Health systems in sub-Saharan Africa have been in a state of decline since the debt crisis of the 1980s and the subsequent effects of structural adjustment, chronic public under-investment and health sector reform. Zimbabweans experience a heavy burden of disease dominated by preventable diseases such as HIV infection and AIDS, malaria, tuberculosis, diarrheal diseases, nutritional deficiencies, vaccine preventable diseases and health issues affecting pregnant women and neonates. According to the latest Zimbabwe Demographic and Health Survey, the number of women dying due to maternal causes for the past 7 year period has increased in Zimbabwe from 725 deaths for every 100 000 live births in 2009 (2002-2009) to 960 deaths for every 100 000 live births in 2010/11 (2003-2010).
With this high burden of ill health, efforts to make sustained and equitable improvements in health are being made by various state and non state actors. One of the clearest objectives is to revive the Primary Health Care (PHC) concept. Primary health care, as contained in the Declaration of Alma-Ata 1978, is: " Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part, both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process."
Zimbabwe’s national health policy commits the Government “to ensure that communities are empowered to take responsibility for their own health and well being, and to participate actively in the management of their local health services.”
Health Centre Committees (HCCs) are a mechanism through which community participation can be effectively integrated to achieve a sustainable people centered health system at the primary care level of the health system. They complement vital community level initiatives like community health workers, and mechanisms for public participation at all levels of the health system. In Zimbabwe, Health Centre Committees (HCCs) were originally proposed by the Ministry of Health and Child Welfare in the early 1980s to assist communities to identify their priority health problems, plan how to raise their own resources, organize and manage community contributions, and tap available resources for community development. In 2010 Health Centre Committees in two districts in Mashonaland East province collaborated with Village Health Workers to mobilize expectant mothers to deliver at health facilities nearest to them, contributing to improving maternal and neonatal survival. In Chikwaka community in Goromonzi district, the HCC has in 2011-2012 taken the lead in mobilizing financial and material resources- bricks, quarry, river, pit sand and labour- to construct a Maternity Waiting Home at a primary care facility in their ward. These are examples of how HCCs are able to organize, identified local health problems, tap into their own available resources and take action for community development.
Despite setting their roles and functions as early as the 1980’s, HCCs still do not yet have a statutory instrument that specifically governs their roles and functions. This is a gap in the formal provisions for how communities should organize on health and PHC at primary care (health centre) level. While PHC is not only an issue for the health sector, and is thus taken up by more general local government structures, it is necessary that mechanisms exist within the health sector to align the health system to PHC and community issues, as well as to link and give leadership input to these more general structures.
The absence of formal recognition may mean that other sectors do not act on health as it is not adequately profiled in their wider deliberations. The 2009-2013 National Health Strategy recognized this gap and made specific note of the importance of establishing health centre committees within the health system. The strategy identifies that “…during the next three years, communities, through health centre committees or community health councils will be actively involved in the identification of health needs, setting priorities and managing and mobilizing local resources for health”.
A 2009 Training and Research Support Centre (TARSC) and CWGH assessment on PHC (http://tinyurl.com/5rdnh7v) found Health Centre Committees (HCCs) functioning (ie having met) in only 40% of the 20 districts surveyed. The HCCs present these were found to lack coherent integration with planning systems, and to be functional in only a third of sites. Nevertheless HCCs were found in this survey to be associated with higher levels of satisfaction with services, attributed to the communication, improved understanding and support for morale that they build between communities and health workers.
HCCs offer an opportunity to take forward the shared local priorities across health workers and communities and to discuss how to accommodate differing priorities between them. In a 2004 study by Loewenson et al (http://tinyurl.com/c8bd86k) , HCCs were associated with improved PHC outcomes compared to areas where they did not exist.
HCCs ensure the proper planning and implementation of primary health care in coordinated efforts with other relevant sectors. In doing this, they promote health as an indispensable contribution to the improvement of the quality of life of every individual, family and community as part of overall socio-economic development. Primary Health Care (PHC) approaches seek to build and depend on a high level of ownership and participation from involved and affected communities. The HCC is the mechanism by which people get involved in health service planning at local level. In Zimbabwe Health Centre Committees (HCCs) identify priority health problems with communities, plan how to raise their own resources, organize and manage community contributions, and advocate for available resources for community health activities. They discuss their issues with health workers at the HCC, report on community grievances about quality of health services, and discuss community health issues with health workers.
CWGH and TARSC in partnership with the Primary Health Care taskforce have developed HCC guidelines that have been proposed as the basis for a Statutory Instrument to formally recognize the role of these structures. An HCC Training Manual developed by TARSC and CWGH has been peer reviewed by the Ministry of Health and Child Welfare to strengthen the capacities to deliver on their roles, backed by health literacy activities that strengthen the wider community literacy on health to encourage wider input to and hold these mechanisms accountable. While community participation demands much more than HCCs, institutionalizing and giving a formal mandate to HCCs is critical and key to achieving a sustainable people centered health system in Zimbabwe.
