Access to essential medicines is a necessary requirement for equitable health systems and improved population health. According to the United Nations Conference on Trade and development (UNCTAD) the number of people with regular access to essential medicines in developing countries increased from two to four billion in the five years between 1997 and 2002. However, UNCTAD also report that nearly 2 billion people do not access essential medicines, most living in least developed countries (LDCs). High medicine costs relative to incomes, inadequate public or international funding for medicines relative to need, limited local production and the limiting effects of intellectual property have contributed to this gap, together with weaknesses in health services.
The African Union (AU) seeks to strengthen local manufacturing of medicines on the continent as one remedy to this situation. AU leaders identified an over reliance on imports of medicines from outside the region as a key challenge. For example, Chaudhuri in 2008 observed that of Tanzania’s US$110 million pharmaceutical market in 2004/2005, $78 million or 71 percent came from imports and only 29 percent from local production. Out of the 3388 drugs registered for sale in Tanzania, only 269 products (or about 8%) were from Tanzanian local manufacturers. In contrast in Zimbabwe in the early 2000s the local pharmaceutical industry supplied nearly half of the country’s essential medicine requirements, according to the United Nations Industrial Development Organisation (UNIDO). Further as only South Africa has limited primary production of active pharmaceutical ingredient and intermediates, the local production underway in Africa is reliant on imported active ingredients. UNIDO indicates for Zimbabwe, for example, that while imports of finished pharmaceutical products do not face tariffs, inputs for the manufacture of pharmaceuticals do, with import duties ranging from 5 to 15 per cent, raising production costs.
To address the constraints and widen capacity for local production in the continent the AU set a Pharmaceutical Manufacturing Plan for Africa that was adopted by the AU Summit in 2007.
The AU Pharmaceutical Manufacturing Plan was complemented by a Pharmaceutical Manufacturing Business Plan (PMPA) that identified priority areas for actions, such as mapping of productive capacities, addressing intellectual property issues and capital requirements. The plan also raises the bottlenecks to medicine production in Africa. According to the text of the plan: “This Business Plan is based on the belief that industrial development and the development of the pharmaceutical sector is not in conflict with public health imperatives and that the industry should in fact be developed with the long term aim of promoting access to quality essential medicines.” Complementing the AU plan, the Southern African Development Community and the East African Community have also developed similar plans and proposed policy measures to overcome barriers to medicines access, such as pooling procurement to make medicines more affordable.
Despite the presence of these plans, there is still limited local medicine production on the continent. Setting up a pharmaceutical plant requires massive investments in infrastructure, technology, skilled professionals and strategic leadership. Many of these critical inputs were also identified as bottlenecks in the AU plan. Many African countries do not have adequate capital, and investors may be discouraged by high tariffs for and erratic supplies of electricity and water, ageing transport infrastructure, old plant and equipment and shortages of skilled industrial pharmacists and scientists. African countries also have lower capacities and resources for pharmaceutical research and development. One of the reasons therefore for the plans not being operationalized was the absence of strategic allies, resources and leadership to translate them into practice.
In recent years that scenario is beginning to change. New actors and partnerships are emerging in production of pharmaceuticals on the continent, providing new opportunities to deal with bottlenecks. These include the US$23 million Brazil-Mozambique plant for manufacture of anteretrovirals (ARVs), and the US$38 pharmaceutical plant set up in Uganda as a co-operation between Cipla (of India) and Quality Chemicals (Uganda) for the manufacture of ARVs and anti-malarials. These partnerships provide capital and strategic expertise that can be crucial for ESA countries in their efforts to set up local production. However to take advantage of this, ESA countries need an industrial policy that taps into the knowledge that exists in these countries, and that ensures the same technology transfer into Africa as these countries secured from high income countries.
These new opportunities for south-south co-operation provide a window of possibility for overcoming bottlenecks identified in the AU plan, but only if this is negotiated for as a key element of these emergent partnerships. South-south co-operation also needs to be complemented by, and not to displace regional processes. Regional level production and distribution agreements provide wider markets for medicines produced, generating economies of scale, better use of installed capacities, and greater possibilities of local supply of active ingredients and other raw materials. For example Varichem Pharmaceuticals, Zimbabwe, one of the first companies in Sub-Saharan Africa to manufacture generic antiretrovirals (ARVs), was issued with a compulsory licence to manufacture generic ARVs in April 2003 and produced its first generic ARVs in October 2003. Namibia and Botswana gave manufacturing licences to Varichem to supply medicines in their countries. Regional co-operation has been important to tap larger markets, to make full use of capacities that do exist, to harmonise medicine regulation and support skills development. It will continue to play a role in strengthening the negotiating position of countries in the region in ensuring that new partnerships in medicine production play a role in overcoming the bottlenecks identified in the AU plan to localise medicine production on the continent.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: firstname.lastname@example.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
2. Latest Equinet Updates
This annotated bibliography was prepared as a resource for people working on different dimensions of social power, social participation and social accountability in health. Social power, participation and accountability are central concepts in building people centred health systems. This annotated bibliography was commissioned by the Community of Practitioners on Accountability and Social Action in Health (COPASAH) and prepared by Training and Research Support Centre (TARSC) within the Regional Network for Equity on Health in East and Southern Africa (EQUINET). The annotated bibliography captures English language literature, and includes materials that are open access in full online. It focuses with a few exceptions on materials published post 2000 and is based on materials accessed through the use of social power / accountability/ participation in health as key words in online searches and literature forwarded from COPASAH members. The limitations of the compilation are discussed. The bibliography is presented in four parts: Section 1 presents papers on social power in health, Section 2 presents papers on social participation in health, Section 3 presents papers on social accountability in health, and Section 4 presents papers on the use of these three concepts in knowledge generation.
This review is part of EQUINET's programme of work on Contributions of global health diplomacy in east and southern Africa. Access to essential medicines is one of the key requirements for achieving equitable health systems and better public health in east and southern Africa (ESA). One constraint to this is that the region’s medicine production capacity remains weak. In May 2007, the African Heads of State and Government adopted the Pharmaceutical Manufacturing Plan for Africa (PMPA) to maintain a sustainable supply of quality essential medicines to improve public health and promote industrial and economic development in Africa. The PMPA includes six priority areas: mapping productive capacity; situation analysis; developing a manufacturing agenda; addressing intellectual property issues; political, geographical, economic considerations; and financing. This review compiles from existing literature bottlenecks to local medicine production in the region. It seeks to inform follow-up case study work on the extent to which relationships and agreements with Brazil, India and China are addressing the bottlenecks identified in the African Union (AU), SADC and EAC plans for pharmaceutical manufacturing.
