to national and regional health needs and priorities. Potential African Research Leader candidates must supply a high-quality science proposal, be affiliated to an African research organisation and have a UK partner (investigator and institution).
The International Development Research Centre and the Canadian Global Tobacco Control Forum are calling for concept notes concerning the expansion of fiscal policies for global and national tobacco control. The key objective of this call is to generate knowledge designed to accelerate the adoption of effective fiscal policies for tobacco control in low-and middle-income countries (LMICs). Key thematic areas include: research on the impact of various types of tobacco taxes or pricing policies; region-based research to establish actual and model budgets for tobacco control; research on coordinated regional and global taxes, tariffs and/or other levies on tobacco products and the profits from tobacco sales; and research to identify barriers to, and strategies for, accessing Official Development Assistance for tobacco control. The principal applicant must be a citizen or permanent resident of a LMIC and with a primary work affiliation in a LMIC institution.
The International Development Research Centre is calling for concept notes concerning the promotion of healthy diets as a key strategy for the prevention of non-communicable diseases (NCDs) in low- and middle-income countries(LMICs). The key objective of this call is to support Southern-led research designed to influence the adoption and implementation of effective policies and programmes for the promotion of healthy diets in LMICs. Key thematic areas include: research on policies, population-wide programs and community-based interventions that aim to discourage production and consumption unhealthy food products and promote healthy eating; and evidence syntheses or situation analyses to inform policy dialogues and the adoption and implementation of key interventions to address unhealthy diets as a key NCD risk factor. Please note that three major cross-cutting issues are central to the NCD programme: equity, intersectoral action and commercial influence on public health-related policy. The principal applicant must be a citizen or permanent resident of a LMIC and with a primary work affiliation in a LMIC institution.
The World Health Organisation (WHO) is calling for papers for all sections of the Bulletin and encourage authors to consider contributions that address any of the following topics: disease burden assessments in low-income countries, since information in this area is scarce; vaccination implementation and policy, particularly on the cost and public health benefit of vaccination programmes; and the evaluation of nonpharmaceutical public health measures since these are widely described as control measures, but there is less published evidence on their effectiveness than for pharmaceutical interventions (vaccines and medicines). In particular, WHO seeks submission of papers that document experiences from low-resource settings.
At the Fourth High-Level Forum on Aid Effectiveness, approximately 2,000 delegates will review global progress in improving the impact and effectiveness of aid, and make commitments that set a new agenda for development. The Forum follows meetings in Rome, Paris and Accra that helped transform aid relationships between donors and partners into true vehicles for development cooperation. Based on 50 years of field experience and research, the five principles that resulted from these fora encourage local ownership, alignment of development programmes around a country’s development strategy, harmonisation of practices to reduce transaction costs, the avoidance of fragmented efforts and the creation of results frameworks.
On the occasion of the ten-year anniversary of the Doha Declaration, Medicins sans Frontieres (MSF) is launching an ‘ideas contest’ on how to revise TRIPS so that it genuinely meets global public health needs. Contestants are asked to respond to the following question: Can TRIPS be reformed to meet public health needs? If your answer is YES, describe your idea for how the treaty should be changed. If NO, explain why not, and propose an alternative. Anyone is eligible to submit an entry, either as an individual, a team, and/or on behalf of an institution. The contest seeks to attract ideas from around the world from creative thinkers who may be academics, students, activists, analysts, government officials, journalists, or from the private sector. Submissions from low- and middle-income countries are particularly encouraged. There are two submission options: Option 1: A written essay of 500-1000 words (excluding footnotes and references). Option 2: An audio visual entry: video, audio, slideshow or photofilm of no more than five minutes. Submissions should succinctly describe a proposal to change the TRIPS Agreement so that it is conducive to global public health.
Every Saturday at 12 noon Eastern Standard time, African Views Radio holds regular discussions on health care systems in Africa in a show called African Health Dialogues. The forum is accessible to online audiences live on air and also via podcast. There is also an opportunity for people to call in via phone to participate in the discussions from any part of the world. The first show aired on 30 July 2011 and explored the status of healthcare systems in Africa with respect to the past, present and future. The producers of the programme are inviting participants to call in and join the discussions.
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