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 visit www.equinetafrica.org
1. Editorial
2. Latest Equinet Updates
The Consultation on Improving Access to Health Workers at the Frontline for Better Maternal and Child Survival was held at the InterContinental Hotel in Nairobi, Kenya from 25 to 27 June 2012. The objective of the consultation was ‘to speed up and scale up country responses to the human resource needs of both the UN Global Strategy for Women’s and Children’s Health (Every Woman Every Child), and the Global Plan towards the Elimination of New HIV Infections Among Children by 2015 and Keeping their Mothers Alive (Global Plan) as a key aspect of both plans’. The communique presents the key proceedings and opportunities, experiences and challenges to guide further action. The Consultation underscored the need for ministries of health, continental mechanisms such as the AUC, regional organisations such as ECSA HC, SADC, WAHO and OCEAC, development partners, FBOs, funding agencies, academic and research institutions, and civic society organisations to give priority to efforts towards increasing access to health workers at the frontline for better maternal and child survival. Recommendations were made to achieve this.
Fair financing of health services requires that countries reduce their reliance on out-of-pocket (OOP) funding for health services and improve their pre-payment financing through general tax revenue and health insurance (particularly mandatory health insurance). While many countries in east and southern Africa (ESA) receive high levels of external funding, it is critical to increase domestic government funding for the health system to support this move away from out-of-pocket funding to provide effective financial protection from the costs of health care. This policy brief reviews progress in reducing out-of-pocket payments in ESA countries and in increasing government funding for health, particularly in terms of meeting the Abuja target of 15% of the government budget being devoted to the health sector and a target of government spending of US$60 per capita. While there has been some progress in some countries, most ESA countries are still far from achieving these fair financing targets. The brief highlights areas that merit action to meet policy commitments on fair financing.
This paper synthesises reports on community participation (CP) concept and its practicability in countries’ health service systems, much focus being on developing countries. The authors were supported through EQUINET to narratively review the published and grey literature traced from electronic sources and hard copies as much as they could be accessed.
CP is a concept widely promoted, but few projects/programmes have demonstrated its practicability in different countries. In many countries, communities are partially involved in one or several stages of project cycles - priority setting, resource allocation, service management, project implementation and evaluation. There is tendency of informing communities to implement the decisions that have already been passed by elites or politicians. In most of the project/programmes, professionals dominate the decision making processes by downgrading the non-professionals or non-technical people’s knowledge and skills. CP concept is greatly misinterpreted and sometimes confused with community involvement. In some cases, the community participates in passive manner. There is no common approach to translate CP into practice and this perpetuates debates on how and to what extent to which the community members should participate. The authors argue that persistent misconceptions about CP perpetuate inequalities in many countries’ health systems, suggesting that more concerted measures are needed.
3. Equity in Health
he Africa Progress Report 2012 is the Africa Progress Panel’s flagship publication. Its purpose is to provide an overview of the progress Africa has made over the previous year. The report draws on the best research and analysis available on Africa and compiles it in a refreshing and provocative manner. Through the report, the Panel recommends a series of policy choices and actions for African policy makers who have primary responsibility for Africa’s progress, as well as vested international partners and civil society organisations. The report warns that Africa’s strong economic growth trajectory – which will see the region increase the pace of growth well beyond 5 per cent over the next two years – is at risk because of rising inequality and the marginalisation of whole sections of society. The report calls for a “relentless focus” by policymakers on jobs, justice and equity to ensure sustainable, shared growth that benefits all Africans. Failure to generate equitable growth could result in “a demographic disaster marked by rising levels of youth unemployment, social dislocation and hunger.” Africa’s governments and development partners must urgently draw up plans for a big push towards the 2015 Millennium Development Goals, the report says.
According to this report, steady economic growth and improvements in poverty reduction on the continent are reported to have had a positive impact on MDG progress, with sustained progress toward several MDGs. Africa is on track to achieve the targets of: universal primary education; gender parity at all levels of education; lower HIV/AIDS prevalence among 15-24 year olds; increased proportion of the population with access to antiretroviral drugs; and increased proportion of seats held by women in national parliament by 2015. However, the report acknowledges that more needs to be done to address inequalities, including between women and men. It highlights the need to address the sub-standard quality and unequal distribution of social services between rural and urban areas. It suggests active steps to ensure that economic growth translates into new and adequate employment opportunities for Africa’s youthful and rapidly growing population, and supports social protection systems. The report urges policymakers to put greater emphasis on improving the quality of social services and ensuring that investments yield improved outcomes for the poor for MDG progress.
The World Federation of Public Health Associations honooured the author with the Leavell Lectureship Award and this paper is the speech given by the awardee on “Health Equity, from the African Perspective” at the Congress. He raises that addressing equity calls for African countries to break the vicious cycle of poverty and ill-health; to urgently address the water, sanitation and hygiene crisis; to mobilize adequate budget allocation to the health sector and provide social protection for poor people; to strengthen the capacity of health systems to provide effective and equitable quality health care services; to stabilise health personnel; to generate evidence and build transparency and accountability in the use of domestic and externally generated resources allocated for health. All these issues he noted need to be backed by political commitment to make health equity a priority.