This review is part of EQUINET's programme of work on Contributions of global health diplomacy in east and southern Africa. This includes work on the WHO Global Code on Ethical Recruitment of Health workers. The research seeks to explore the extent to which the policy interests of African countries were carried (or not carried) into the Code in the negotiations around the code and the perceived factors affecting this; the extent to which countries in east and southern Africa view and implement the Code as an instrument for negotiating foreign policy interests concerning health workers; and the motivations, capabilities and preparations for monitoring the Code to engage on African policy interests concerning health workers. The paper presents a review of published and grey literature on relevant codes of practice on health workers and on bilateral and multilateral agreements on the health workforce. The information was analysed using the policy analysis triangle to capture the changing context, processes, content and major actors in the development of the WHO Code, and documentation on its progress and implementation since its adoption. It raises issues that are being followed up through field research.
3. Equity in Health
This report outlines five main goals for the post 2015 agenda: ending poverty by 2030; promote gender quality; improve access to quality education, water and sanitation; promote good governance; and build strong effective institutions. It posits five transformative shifts as crucial for achieving all five goals: leave no one behind; put sustainable development at the core; transform economies for jobs and inclusive growth; build peace and effective, open and accountable institutions for all, and forge a new global partnership. Like the Millennium Development Goals, the report suggests that targets would not be binding, but should be monitored closely. The indicators that track them should be disaggregated to ensure no one is left behind and targets should only be considered ‘achieved’ if they are met for all relevant income and social groups. The Panel recommends that any new goals should be accompanied by an independent and rigorous monitoring system, with regular opportunities to report on progress and shortcomings at a high political level. It also calls for a data revolution for sustainable development, with a new international initiative to improve the quality of statistics and information available to citizens.
In Ghana, the United Nations Development Program (UNDP) estimates that the country is largely on track in achieving the MDG 1. Poverty has reduced from over 50 percent in 1992 to 28.5% in 2006, indicating that the poverty target could be achieved well ahead of time. Similarly, the proportion of people living below the extreme poverty line declined from 36% to 18% over the same period. But the author of this blog argues that these figures do not take into account regional disparities: hunger is still rife in Ghana's three northern regions. A key theme emerging from his own research suggests that policy makers tend to tout the aggregate "success story" and become preoccupied with hitting statistical targets rather than improving the overall welfare of all constituents. This highlights the risks when policy-makers focus too much on targets, implying that complex processes can be over-simplified and priorities skewed when policies aim solely at targets. The author argues that the use of targets can encourage a reductionist approach to complex problems, privilege quantitative indicators at the expense of qualitative ones, distort resource allocation, and undermine professional motivation and responsibility. He concludes that, while Ghana’s progress has been remarkable, much work still needs to be done in the northern regions.
During her opening address at the 8th Global Conference on Health Promotion in Helsinki, Finland on 10 June, WHO Director-General Dr. Margaret Chan stated that inequalities, between and within countries, in income levels, opportunities, and health outcomes, are now greater than at any time in recent decades. The rise of non-communicable diseases threatens to widen these gaps even further. she noted that public health must contend with Big Tobacco, Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics. For WHO, formulation of health policies must be protected from distortion by commercial or vested interests. She referred to the Finnish government as an example to follow, as it has been a leading proponent of the need for all sectors of government to consider the health impact of their policies. Finland put the health-in-all-policies approach under the spotlight during its presidency of the European Union in 2006. Such an approach makes perfect sense, she argued. The determinants of health are exceptionally broad. Policies made in other sectors can have a profound, and often adverse, effect on health. The globalisation of unhealthy lifestyles is by no means just a technical issue for public health. It is a political, trade and foreign affairs issue.
In this blog, the author comments on the May 2013 report by the United Nations High Level Panel (HLP), which is included in this newsletter. He expresses disappointment that universal health coverage (UHC) is not one of the twelve goals outlined in the report, despite overwhelming global consensus for UHC. Whilst the panel acknowledged that universal access to basic healthcare services is required to achieve desired outcomes, the author argues that without setting a target to ensure this is realised different actors will continue operating in silos and vertical interventions that can undermine the national health system. Instead the panel proposes ‘ensuring healthy lives’ as goal four. The author considers this as vague and it appears as a call to business as usual. It lacks the enthusiasm inherent in UHC. And, in many parts of the world that are in dire need of health, especially in Africa, the fourth goal resonates as maintaining status quo. Although UHC is not an end in itself, it is a means to ensure equitable access to quality health services and can guarantee the protection of the right to health and better health outcomes. The author argues that this oversight is a challenge to UHC advocates, who should represent UHC in a more ambitious way drawing lessons from proponents of gender equality. He calls on advocates to promote UHC as the appropriate overarching post 2015 health goal, using the forum of the UN Sustainable Development Goals Open Working Group.
4. Values, Policies and Rights
This issue of the Africa Environment Outlook conveys the following key messages to policy makers and other stakeholders: 1. Environmental and health issues deserve priority consideration in national development. 2. Although indoor air pollution is a profound health problem in Africa, it has been inadequately addressed. 3. Biodiversity provides goods and services such as food and medicinal plants that promote human health in Africa. 4. Climate change and variability severely impact human health owing to individuals’ and communities’ limited coping capacities. 5. Coastal and marine resources are integral to the health of coastal populations and need to be conserved and used sustainably. 6. Access to safe water and adequate sanitation is vital to human health and needs to be scaled up by eliminating impediments such as inadequate infrastructure, pollution of water sources, poor hygiene, retrogressive cultural taboos and gender disparities. 7. Sustainable land management is central to human health because land provides the resource base for the provision of ecosystem services such as food, fibre and medicines. 8. The magnitude of domestic and global uncertainties that decision makers have to grapple with imply that espousing the business as usual model when dealing with environmental problems does not only result in failure to meet internationally set goals and targets, it also undermines human health. 9. Although a number of good policies for addressing environmental challenges that affect human health exist, their implementation has been weak. Making policies more effective requires elimination of barriers to implementation.
In this paper, researchers reviewed how government policies in low and middle income countries (LMICs) outline actions that address salt consumption, fat consumption, fruit and vegetable intake, or physical activity. They carried out a structured content analysis of national nutrition, non-communicable diseases (NCDs), and health policies published between 1 January 2004 and 1 January 2013 by 140 LMIC members of the World Health Organisation (WHO). They found policies to be available in 83% of the countries. NCD strategies were found in 47% of LMICs reviewed, but only a minority proposed actions to promote healthier diets and physical activity. The coverage of policies that specifically targeted at least one of the risk factors reviewed was lower in Africa, Europe, the Americas, and the Eastern Mediterranean compared to the other two WHO regions, South-East Asia and Western Pacific. Of the countries reviewed, only 12% proposed a policy that addressed all four risk factors, and 25% addressed only one of the risk factors reviewed. Strategies targeting the private sector were less frequently encountered than strategies targeting the general public or policy makers. This review indicates the disconnect between the burden of NCDs and national policy responses in LMICs. Policy makers urgently need to develop comprehensive and multi-stakeholder policies to improve dietary quality and physical activity, the authors conclude.
In the era of the persisting global north-south health divide, regional integration organisations have emerged as significant legal and diplomatic spaces to advance health goals. In this context, African regionalism is evolving as important frameworks for promoting health diplomacy. This evolving regional health diplomacy is contributing to the reinforcement of social goals of new regionalism in Africa and shaping the drivers of health policy at the global, regional and domestic levels. With reference to case studies of African regional and sub-regional integration organisations, the author of this paper examines the drivers, nature and limits of their practice of health diplomacy. He also analyses the nature of engagement of African regional groupings with select international health regimes. The author identifies the strengths and limits of regionalism for health diplomacy that also advances the protection of public health. The paper concludes with options to foster health diplomacy and its implications for the advancement of health at the domestic, regional and global levels.
The Secretary-General’s High-Level Panel of Eminent Persons on the Post-2015 Development Agenda delivered its report on 30 May 2013 (included in this newsletter). In this statement, CESR welcomes the Panel’s clear affirmation that the framework to replace the Millennium Development Goals in 2015 should be grounded in respect for universal human rights. However, the fragmented and inconsistent incorporation of human rights in its proposals, coupled with the prominence given to an outdated vision of market/business-led development, prevents the report from meeting its own stated aim of proposing a truly “transformative shift”. For the new framework of goals, targets and indicators to meet the human rights litmus test, it must fully reflect the fundamental human rights principles of universality, indivisibility, equality, participation, transparency and accountability. It must also reinforce the duty of states to guarantee at least minimum essential floors of rights enjoyment, to use the maximum of their available resources to realise rights progressively for all, and to engage in international cooperation for this purpose. Human rights advocates have been particularly insistent that, alongside the environmental, economic, and social dimensions, a fourth pillar of sustainable development - accountable governance - is fundamental to putting in place the right institutions and effective incentives to translate international political commitments into lived realities. The report is also particularly weak in addressing corporate accountability.
5. Health equity in economic and trade policies
Much has been written about Africa’s so-called ‘resource curse’, whereby natural resources disrupt an economy and create incentives for wide-scale corruption and even conflict. The effects of the resource curse need not, however, be viewed as inevitable, the author of this article argues. Political choice is key. Botswana has used its mineral wealth to develop into a stable, middle-income country. More recent producers such as Ghana, Liberia and Sierra Leone appear to be making good governance decisions so far. Emerging markets, especially China, continue to ramp up demand for the continent’s commodities, offering a once in a millennium opportunity for African governments to lift millions of people out of poverty. African leaders and the international community, big business and civil society must assume responsibility, the author argues. The most practical and credible form of becoming ‘transparent’, she says, is the Extractive Industries Transparency Initiative (EITI), which requires governments to explain clearly and openly the revenues flowing from its extractive sector so that any party can see how much the country in question receives from oil, gas and mining companies. So far, ten African governments have been judged compliant.
Africa is lacking a clear and unified policy in terms of how it relates to China, argue the authors of this opinion piece. He points to China’s lack of respect for human rights and the problem of China issuing loans without conditions. The cooperation between Africa and its economic development partners (EU, China and US) are strategically different, and each is driven by economic self-interests. It is of vital importance therefore, that Africa approves on an equal footing, strategic and most consistent partner (business or otherwise) who recognises, shares and respects its difficult but critical needs be it political, economic or social as well as sovereignty. Africa must necessarily develop a coherent and structured plan in successfully asserting its political, economic and social ties with China, the authors argue. It must avoid repeating some of the mistakes committed in its past relations with its traditional development partners. In the meantime, African leaders must be able to define and formulate strategic and comprehensive policies, individually, for the influx of Chinese investments. For instance, they must exert pressure on China and together, differentiate and separate investments and loans clearly from interest free loans, grants and aid projects.
Combating international tax avoidance and evasion, corruption and weak governance are crucial if Africa's people are to benefit from the continent's vast natural resource wealth, according to former United Nations secretary general and chair of the African Progress Panel Kofi Annan. He pointed out that trade mispricing, or losses associated with the misrepresentation of export and import values, alongside other illicit outflows cost the continent $38.4-billion and $25-billion respectively between 2008 and 2010. Annan called for a rule-based global system on tax transparency to be developed with the G20. All foreign-owned companies should be required to disclose the ultimate beneficiaries of their profits, he said. Switzerland, the UK and the US – all major conduits – should also signal their intent to clamp down on illicit financial flows. He extended this call to players from other developing nations who have become increasingly active in Africa in the oil, gas and minerals realm. Annan called on major investors in African extractive sectors such as China and emerging investors such as Brazil to also engage. He raised concerns over the structure of investment activity by foreign companies operating in Africa, which is characterised by the extensive use of offshore-registered companies and low tax jurisdictions, and in some cases the complex use of shell corporations.
This year’s Africa Progress Report rejects the view that Africa is blighted by a “resource curse” – an affliction that automatically consigns the citizens of resource-rich nations to a future of economic stagnation, poverty and poor governance. Instead, the Panel argues that the malaise that has afflicted natural resource management in Africa is caused by the wrong domestic policies, weak investment partnerships and failures in international cooperation. This will require decisive leadership by African governments, backed by multilateral action and a commitment by foreign investors to adopt best international practices. There is cause for optimism. Global market conditions point to another decade of high prices for natural resources, creating an environment conducive to economic growth. The report argues that improvements in policies, in public finance management and moves towards greater accountability enables Africa to escape the boom-bust cycle associated with past upswings in commodity markets.
The World Health Organisation (WHO) is involved in a debate related to intellectual property rights over a dangerous new pathogen, the Middle East Respiratory Syndrome (MERS) virus. This report records that the virus was sent to Erasmus without authorisation of the Saudi government, which has sovereign rights, and which has criticised Erasmus' intellectual property stance. When Erasmus eventually began sharing the virus, they did so under a material transfer agreement (MTA) with very strong provisions to protect the university’s own intellectual property, prompting objections from some scientists. Erasmus is reported to have submitted a patent application the content of which is unknown, due to normal procedures at patent offices where publication of applications is delayed for six months or more from the time of their submission. The raising of patent and sovereignty issues over emerging viruses at the World Health Assembly suggests that controversies caused by intellectual property claims over newly identified pathogens will continue to occur unless broader solutions are found to allow viruses to be distributed to researchers while protecting sovereign rights, the author concludes.