Noncommunicable diseases are an increasing health concern worldwide, but particularly in low- and middle-income countries. This study quantified and compared education- and wealth-based inequalities in the prevalence of five noncommunicable diseases (angina, arthritis, asthma, depression and diabetes) and comorbidity in low- and middle-income country groups, using 2002-04 World Health Survey data from 41 low- and middle-income countries. Wealth and education inequalities were more pronounced in the low-income country group than the middle-income country group. Both wealth and education were inversely associated with angina, arthritis, asthma, depression and comorbidity prevalence, with strongest inequalities reported for angina, asthma and comorbidity. Diabetes prevalence was positively associated with wealth and, to a lesser extent, education. Adjustments for confounding variables tended to decrease the magnitude of the inequality.
4. Values, Policies and Rights
Understanding the health policy formulation process over the years has focused on the content of policy to the neglect of context. This had led to several policy initiatives having a still birth or ineffective policy choices with sub-optimal outcomes when implemented. Sometimes, the difficulty has been finding congruence between different values and interests of the various stakeholders. This paper attempts to conceptualise the levers of policy formulation using a qualitative participant observation case study based on retrospective recollection of the policy process and political levers involved in developing the Ghana National Health Insurance Scheme. The study finds that technical experts, civil society, academics and politicians all had significant influence on setting the health insurance agenda. Each of these various stakeholders carefully engaged in ways that preserved their constituency interests through explicit manoeuvres and subtle engagements. Where proposals lend themselves to various interpretations, stakeholders were quick to latch on the contentious issues to preserve their constituency. The paper provides lessons which suggest that in understanding the policy process, it is important that actors engage with the content as well as the context to understand viewpoints that may be expressed by interest groups.
An Intellectual Property Laws Amendment Bill passed by Parliament is awaiting signature by South African President Jacob Zuma in order for it become the law. It is an ambitious piece of legislation that aims to provide protective mechanisms for indigenous knowledge in South Africa. The bill is far-reaching and aims to: improve the livelihoods of indigenous knowledge holders and communities, benefit the national economy, prevent bio-piracy, provide a legal framework for protection and empower local communities and prevent exploitation of indigenous knowledge. Despite this legal advance, there is another view on the issue of indigenous intellectual property rights which states that the issue will always remain on the margins, given the dominant system of knowledge production which in the main takes place in universities. The article concludes that the prevailing view is that given the history of persecution of indigenous peoples under colonialism, the fight to include their voices in the protection of indigenous knowledge systems is important and necessary to inform the way forward.
The conference gathered Ministers of Finance and Health and/or their representatives from 54 African countries, African parliamentarians as well as over 400 participants from the public and private sectors, academia, civil society and media globally. The conference recommended:
1. Intensified dialogue and collaboration between ministries of finance and health and with technical and financial partners; 2. Concrete measures to enhance value for money, sustainability and accountability in the health sector to reach universal health coverage; 3. Integrating socio-economic, demographic and health factors into broader development strategies and policies in an effective manner especially in the formulation of medium term strategic plans; 4. Designing effective investments in the health sector, based on evidence-based strategies leading to the prioritization of high impact interventions, which lead to results; 5. Promoting equitable investment in the health sector; ensure that health financing is pro-poor benefiting disadvantaged areas; strengthening regulatory capacity and developing of a strong African pharmaceutical sector as a growth and job creating sector in Africa; 6. Laying out the path to universal health coverage for each country; 7. Improving efficiency in health systems, including equitable access to skilled health workers; 8. Solidifying sustainable health financing systems; 9. Strengthening accountability mechanisms that align all relevant partners, build on the growing citizens’ voice and 10. Increasing domestic resources for health.
The 17th Conference of the Parties to the United Nations Convention on Climate Change (COP 17) that concluded in December 2011, in Durban, South Africa produced the Durban Platform for Enhanced Action that commits governments to developing a protocol, legal instrument, or an agreed outcome to cut greenhouse gas (GHG) emissions with legal force applicable to all countries by no later than 2015. Foreign ministers and environmental ministers set and drove the conference agenda, and economic considerations underpinned all discussions. Despite climate change posing grave risks to human health, the human health perspective on climate change was relegated to side-event, although it led to a parallel inaugural Global Climate and Health Summit, and the Durban Declaration on Climate and Health and Health Sector Call to Action. The report argues that the marginalisation of human health considerations at UN Fframework Convention on Climate Change conferences is untenable and that human health must be a core, not peripheral, focus at future meetings. The report states that the health community, led by health ministers, must play a central role in climate change deliberations and that health ethics principles must be afforded equal status to economics principles in climate change deliberations.
5. Health equity in economic and trade policies
From the United Nations Conference on Sustainable Development (Rio+20) "The Future We Want", the conference outcome document, agreed upon by member states attending the 20-22 June conference, highlights the fact that better health is a “precondition for, an outcome of, and an indicator of all three dimensions of sustainable development”. The outcome document emphasizes the importance of universal health coverage to enhancing health, social cohesion and sustainable human and economic development. It acknowledges that the global burden and threat of non-communicable diseases (NCDs) constitutes one of the major sustainable development challenges of the 21st century. The document states: “We are convinced that action on the social and environmental determinants of health, both for the poor and the vulnerable and the entire population, is important to create inclusive, equitable, economically productive and healthy societies. We call for the full realization of the right to the enjoyment of the highest attainable standard of physical and mental health”.