The TRIPS Council of the World Trade Organisation (WTO) decided on 11 June 2013 to allow Least Developed Countries (LDCs) to delay implementation of the TRIPS Agreement until 1 July 2021. At the end of this period, LDCs can request further extension. The terms of the June 2013 decision this time are better than the terms in the previous extension, granted in 2005, says South Centre. This is attributed to the determination and skill of the LDC Group, led by Nepal, during month long negotiations between the LDC Group and developed country members of the WTO. The new extension period is for eight years, starting on 1 July 2013. This is longer than the seven and a half years transition period provided in the 2005 decision. It is also significantly below what the LDC Group had asked for in its formal proposal IP/C/W/583, in which the Group had requested that the transition period should last so long as the country remains an LDC. The 11 June 2013 decision has also removed the condition introduced in the earlier 2005 decision that LDCs cannot roll-back the level of implementation of the TRIPS agreement that they have already undertaken in their national legislation.
6. Poverty and health
The Commission on Social Determinants of Health (CSDH) was tasked by the World Health Organisation (WHO) with summarising the evidence on how the structure of societies, through myriad social interactions, norms and institutions, are affecting population health, and what governments and public health can do about it. To guide the Commission, the WHO Secretariat conducted this review and summary of different frameworks for understanding the social determinants of health (SDH). Developing a conceptual framework on social determinants of health (SDH) for the CSDH needs to take note of the specific theories of the social production of health. Three main theoretical non-mutually exclusive explanations were reviewed: (1) psychosocial approaches; (2) social production of disease/political economy of health; and (3) eco-social frameworks. In turning to policy action on SDH inequities, three broad approaches to reducing health inequities can be identified, based on: (1) targeted programmes for disadvantaged populations; (2) closing health gaps between worse-off and better-off groups; and (3) addressing the social health gradient across the whole population. A consistent equity-based approach to SDH must ultimately lead to a gradients focus. However, strategies based on tackling health disadvantage, health gaps and gradients are not mutually exclusive. They can complement and build on each other.
The global food system is under acute and rising pressure - and Africa's farmers are feeling its full force. There is still more than enough food in the world to feed everyone, says the Panel in this report, but population and economic growth as well as the search for low-carbon energy sources are driving up demand for arable land, while climate change, ecological constraints and lower levels of productivity growth in agriculture are limiting food supply. While these emerging strains in the global food system offer Africa some opportunities, they also carry very large risks. Higher food prices could create incentives for African governments to invest in agriculture and raise productivity, or they could lead to a dramatic worsening of poverty and malnutrition among vulnerable populations. Africa's vast untapped potential in agriculture could become a source of rural prosperity and more balanced economic growth, or it could act as a magnet for more speculative investments, land grabs and the displacement of local communities. Carbon markets might open up opportunities for small farmers to benefit from climate change mitigation efforts in rich countries, though the benefits have so far proven limited and the future of these markets remains uncertain. What is certain is that Africa's farmers will bear the brunt of dangerous climate change, with drought and unpredictable rainfall patterns reinforcing rural poverty and undermining food systems.
Maternal and child undernutrition, consisting of stunting, wasting, and deficiencies of essential vitamins and minerals, was the subject of a Series of papers in The Lancet in 2008. In the series, researchers quantified the prevalence of these issues, calculated their short-term and long-term consequences, and estimated their potential for reduction through high and equitable coverage of proven nutrition interventions. Authors of the 2008 series identified the need to focus on the crucial period from conception to a child’s second birthday - the 1,000 days in which good nutrition and healthy growth have lasting benefits throughout life. They also called for greater priority for national nutrition programmes, stronger integration with health programmes, enhanced intersectoral approaches, and more focus and coordination in the global nutrition system of international agencies, external funders, academia, civil society, and the private sector. Five years after the initial series, the the Lancet has re-evaluated the problems of maternal and child undernutrition in this document and also examines the growing problems of overweight and obesity for women and children and their consequences in low-income and middle-income countries (LMICs). Many of these countries are said to have the double burden of malnutrition - continued stunting of growth and deficiencies of essential nutrients along with the emerging issue of obesity. The Lancet also assesses national progress in nutrition programmes and international efforts toward previous recommendations.
7. Equitable health services
In this study, the authors collected data as part of a multi-site cross sectional study, Researching Equity in Access to Healthcare (REACH), to examine HIV testing coverage in tuberculosis (TB) patients. They administered a structured questionnaire to 300 patients accessing TB treatment in five rural primary health care clinics in Hlabisa subdistrict, KwaZulu-Natal, South Africa, a high TB and HIV burden area. Results showed high HIV testing rates among TB patients, suggesting that TB-HIV co-infected patients can be managed appropriately for treatment of both infections. The decentralised programme appears largely successful in attaining universal HIV testing in TB patients in this resource-limited setting. However, there is scope for further improvement such as in DOTS delivery, which is a sustainable and effective way of ensuring good adherence to TB treatment, the authors argue. Patients mostly use the closest clinic for both TB treatment and HIV testing, suggesting a receding fear of stigma of HIV. But the small number of patients not using the closest clinic are far less likely to undergo HIV testing, possibly indicating vulnerability expressed both in the location of seeking TB treatment and HIV testing uptake. Policy makers should encourage integration of services and cross-testing in HIV-TB facilities, the authors conclude.
In this study, researchers describe the approaches to defining and improving quality of health services across the five country programmes funded through the Doris Duke Charitable Foundation African Health Initiative. They describe the differences and similarities across the programmes in defining and improving quality as an embedded process essential for HSS to achieve the goal of improved population health. The programmes measured quality across most or all of the six WHO building blocks, with specific areas of overlap in improving quality falling into four main categories: 1) defining and measuring quality; 2) ensuring data quality, and building capacity for data use for decision making and response to quality measurements; 3) strengthened supportive supervision and/or mentoring; and 4) operational research to understand the factors associated with observed variation in quality. Learning the value and challenges of these approaches to measuring and improving quality across the key components of health system strengthening as the projects continue their work, the authors conclude.
The PHIT Partnership’s health systems support aligns with the World Health Organisation’s six health systems building blocks. Health system strengthening (HSS) activities focus across all levels of the health system to improve health care access, quality, delivery, and health outcomes. Interventions are concentrated on three main areas: targeted support for health facilities, quality improvement initiatives, and a strengthened network of community health workers. The impact of health system strengthening activities will be assessed using population-level outcomes data collected through oversampling of the demographic and health survey (DHS) in the intervention districts. The overall impact evaluation is complemented by an analysis of trends in facility health care utilisation. A comprehensive costing project captures the total expenditures and financial inputs of the health care system to determine the cost of systems improvement. Building on early successes, the work of the Rwanda PHIT Partnership approach to HSS has already seen noticeable increases in facility capacity and quality of care. The rigorous planned evaluation of the Partnership’s HSS activities will contribute to global knowledge about intervention methodology, cost, and population health impact.
In this paper, the authors explore affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. Between June 2008 and September 2009, they conducted a mixed-method study combining 1,231 quantitative exit interviews with 16 qualitative in-depth interviews with women in two urban and two rural health sub-districts in South Africa. Barriers were found to be unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability. Negative provider-patient interactions also inhibited access and compromised quality of care, including staff inattentiveness, turning away women in early labour, shouting at patients and insensitivity towards those who had experienced stillbirths. To move towards achieving its Millennium Development Goals, the authors argue that South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery.
In 2007, the Doris Duke Charitable Foundation approved $60 million for the African Health Initiative to support a small portfolio of diverse approaches to health systems strengthening over a period of five to seven years (until 2015). Five projects in sub-Saharan countries were selected. While the Partnerships have all drawn on the World Health Organisation’s six building blocks approach to health systems strengthening, implementation has shown that dynamic, interactive elements of the system are not reflected in the six building blocks, specifically the important role of communities in promoting their own health, nor the growing role of community health workers in primary health care delivery. While not designed to address this question, the interventions offer a range of strategies. Some community health workers undergo several months of training, others just a few weeks. The cadres are drawn varyingly from the communities they serve and have different levels of educational attainment. Their connection to the formal health sectors varies —some are volunteers, others are employees, others received compensation but are not salaried. In addition, whether households are approached singly or through a community mobilisation process also varies. These variations offer a chance to reflect on how different approaches may have a bearing on implementation.
The BHOMA project is being carried out 42 primary health care facilities that serve a largely rural population of more than 450,000 in Zambia’s Lusaka Province. It has deployed six QI teams to implement consensus clinical protocols, forms, and systems at each site. The QI teams define new clinical quality expectations and provide tools needed to deliver on those expectations. They also monitor the care that is provided and mentor facility staff to improve care quality. The programme engages community health workers to actively refer and follow up patients. Project implementation occurs over a period of four years in a stepped expansion to six randomly selected new facilities every three months. The patient-provider interaction is an important interface where the community and the health system meet. This project aims to reduce population mortality by substantially improving this interaction. Success hinges upon the ability of mentoring and continuous QI to improve clinical service delivery. It will also be critical that once the quality of services improves, increasing proportions of the population will recognise their value and begin to utilise them.
The authors of this study set out to identify the progress made by the Tanzanian Ministry of Health and Social Welfare (MOHSW) in achieving the objective it had set in its National Adolescent Health and Development Strategy: 2002–2006, namely to systematise and extend the reach of Adolescent Friendly Health Services (AFHS) in the country. They reviewed plans and reports from the MOHSW and journal articles on AFHS. Results showed that the MOHSW identified four key problems with what was being done to make health services adolescent friendly in the country – firstly, it was not fully aware of the various efforts under way; secondly, there was no standardised definition of AFHS; thirdly, it had received reports that the quality of the AFHS being provided by some organisations was poor; and fourthly, only small numbers of adolescents were being reached by the efforts that were under way. The MOHSW responded to these problems by mapping existing services, developing a standardised definition of AFHS, charting out what needed to be done to improve their quality and expand their coverage, and integrating AFHS within wider policy and strategy documents and programmatic measurement instruments. It has also taken important preparatory steps to stimulate and support implementation. The authors argue that the focus of the effort must now shift from the national to the regional, council and local levels, with substantial and ongoing support from the Ministry.
8. Human Resources
On 25 May 2013, 98 community care workers representing over 50 organisations with the Community Care Workers (CCW) Forum, the Wellness Foundation and the People’s Health Movement of South Africa met to reaffirm the importance of community care workers in South Africa’s health system and to expose the terrible working conditions that many community care workers are experiencing. CCWs work in the homes of the poorest of the poor often without protective face masks, gloves and other basic materials. The People’s Health Movement calls for these CCWs to enjoy decent work conditions and receive adequate recognition. It proposes a ‘two-tier’ system like that of Thailand, where high coverage is achieved by instituting where there is one full-time CCW for every 300-500 households, who then supervises 10 part-time CCWs who have more limited training. Such high coverage of households has been shown to have a dramatic impact on health outcomes, especially of young children. The ratio currently proposed in South Africa of one CHW to 270 households is extremely unlikely to have such an effect given South Africa’s very high burden of disease, and the large percentage of people requiring time-consuming home care. In addition to rendering health care more accessible and equitable, the two-tier system would create jobs, and indirectly improve health by reducing the prevalence and depth of poverty.
In this presentation, the author assesses implementation of the World Health Organisation’s (WHO) Code for Ethical Recruitment. She reports that 32 countries achieved valuable steps towards implementing the Code. In some of these countries, actions have taken to communicate and share information across sectors, measures have been taken to involve all stakeholders in decision making processes, including actions considered to introduce to laws or policies, records are maintained of all recruiters authorised by competent authorities to operate within their jurisdiction and good practices are encouraged and promoted among recruitment agencies. In some of these countries, migrant health workers enjoy the same legal rights and responsibilities as those domestically trained, as well as the same opportunities as domestically trained to strengthen their professional education, qualifications, career development , and health personnel are recruited internationally, using mechanisms that allow to assess the benefits and risks associated with employment positions. Furthermore, 22 countries have mechanisms to regulate the authorisation to practice by internationally recruited health personnel and maintain statistical records and 11 have a database of laws and regulations related to health workforce migration and recruitment.
In this blog, the author argues that a palpable effect of Kenya’s new constitution is that it has allowed the formation of new trade unions such as the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU). Since its formation, the group has become a key stakeholder in promoting the needs of Kenyan health professionals. Another change the constitution brought about is the permission of dual citizenship, which has the potential to increase circular migration among health professionals who have previously departed the country. Finally, the new constitution prioritises the right to health in Section 43 (1) (a), noting that every Kenyan has the “right to the highest attainable standard of health which includes the right to health care services including reproductive health care.” This places a high level of expectation on the government and health care workers, creating a basis for the public to demand such a right. To convert these potential gains into practice, however, much work remains to be done, particularly in researching how the health system has responded. One of the greatest challenges the author has faced in conducting her own research on migration is in encountering stakeholders who are unwilling to cooperate either directly or indirectly, which she views as a part of a resistance to an evidence-based culture, even among some in the health sector.
The Tanzania Connect Project is a randomised cluster trial located in three rural districts with a population of roughly 360,000 ( Kilombero, Rufiji, and Ulanga). Connect aims to test whether introducing a community health worker into a general programme of health systems strengthening and referral improvement will reduce child mortality, improve access to services, expand utilisation, and alter reproductive, maternal, newborn and child health seeking behaviour; thereby accelerating progress towards Millennium Development Goals 4 and 5. Connect has introduced a new cadre — Community Health Agents (CHA) — who were recruited from and work in their communities. To support the CHAs, Connect developed supervisory systems, launched information and monitoring operations, and implemented logistics support for integration with existing district and village operations. Connect will not only address Tanzania’s need for policy and operational research, it will bridge a critical international knowledge gap concerning the added value of salaried professional community health workers in the context of a high density of fixed facilities.