In order to ensure their population's regular access to essential medicines, many countries are faced with the policy question of whether to import or manufacture drugs locally. For domestic manufacturing to be viable and cost-effective, the local industry must be able to compete with international suppliers of medicines. This paper considers the 'make-or-buy' dilemma by using Tanzania as a case study. Key informant interviews, event-driven observation, and purposive sampling of documents were used to evaluate the case study. The case study focused on Tanzania's imitation technology transfer agreement to locally manufacture a first-line ARV (3TC + d4T + NVP), reverse engineering the ARV. The study finds that Tanzania is limited by weak political support for the use of Trade-Related Aspects of Intellectual Property Rights (TRIPS) flexibilities, limited production capacity for ARVs and limited competitiveness in both domestic and regional markets. The Ministry of Health and Social Welfare encourages the use of flexibilities while others push for increased IP protection. Insufficient production capacity and lack of access to externally -financed tenders make it difficult to obtain economies of scale and provide competitive prices. Within the "make-or-buy" context, it was determined that there are significant limitations in domestic manufacturing for developing countries. The case study highlights the difficulty governments face to make use of economies of scale and produce low-cost medicines, attract technology transfer, and utilize the flexibilities of the WTO Agreement on TRIPS. The results demonstrate the importance of evaluating barriers to the use of TRIPS flexibilities and long-term planning across sectors in future technology transfer and manufacturing initiatives.
The report asserts that in South Africa, as in other jurisdictions, “Big Food” (large commercial entities that dominate the food and beverage environment) is becoming more widespread and is implicated in unhealthy eating. “Small food” remains significant in the food environment in South Africa, and it is both linked with, and threatened by, Big Food. Big Food in South Africa involves South African companies, some of which have invested in other (mainly, but not only, African) nations, as well as companies headquartered in North America and Europe. These companies have developed strategies to increase the availability, affordability, and acceptability of their foods in South Africa; they have also developed a range of “health and wellness” initiatives. Whether these initiatives have had a net positive or net negative impact is not clear. The authors argue that the South African government should act urgently to mitigate the adverse health effects in the food environment in South Africa through education about the health risks of unhealthy diets, regulation of Big Food, and support for healthy foods.
6. Poverty and health
The 2012 Africa Human Development Report argues that sustainable increases in agricultural productivity protect food entitlements—
the ability of people to access food. Furthering human development
requires nutrition policies that unleash the potential of today’s and future generations. Also, communities must be resilient enough to absorb
shocks and have the power to make decisions about their own lives. The Report shows that the basic right to food and the right to life itself is
being violated in sub-Saharan Africa to an intolerable degree. Building
a food secure continent requires transformative change— change that will be most effective if accompanied by a shift of resources, capacities and
decisions to smallholder farmers, poor communities and women. When women and other vulnerable groups gain a voice in the decisions affecting their lives and livelihoods, their capacity to produce,trade and use food is materially enhanced.
Uganda’s Indigenous Batwa people are among the most vulnerable populations in the world and have limited access to key social determinants of health, including health care, education, clean water, employment and adequate clothing, food, and security. The Batwa people were evicted from their native forests following an environmental policy enacted in 1991 and are now considered conservation refugees undergoing a drastic transition from forest dwellers to agriculturalists. The shift has negatively affected people’s health. The report argues that coordinated action among public and private sectors is required to improve Batwa health through the enforcement of their rights and increased participation in policies and programs affecting their well-being.
7. Equitable health services
This study explored possible differences in health care seeking behaviour among a rural and urban African population. Four rural and urban SetTswana communities which represented different strata of urbanisation in the North West Province, South Africa, were selected. Structured interviews were held with 206 participants. Data on general demographic and socio-economic characteristics, health status, beliefs about health and (access to) health care was collected. The results illustrated differences in socio-economic characteristics, health status, beliefs about health, and health care utilisation. Inhabitants of urban communities rated their health significantly better than rural participants. Although most urban and rural participants consider their access to health care as sufficient, they still experienced difficulties in receiving the requested care. Rural participants had significantly lower employment and available weekly budget for health care and transport costs. Urban participants were more than 5 times more likely to prefer a medical doctor in private practice.
Maternal mental health is largely neglected in low- and middle-income countries. There is no routine screening or treatment of maternal mental disorders in primary care settings in South Africa. The Perinatal Mental Health Project (PMHP) developed an intervention to deliver mental health care to pregnant women in a collaborative, step-wise manner making use of existing resources in primary care. Over a 3-year period, 90% of all women attending antenatal care in the maternity clinic were offered mental health screening with 95% uptake. Of those screened, 32% qualified for referral to counselling. Through routine screening and referral, the PMHP model demonstrates the feasibility and acceptability of a stepped care approach to provision of mental health care at the primary care level.
Universal coverage by health services is one of the core obligations that any legitimate government should fulfil vis-à-vis its citizens. However, universal coverage may not in itself ensure universal access to health care. Among the many challenges to ensuring universal coverage as well as access to health care are structural inequalities by caste, race, ethnicity and gender. Based on a review of published literature and applying a gender-analysis framework, this paper highlights ways in which the policies aimed at promoting universal coverage may not benefit women to the same extent as men because of gender-based differentials and inequalities in societies. It also explores how ‘gender-blind’ organisation and delivery of health care services may deny universal access to women even when universal coverage has been nominally achieved.