In this paper, the authors explored the perspectives and experiences of key Mozambican public sector health managers who coordinate, implement, and manage the myriad donor-driven projects and agencies. Over a four-month period, they conducted 41 individual qualitative interviews with key Ministry workers at three levels in the Mozambique national health system, using open-ended semi-structured interview guides, as well as reviewed planning documents. All respondents emphasized the value and importance of international aid and vertical funding to the health sector and each highlighted program successes that were made possible by recent increased aid flows. However, three serious concerns emerged: 1) difficulties coordinating external resources and challenges to local control over the use of resources channeled to international private organizations; 2) inequalities created within the health system produced by vertical funds channeled to specific services while other sectors remain under-resourced; and 3) the exodus of health workers from the public sector health system provoked by large disparities in salaries and work. The vertical approach starved the Ministry of support for its administrative functions. Few studies have addressed the growing phenomenon of “internal brain drain” in Africa which proved to be of greater concern to Mozambique’s health managers.
9. Public-Private Mix
A new, pernicious epidemic is stalking the health care systems of the world, according to this book: the rampant spread of neoliberal, pro-market “reforms,” devised and promoted by a narrow policy-making academic and political elite in the wealthiest countries. The author argues that it can only be eradicated by the spread of information, political campaigning and critical thinking, with regular injections of evidence and social solidarity. The so called “reforms” are driven not by evidence, but by ideology – and behind the ideology is a massive material factor: the insatiable pressure from the private sector to recapture a much larger share of the massive $5 trillion-plus global health care industry, much of which only exists because of public funding. Since 1980 global agencies like the World Bank, new powerful players like the Gates Foundation, and even at times the World Health Organisation, have played a role in promoting these changes, along with academics whose loyalty appears to be to the giver of the research grant rather than to the evidence. Market-style reforms result in systems more unequal, more costly, more fragmented and less accountable – but which offer more profits to the private sector. The policies can be rejected and defeated by mass political action, argues the author. The question is to develop a political leadership with the courage to embrace them and fight for them.
The Australian government has urged other countries to also stand up to the tobacco industry, saying it was confident of victory in a new legal battle over its landmark plain packaging rules. Big tobacco will stop at nothing to intimidate countries to not take appropriate public health measures, said Australia’s health minister, Jane Halton, said at a recent meeting marking World No Tobacco Day. Australia’s new legislation, in force since December, aims to cut smoking rates by requiring tobacco products to be sold in drab green boxes with the same typeface and graphic health warnings. Halton addressed a session of the World Health Organisation (WHO), as the UN agency seeks tougher global measures to reign in tobacco use, which claims six million lives a year. Tobacco continues to cause enormous suffering and death which is totally avoidable, she told participants. New Zealand and Ireland are planning plain packaging rules, despite a tobacco industry-backed challenge to Australia’s law at the World Trade Organisation by cigar-producers Cuba, Honduras and the Dominican Republic, plus Ukraine. The plaintiff countries maintain that Australia’s law breaches international trade rules and intellectual property rights to brands – arguments that failed to convince Australia’s High Court in a case brought by tobacco firms.
Why are soft drinks and junk foods so popular? The author of this article discusses processes of product optimisation, and the balance of salt, sugar and fat content of a product aimed at in products to ensure that consumers crave and continue to buy a product. Complex formulas are reported that pique the taste buds enough to be alluring but that do not have a distinct, overriding single flavour that tells the brain to stop eating. With the current global epidemic of obesity and rising levels of non-communicable diseases, the author advocates legislation rather than self-regulation on these issues.
10. Resource allocation and health financing
Unless the concept is clearly understood, universal health coverage (UHC) can be used to justify practically any health financing reform or scheme, says the author of this paper. He unpacks the definition of health financing for universal coverage as used in the World Health Organisation’s World Health Report 2010 to show how UHC embodies specific health system goals and intermediate objectives and, broadly, how health financing reforms can influence these. For health financing policy to be aligned with the pursuit of UHC, health system reforms need to be aimed at improving coverage, financial protection, efficiency, equity in health resource distribution, transparency and accountability. The unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Concern only with specific schemes is incompatible with a universal coverage approach and may even undermine UHC, particularly in terms of equity. Conversely, if a scheme is fully oriented towards system-level goals and objectives, it can further progress towards UHC. Policy and policy analysis need to shift from the scheme to the system level, the author concludes.
This report is the first ever to track what developing countries are spending on the Millennium Development Goals (MDGs), finding that recent spending increases explain the rapid progress on the MDGs. But the vast majority of countries are spending much less than they have promised, or than is needed. Aid cuts, low implementation rates and low recurrent spending all threaten to reverse existing progress. This Government Spending Watch report suggests that developing countries need to make data on MDG spending more accessible to their citizens; to strengthen policies for revenue mobilisation (notably combating tax avoidance and tax havens), debt and aid management; and to spend more on agriculture, water, sanitation and hygiene, and social protection. External funders need to report and repatriate illicit outflows; end laws and investment treaties which reduce poor countries’ revenues; increase innovative financing such as financial transaction and carbon taxes; put more aid through developing country budgets; maximise budget and sector support to make spending more accountable; and report planned disbursements to developing countries. The International Monetary Fund also needs to sharply increase space for sustainable spending in its programmes.
As Uganda’s government programming is so dependent on external funding (aid), recent funding cuts will be felt across nearly every sector, says the author of this article. The withdrawal of external funding is affecting policy goals and work in agriculture and health and government salaries for teachers, health personnel and local administrators. The rehabilitation and integration of Northern Uganda, still struggling to recover following protracted conflict, and programmes in Karamoja region are likely to be affected. Shifting the burden to taxpayers for initiatives formerly funded by external funders is unlikely to be accepted unless issues of corruption and effective spending are addressed, argues the author. Regardless of whether government programmes are funded externally or from taxpayers, citizens seek greater transparency through consistent and open procedures in financial management.
The new consensus towards universal health care (UHC) suggests that an evidence-based approach to policy may finally be prevailing over an ideologically driven approach. While the new consensus shifting in favour of UHC is to be welcomed, the author argues that the international health community cannot dismiss the unnecessary suffering and harm caused by the reckless adoption of ideologically driven user fees policies over the last 30 years. It is incumbent on the international health community to reflect and take stock of what went so badly wrong that led to the widespread application of user fees in the world’s poorest countries and take steps to determine accountability for those responsible. The past victims of user fees must have their voices heard and all potential avenues for compensation must be fully pursued, as their right to health was violated for so long. More broadly, the current lack of accountability and liability in the economics profession should be of concern to the international health community as it increasingly relies on the advice and direction of health economists.
Since 2008 there has been much debate about where agencies, NGOs, programmes and countries might turn to for sustainable funding. One thing is very clear, says the author of this blog: Global Health, including HIV, no longer enjoys the same enthusiasm it once did. The relative ease of garnering financing for malaria bed nets or innovations in drug distribution that NGOs and agencies experienced in 2005 has yielded to tough slogging for basic financing in 2013. For ministries of health and country-based health programmes this shift ushers need to look to domestic sources for support. South Africa is the first significant aid recipient to set a goal for complete health self-reliance, and actually meet most of its targets en route. Combined with a package of new taxes on everything from cell phone use to plane flights, alcohol and tobacco levies could garner African countries an additional $15.5 billion. Two obstacles obviously stand in the way, according to the author: The political will for governments to implement what undoubtedly would be unpopular use taxes, and the monumental fights within government over allocation of those revenues. Just because a country gleans a fresh $1 billion from such taxes by no means assures the government will allocate most, or even any of it, to health programmes.
In this speech to the World Health Assembly, World Bank Group President Jim Yong Kim outlines five specific ways the World Bank Group will support countries in their drive towards universal health coverage. First, he pledges the bank will continue to ramp up its analytic work and support for health systems. Second, he highlights the World Bank’s commitment to support countries in an all-out effort to reach Millennium Development Goals 4 and 5, on maternal mortality and child mortality. The third commitment is that, with the World Health Organisation and other partners, the World Bank Group will strengthen its measurement work in areas relevant to universal health coverage. Fourth, the Bank will deepen its work on what is called ‘the science of delivery’, a new field that the World Bank Group is helping to shape, in response to country demand. Fifth and finally, the World Bank Group will continue to step up its work on improving health through action in other sectors, such as agriculture, clean energy, education, sanitation, and women’s empowerment. Kim argues that the fragmentation of global health action has led to inefficiencies: parallel delivery structures; multiplication of monitoring systems and reporting demands; and ministry officials who spend a quarter of their time managing requests from misguided international partners. He calls for integrated management of health issues facing the world today.
11. Equity and HIV/AIDS
The authors of this study investigated factors associated with patterns of plural healthcare usage among patients taking antiretroviral therapy (ART) in diverse South African settings. They conducted a cross-sectional study of ART patients in two rural and two urban sub-districts, involving 13 accredited facilities and 1,266 participants selected through systematic random sampling. They used structured questionnaires in interviews and reviewed participant’s clinic records. Results showed that 19% of respondents reported use of additional healthcare providers over and above their regular ART visits in the prior month. Increased plural healthcare utilisation, inequitably distributed between rural and urban areas, was found to be largely a function of higher socioeconomic status, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Healthcare expenditure of a catastrophic nature remained a persistent complication. Although plural healthcare utilisation did not appear to influence clinical outcomes, there were potential negative impacts on the livelihoods of patients and their households.
This study aims to demonstrate changes in population level HIV mortality in two high HIV prevalence slums in Nairobi with respect to the initiation and subsequent scale up of the national antiretroviral therapy (ART) programme. The authors used data from 2070 deaths of people aged 15–54 years that occurred between 2003 and 2010 in a population of about 72,000 individuals living in two slums covered by the Nairobi Urban Health and Demographic Surveillance System. Results indicated that, overall, HIV mortality declined significantly from 2.5 per 1,000 person years in the early period to 1.7 per 1,000 person years in the late period. The risk of dying from HIV was 53% less in the late period compared to the period before, controlling for age and gender. Women experienced a decline in HIV mortality between the two periods that was more than double that of men. At the same time, the risk of non-HIV mortality did not change significantly between the two time periods. In conclusions, population-level HIV mortality in Nairobi’s slums was significantly lower in the approximate period coinciding with the scale-up of ART provision in Kenya. However, further studies that incorporate ART coverage data in mortality estimates are needed. Such information will enhance our understanding of the full impact of ART scale-up in reducing adult mortality among marginalised slum populations in Kenya.
In a previous issue of the Southern African Journal of HIV Medicine, Pillay and Black summarised the trade-offs of the safety of efavirenz use in pregnancy. Highlighting the benefits of the World Health Organisation’s proposed options for the prevention of mother-to-child transmission (PMTCT) of HIV, the authors argued that the South African government should adopt Option B as national PMTCT policy and pilot projects implementing Option B+ as a means of assessing the individual- and population-level effect of the intervention. The authors of this article echo this call and further propose that the option to remain on lifelong antiretroviral therapy, effectively adopting PMTCT Option B+, be offered to pregnant women following the cessation of breastfeeding, for their own health, following the provision of counselling on associated benefits and risks. Here they highlight the benefits of Options B and B+.
12. Governance and participation in health
This is the story of the leaders of a women's organisation, Mahila Swasthya Adhikar Manch (Women’s Health Rights Forum) in the state of Uttar Pradesh in India. It recounts how a group of women from the extremely marginalised sections of society have become empowered and are monitoring their entitlements around health services and other services which are related to the social determinants of health. It describes the evolution of the group, its activities and some of the results of their advocacy action with a focus on their empowerment process. This story of women’s empowerment is closely inter-twined with that of a group of facilitating organisations, who have not only contributed to this process, but also gained in confidence and credibility to strengthen the overall call for greater state accountability at different levels. The case study also discusses how this process which has led to a series of gains for these marginalised women both at a personal level and in improving accountability processes at the local level; still remains incomplete in the context of their overall political empowerment and autonomy.
The Uganda National NGO Forum has launched the first CSO-NDP monitoring report that captures citizen voices on Government’s National Development Plan (NDP) and public service delivery. The monitoring strategy for the NDP addressed the demand side challenge of limited Monitoring and Evaluation activities. The report ensured well documentation of citizens’ views which were later shared with stakeholders at different levels of Government. The monitoring survey was conducted in 51 districts and reached 20,000 households in the districts covered. Data was collected from seven sectors through review of government documents and questionnaires administered at four different levels; households, community, sub county and district levels. The report covers findings from seven selected NDP sectors; agriculture; markets and cooperatives; transport; labour and employment; health; water and sanitation; and justice, law and order. With regard to health, most households meet their healthcare costs despite the free primary healthcare policy. Nearly seven out of ten households do not receive their full drug prescription. Sanitary conditions are far from the minimum norms and standards in most households. No more than three in 10 homesteads have a given sanitary facility.