8. Human Resources
In 2006, the World Health Organization (WHO) reported that 57 countries, most of them in Africa and Asia, face a severe health workforce crisis. They estimate that over 2 million health service providers and 1.8 million management support workers are needed to fill the gap (WHO, 2009). Health workers play a critical role in the effective delivery of health services, especially in high disease-burdened countries like South Africa. Constraints in the health workforce have emerged as a key obstacle to scaling-up access to prevention and treatment for the 5.7 million people currently living with HIV/AIDS in South Africa. A recent strategic plan, released in 2012 by the South African government, aims to address the gaps in human resources for health and is expected to mitigate the resource shortage within the next 15 to 25 years. This report analyses the plan and proposes that actors in other health systems, especially those in high HIV-burden, low-resource countries, may be able to learn from the forthcoming experience of implementing the strategy in South Africa.
In this assessment, researchers aimed to identify critical gaps in the core competencies of the Makerere University College of Health Sciences medicine and nursing, as well as ways to overcome them to achieve the government’s Health Sector Strategic Plan (HSSP) goals. Documents from the Uganda Ministry of Health as well as medicine and nursing curricula were analysed, and 19 key informant interviews) and seven focus group discussions with stakeholders were conducted. The researchers found that the core competencies that medicine and nursing students are expected to achieve by the end of their education were outlined for both programmes. The curricula are in the process of reform towards competency-based education and, on the surface, are well aligned with the strategic needs of the country. But implementation is inadequate, and the researchers argue that learning objectives need to be more applicable to achieving competencies, learning experiences need to be more relevant for competencies and setting in which students will work after graduation (i.e. not just clinical care in a tertiary care facility), and student evaluation needs to be better designed for assessing these competencies.
9. Public-Private Mix
In this report, Médecins Sans Frontières (MSF) notes that middle-income countries with large numbers of people living with HIV, such as South Africa, will no longer benefit from preferential pricing when buying antiretroviral drugs from large pharmaceutical companies. According to the report, pharmaceutical firm ViiV Healthcare - owned by Pfizer and GlaxoSmithKline - no longer offers reduced prices to middle-income countries, even when their programmes are fully funded by the Global Fund to fight HIV, Tuberculosis and Malaria. Merck has also ceased to offer discounted prices to all lower middle- and upper middle-income countries, proposing instead to negotiate discounts on a case-by-case basis. Previously, Merck offered middle-income countries discounts that were still up to ten times the price of generic versions. MSF warns that drug company discount programmes are not a long-term solution, and urges governments to start using Trade-related Aspects of Intellectual Property Rights (TRIPS) measures to override patents.
10. Resource allocation and health financing
Health and education budgets are cut in times of financial crises despite the fact that the opposite should be happening, according to South African health department Director-General Precious Matsoso. Addressing the plenary at the 3rd People’s Health Assembly Matsoso said that while the country was supposed to be rolling out National Health Insurance (NHI), it had to do so with only R11-million per pilot district from Treasury. She argued that social services should not suffer when there is a crisis, the opposite should happen. Instead, she said, we see that when there is a financial crisis, there is a cut in social spending and health. Prior to this, Professor Di McIntyre, who is also a key NHI advisor to the health minister, reiterated that NHI was about the comprehensive reform of the health system. She said one of her key concerns while establishing NHI was the underfunding of the NHI pilot sites by Treasury and the “enormous pressure to protect the positions of the high income groups and private sector profits”.
This paper discusses the range of mechanisms to improve domestic financing that have been utilized worldwide, from which Ministries of Health and Finance can draw a context-specific toolkit for strengthening domestic financing for women’s and children’s health. While evidence exists about how mechanisms have been used in different settings, there remains limited cost-effectiveness data to help guide decision-makers in low and middle income countries on when and where such mechanisms are most effectively and efficiently deployed. Financing mechanisms must be carefully coordinated and integrated to promote universal coverage and avoid fragmentation of health systems.
The dialogue found that countries challenges of high turnover of Health Ministers, shortage of human and financial resources for scaling up action, and weak health information systems. The dialogue recommended flooding health systems with low and middle level staff. The meeting called for resourcing of the Global Fund, which should also “open a window” for maternal, newborn and child health. Mobilization of more domestic resources, accountability, ownership and good coordination were reported as essential for “more money for more health”. The Assembly recommended the development and adoption of national policies, to ensure health is integrated in national development strategies and also costing of national development plans with appropriate economic and other expertise. It was concluded that national and district health accounts should be institutionalized, to track expenditures and ensure decentralization to reach to the communities. Harmonization of health initiatives by development partners was recommended to support and strengthen national plans and programmes, under national ownership and leadership.
Using South Africa as a case study, this review examines whether private health systems are susceptible to regulation and therefore able to support an extension and deepening of coverage when complementing a pre-existing publicly funded and delivered health system. The study finds that the private health system in South Africa has played an important supplementary role in achieving universal coverage throughout its history, but more especially in the post-Apartheid period. However, the quality of this role has been erratic, influenced predominantly by policy vacillation. The objective of universal coverage can be seen in two dimensions, horizontal extension and vertical deepening. Private systems play an important role in deepening coverage by mobilising revenue from income earners for health services over-and-above the horizontal extension role of public systems and related subsidies. South Africa provides an example of how this natural deepening occurs whether regulated or unregulated. It also demonstrates how poor regulation of mature private systems can severely undermine this role and diminish achievements below attainable levels of social protection. When measures to enhance risk pooling are introduced, coverage is expanded and becomes increasingly fair and sustainable. When removed, however, the system becomes less stable and fair as costs rise and people with poor health status are systematically excluded from cover.
African States are on average far from meeting key health financing goals such as the Abuja Declaration target of allocating 15% of the government budget to health. Out-of-pocket expenditure is still higher than 40% of the total health expenditure in 20 of 45 African countries, and in 22 countries the total health expenditure does not reach even the minimal level of US$ 44 per capita defined by the High Level Task Force on Innovative International Financing for Health Systems (HLTF). Only three countries have attained the Abuja Declaration and HLTF targets. Many countries have limited capacity of raising public revenue mainly because the informal nature of their economies makes collection of tax and contributions difficult. This limits their opportunities for investing in health. The paper presents trends in health financing in African countries and calls for close collaboration between the ministries of finance and health and inter-ministerial dialogue to develop a health financing strategy that supports efforts to strengthen all the other health system dimensions to move towards universal health coverage.
11. Equity and HIV/AIDS
Punitive laws and human rights abuses are costing lives, wasting money and stifling the global AIDS response, according to a report by the Global Commission on HIV and the Law, an independent body of global leaders and experts. The Commission report, "HIV and the Law: Risks, Rights and Health," finds evidence that governments in every region of the world have wasted the potential of legal systems in the fight against HIV. The report also concludes that laws based on evidence and human rights strengthen the global AIDS response - these laws exist and must be brought to scale urgently."Bad laws should not be allowed to stand in the way of effective HIV responses," said Helen Clark, United Nations Development Programme Administrator. "In the 2011 Political Declaration on HIV and AIDS, Member States committed to reviewing laws and policies which impede effective HIV responses."
In recent years, innovative contraceptive methods that are discreet and female-initiated have expanded contraceptive access to millions of women who wish to prevent, space, or limit pregnancies but must do so without their partners’ cooperation. The International Partnership for Microbicides (IPM), developers of a new microbicide ring currently undergoing clinical trial in South Africa, hope to apply this same principle to HIV prevention. If proven safe for long-term use, the monthly vaginal ring, which steadily releases the antiretroviral (ARV) drug dapivirine, will serve as a valuable HIV prevention option for women, particularly those who wish to become pregnant or who are unable to safely negotiate condom use or monogamy with their partners. Offering new HIV prevention options to women is particularly important in high-prevalence regions like sub-Saharan Africa, where 60 percent of HIV infections are among women and girls.
12. Governance and participation in health
More than one thousand activists, academics and students from over 60 different countries gathered at the historic University of Western Cape for the third global assembly (PHA3). Walter Flores Gutaemala provided his insights on the Assembly in this opnion piece. He noted that the best plenary took place on the last day. Prof. Jaime Breilh from Ecuador gave a devastating account of how current public health programs and goals, such as the ones addressing nutrition and food security, are lagging so far behind of the ongoing acceleration of accumulation of capital that is destroying and contaminating water and food sources around the world. Large-scale land grabbing in the southern continents by large corporations is making the goal of food sovereignty implausible. The assembly concluded with a call for action that did not satisfy all participants. Clearly, some people wanted more concrete actions and less rhetoric. He comments that although a “call for action” is important, it does not mobilize people on its own, and notes that a clear goal and a path for action, combined with collective indignity and solidarity makes us move.
With evolving South African legislation supporting community involvement in the health system, early policy developments focused on Community Health Committees (HCs) as the principal institutions of community participation. Formally recognized in the National Health Act, the Act deferred to provincial governments in establishing the specific roles and functions of HCs. As a result, stakeholders developed a Draft Policy Framework for Community Participation in Health (Draft Policy) to formalize participatory institutions in the Western Cape province. With the Draft Policy as a frame of analysis, the researchers conducted documentary policy analysis and semi-structured interviews on the evolution of community participation policy. Moving beyond the specific and unique circumstances of the Western Cape, this study analyzes generalizable themes for community participation in the health system. Framing institutions for the establishment, appointment, and functioning of community participation, the Draft Policy proposed a formal network of communication – from local HCs to the health system. However, this participation structure has struggled to establish itself and function effectively as a result of limitations in community representation, administrative support, capacity building, and policy commitment. Without legislative support for community participation, the enactment of superseding legislation is likely to bring an end to HC structures in the Western Cape. The authors conclude that attempts to realize community participation have not adequately addressed the underlying factors crucial to promoting effective participation, with policy reforms necessary: to codify clearly defined roles and functions of community representation, to outline how communities engage with government through effective and accountable channels for participation, and to ensure extensive training and capacity building of community representatives. Given the public health importance of structured and effective policies for community participation, and the normative importance of participation in realizing a rights-based approach to health, this analysis informs researchers on the challenges to institutionalizing participation in health systems policy and provides practitioners with a research base to frame future policy reforms.
After two years of participatory engagement and planning, the People’s Health Movement gathered 800 people from 90 countries for the 3rd People’s Health Assembly. The Assembly strengthened and deepened solidarity; expressed outrage at the continuing global health crises that are embedded in myriad structural and socio-political inequities; developed principles for alternative economic, political and social orders; and re-committed delegates to work towards the world envisioned by the movement. The Assembly reaffirmed commitment to the People’s Charter for Health and the Cuenca Declaration which are the foundational documents to the Call to Action drafted at the Assembly reported here. The Call to Action guides the movements work until the fourth People’s Health Assembly is held.
PlusNews reports that at least a hundred protesters arrived at South Africa's parliament on 11 July 2012 to demonstrate their disapproval of the ongoing court case by Swiss pharmaceutical company Novartis against the Indian government over its patent laws. As the case draws to a close, health organizations say a win for the pharmaceutical company will be a loss to the developing world, which sources the bulk of its generic medicines from India. Novartis approached the Indian government six years ago, seeking to register a cancer drug already commonly marketed under the name Gleevec. The patent was denied and a long-running court battle ensued, but at each step Indian courts have ruled against Novartis and the company has appealed. India has laws against “evergreening”, a term used to describe instances where drug companies maintain artificially high prices on medicines for longer by continually extending patent protection for minor modifications to existing drugs. India's Supreme Court is expected to hand down the judgment that will draw the legal saga to a close on 22 August. This could not only limit the country's ability to produce generics, but also set a precedent in other countries - like South Africa - looking to revamp patent laws.
Studies in rural and urban development since the 1970s have found high correlations between project performance and levels of community participation in many Third world countries. Relevant examples of such
correlation include the agricultural extension services in Kenya, the control of infectious diseases in Israel and the rural water supply and irrigation projects in Asia Region. This paper examines the major
limitations in participatory health development in Nigeria. The author finds that even though most of the assertions in literature about the health behaviour of the rural dwellers in community-based health programmes are upheld, there are exceptions. For example the
health behaviour of people in traditional societies is found to always be an economic rational one. This is in contradistinction to the view in most literature that posits that the health behaviour of the traditional people is almost always determined by socio-cultural and magico-religious considerations.
Brief nine of the National Reconciliation and Transitional Justice Audit reveals perspectives on issues of conflict, peace and justice by the community in Nakapiripirit in Karamoja, in the north-east of Uganda. The major concern of the participants in Nakapiripirit was the strained relationship between themselves as citizens in Karamoja and the state. According to them, the relationship has been characterized by mutual distrust right from colonial times up to now, coupled with deliberate marginalization and an attempt to take away the Karimojong's way of life. They lamented that the rest of Uganda looks at Karamoja as a region apart and says that 'we shall not wait for Karamoja to develop'. In their view, conflicts in Uganda are a reflection of bad governance practices, such as corruption, unfree and unfair elections, lack of term limits, and an absence of border security. This inspires anger towards the Government and provokes rebellion. Impacts of conflicts include more strained relationships between citizens and the state, and delayed development. In that sense, causes and impacts of conflict constitute a vicious cycle.
13. Monitoring equity and research policy
This document presents the context, including mapping of key actors and their capacity in relation to health policy and systems analysis (HPSA) research and teaching and their potential implications on capacity of the University of Ghana School of Public Health (UG-SPH) in HPSA research and teaching, networking and getting research into policy and practice (GRIPP). It assesses the capacity needs at the organizational and individual levels within the UG-SPH in relation to HPSA research and teaching and getting research into policy and practice.
Coinciding with the International Day against Drug Abuse and Illicit Trafficking, the WHO launched its Global Health Observatory Database – Resources for the Prevention and Treatment of Substance Use Disorders. This global information system maps and monitors health system resources at the country level to respond to the health problems due to substance use. The system provides data for each of the assessed countries, such as funding, staff and services, and thereby complements already available information on the scope and associated harms of substance use disorders. The country profiles included in the new system cover 147 countries, which is 88 per cent of the world’s population. Current estimates indicate that worldwide, about 230 million adults aged 15-64 – or five per cent of the world’s adult population – used an illicit drug at least once in 2010, including about 27 million people with severe drug problems.
14. Useful Resources
International Human Rights Funders Group and the Foundation Center have launched the first-ever visualization tool of the contemporary scope and landscape of global human rights grantmaking. The tool is designed to enable both grantmakers and grantseekers to search for human rights funders by several key criteria: areas of rights funding, activities supported and geographic focus. The map will be the first tool to be released as part of the centre’s Advancing Human Rights: Knowledge Tools for Funders initiative and will enable funders to search for grants by rights issue, population served, and location of grantee. To access the map, a user account must be created.
A new Governance Handbook issued by the Global Fund describes the Fund's various structures and governance processes. The handbook was conceived primarily as an operations guide for members of the Global Fund Board and their delegations, but it has also been made public. Separate sections of the handbook are devoted to topics such as the history of the Global Fund, the roles of the Board and its committees, and the current funding model and how it may evolve.
A new online collection of research, documentation and articles on Health Ethics has been launched by Globethics.net in its Global Digital Library on Ethics (GlobeEthicsLib). Initially including more than 500 documents, the collection is a unique online resource covering topics related to health ethics such as pharmaceuticals, health economics, health politics, access to medical care, environmental issues and bioethics. The collection is available to participants who register with Globethics.net.
15. Jobs and Announcements
As part of the Nutrition Society’s efforts to support learned societies in the developing countries, the Nutrition Society ANEC Travel Fellowship 2012 Award supports deserving students worldwide to enable them participate in the 5th Africa Nutritional Epidemiology Conference (ANEC V) in Bloemfontein, South Africa 30 September to 4 October 2012. ANEC V this year comes under the Umbrella of the Nutrition Congress Africa 2012 (NCA2012) which is a joint scientific meeting between the South African Nutrition Congress, South African Dietetics Association and the African Nutrition Society. The Fellowship is open to university students or young scientists with an interest in nutrition who wish to participate in the Nutrition Congress Africa (NCA2012), the largest continental scientific gathering on nutrition in Africa taking place between the 30 September to 4 October 2012 in Bloemfontein, South Africa. The award is given towards travel costs including return air travel, accommodation and conference participation.
The 2012 CIVICUS World Assembly intends to be more than the primary annual gathering of civil society and other stakeholders of society. It will also see the start of a process of defining a new charter of citizen demands. This comes in response to recent changes in civil society organisation, marked by crisis, volatility and rising dissent, in which the relationships between the state, business, citizens and other parts of the social sphere are being redefined and renegotiated. The World Assembly has three themes: 1. Changing nations through citizens: how can the power of citizen action be maximised to achieve social and political change at the national level? 2. Building partnerships for social innovation: what new partnerships are needed for change, how can they be brokered and what principles should underpin them? 3. Redefining global governance: what needs to change in multilateral processes and institutions to enable effective citizen’s participation?
The theme of ADFVIII will be on “Governing and Harnessing Natural Resources for Africa’s Development”, with a focus on mineral, land, fishery and forest resources. The forum will discuss the following key aspects of integrated natural resources management and development:
* Knowledge base, human and institutional capacities;
* Policy, legal and regulatory issues;
* Economic issues (taxation, investment, benefits, linkages and value creation);
* Governance, human rights and social issues;
* Participation and ownership;and
* Environmental, material stewardship and climate change.
A vibrant and cutting edge Cape Town-based NGO seeks an Advocacy and Human Rights Defence Manager to manage its Advocacy Programme. The position is available from the 1st August 2012. The organisation promotes the health and human rights of sex workers within the existing legal system in which sex work is criminalised, by providing and facilitating access to health care services for sex workers in several provinces in South Africa; facilitating the defence of sex workers’ human rights in and outside of court; providing safe spaces for sex worker empowerment and organising, and conducting action-oriented research and monitoring of sex worker human rights issues.
The 3rd AGM of Schools of Public Health and the 4th Global Health summit to be hosted by Association of Schools of Public Health in Africa (ASPHA) will provide Schools of Public Health across the Globe a forum for sharing innovative ideas and adapting scientific knowledge specific to our particular environs to promote health, reduce disease burden and alleviate poverty to help accelerate health development in Africa. The theme is “Policy and Health Systems Research-The Contribution of Schools of Public Health”. Deadline of submission of Abstract: 14th August, 2012
International Health, an official journal of the Royal Society of Tropical Medicine and Hygiene, is looking for papers on the mental health issues faced by patients and professionals in both developed and lower income countries. They are welcoming original papers, short communications, reviews and commentaries on all aspects of mental health.
A new Society for health systems research will be established at the Second Global Health Systems Research Symposium in Beijing (31 October to 3 November 2012). Draft documents and other information materials are available at: http://www.hsr-symposium.org/index.php/health-systems-society. A group of health systems researchers from various settings are seeking to encourage interest in and ideas for the Society, to support the Working Group tasked to develop it for its launch in Beijing. They would particularly like to encourage discussion and feedback on specific questions, available through the link below. Please post your ideas through the link below. All ideas posted will be available to all those interested in the Society, and will be of particular value to the Working Group currently planning for the launch of the Society at the Symposium in Beijing.
IDRC’s Research Awards provide a unique opportunity to enhance research skills and gain a fresh perspective on crucial development issues. This one-year, paid, in-house program of training and mentorship in research, research management, and grant administration allows awardees to pursue their research goals in a dynamic team environment in one of the world’s leaders in generating new knowledge to meet global challenges. The successful candidate is required to have strong research, analytical, and writing skills, as well as familiarity with key institutions (including Canadian) active in global health research and policy. Proficiency in English and French is essential. An understanding of the health implications of urbanization, social and gender analysis would be considered an asset.
The Symposium will focus on the science to accelerate universal health coverage around the world. It will cover three main themes: knowledge translation; state-of-the-art health systems research; and health systems research methodologies. There will also be three cross-cutting themes: innovations in health systems research; neglected priorities or populations in health systems research; financing and capacity building for health systems research.
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