Activists from the People’s Health Movement met during the World Health Organisation’s 8th Global Conference on Health Promotion to critique the official Conference Statement (included in this newsletter) and develop a progressive call for action based on strong social justice principles. This draft reflects their deliberation and is being circulated for further comment and debate. They support the leadership of WHO Director-General Margaret Chan in condemning the economic power of large industries, including food, tobacco, soda and alcohol, and their destructive impact on the health of people around the globe. They note further that speakers and discussants in this Conference have highlighted the link between the “Health for All” Declaration of Alma Ata in 1978 and the unfinished agenda of health promotion, stemming from the Ottawa Declaration of 1986. They support the calls in this conference for a ‘whole‐of‐government’ approach that includes Health in All Policies, a social justice framework in monitoring and evaluation of health policies, and the health‐related human rights that promote health for all. They believe, however, that the Helsinki Statement does not sufficiently translate the analysis of the determinants of health inequities and poor health into specific actions which address the unfair economic system that underpins health inequities. They therefore issue this call to action, recognising that this entails both short and long term political struggle for social justice.
This paper describes the Ghana Essential Health Intervention Project (GEHIP), a plausibility trial of strategies for strengthening Community-based Health Planning and Services (CHPS). The researchers found that GEHIP improves the CHPS model by: extending the range and quality of services for newborns; training community volunteers to conduct the World Health Organisation service regimen known as integrated management of childhood illness (IMCI); simplifying the collection of health management information and ensuring its use for decision making; enabling community health nurses to manage emergencies, particularly obstetric complications and refer cases without delay; adding $0.85 per capita annually to district budgets and marshalling grassroots political commitment to financing CHPS implementation; and strengthening CHPS leadership at all levels of the system. By demonstrating practical means of strengthening a real-world health system while monitoring costs and assessing maternal and child survival impact, GEHIP is expected to contribute to national health policy, planning, and resource allocation that will be needed to accelerate progress with the Millennium Development Goals.
This briefing paper elicits the perspective of the African non-governmental organisations (NGOs) on the concept of universal health coverage (UHC). It defines the basic concepts and also explores the role NGOs can play to improve the definition and implementation of UHC to improve health outcomes for all. It describes some of the common misunderstandings and misgivings expressed by NGOs, such as the belief that UHC is limited in scope and does not address the social determinants of health. Examples from African countries that have successfully implemented UHC are provided. UHC does not only mean protection from catastrophic expenditure – it means that all people are able to access health services when they need them. In this regard it specifically targets the poorest and most vulnerable. In most instances, civil society organisations have played a significant role in ensuring that national policies reflect in the reality on the ground.
This action research is an effort to capture the voices of community leaders and bring the resilience priorities of poor, disaster-prone communities into debates that will shape the new policy frameworks on disaster risk reduction to be launched in 2015. For the most part members of poor, disaster-prone neighbourhoods worst affected by natural hazards and climate change are absent from current consultations. Yet, it is these communities whose survival and wellbeing will be most affected by the policies and programmes that emerge from these debates. Five recommendations emerged from this study. 1. Invest in community-led transfers to scale up effective resilience practices. 2. Incentivise community-led, multi-stakeholder partnerships; create mechanisms that formalise community roles in government programmes to make them more responsive and accountable to community resilience priorities. 3. Foster community organising and constituency building in addition to technical know-how for building resilience. 4. Set aside decentralised, flexible funds to foster multi-dimensional community resilience building efforts. 5. Recognise grassroots women’s organisations and networks as key stakeholders in planning, implementing and monitoring resilience programmes.
13. Monitoring equity and research policy
In this paper, the authors describe the components of the African Health Initiative framework; this includes the conceptual model, core metrics to be measured in all sites, and standard guidelines for reporting on the implementation of partnership activities and contextual factors that may affect implementation, or the results it produces. They also describe the systems that have been put in place for data management, data quality assessments, and cross-site analysis of results. The conceptual model for the Initiative highlights points in the causal chain between health system strengthening activities and health impact where evidence produced by the partnerships can contribute to learning. This model represents an important advance over its predecessors by including contextual factors and implementation strength as potential determinants, and explicitly including equity as a component of both outcomes and impact. Specific measurement challenges include the prospective documentation of programme implementation and contextual factors. Methodological issues addressed in the development of the framework include the aggregation of data collected using different methods and the challenge of evaluating a complex set of interventions being improved over time based on continuous monitoring and intermediate results.
As the first-ever global-level strategy on Health Policy and Systems Research (HPSR), this document represents a unique milestone in the evolution of health policy and systems research. It has three broad aims. First, it seeks to unify the worlds of research and decision-making and connect the various disciplines of research that generate knowledge to inform and strengthen health systems. It is targeted at decision-makers at all levels of the health system - from national policy-makers to front line providers of health services - and seeks support to make HPSR increasingly demand-driven and responsive to the needs of 21st century health systems. Second, this strategy contributes to a broader understanding of the field of HPSR by clarifying the scope and role of HPSR. It provides insight into the dynamic processes through which HPSR evidence is generated and used in decision-making. Finally, it is hoped that this strategy will serve as an agent for change. It advocates for a paradigm that emphasises the need for close collaboration between researchers and decision-makers rather than work along parallel pathways. The strategy speaks to decision-makers and researchers as part of one community and proposes actions that both can take in order to strengthen the performance of health systems. It calls for a more prominent role for HPSR at a time when the health systems mandate is evolving towards broader goals of universal health coverage and equity.
In this report, the author explores how the evaluation of intersectoral action for health (IAH) and health in all policies (HiAP) is being implemented from the experience of expertise directly involved in such work. The World Health Organisation (WHO) selected 11 respondents for their involvement in work on IAH and systems scale analysis. They were interviewed and the documents they provided were reviewed. The respondents were drawn from local government, national- and global-level institutions, mainly from high-income countries with only two from middle- or low-income countries. The findings suggest that having an explicit and shared conceptual framework for IAH work at inception is necessary to clarify the pathways for change, the outcomes and measures for assessing performance and impact, to prioritise action and to test the thinking informing IAH work. While the learning from this may be context-specific, learning networks provide a means for a meta-analysis of case studies, to build more generic knowledge around conceptual frameworks. For most respondents, a model of reflexive or negotiated evaluations was seen as most useful for concept, performance and impact evaluation, embedded within the planning and implementation of IAH, with knowledge jointly constructed by different actors, including local communities, and linked to the review of practice. All those interviewed encouraged further work to develop approaches and methods for the evaluation of IAH. While noting the limitations on generalisations due to the small sample, the findings suggest some recommendations for supporting promising practice on the evaluation of IAH.
Expert consultations were held at the Harvard School of Public Health, Boston, from 8 to 9 May 2013, in order to develop operational strategies that can be used by governments and other stakeholders to embed research into decision-making processes, a key recommendation of the WHO Strategy on Health Policy and Systems Research (included in this newsletter). It was agreed that a framework needs to be developed, to guide the embeddedness of research into decision-making. This framework should be based on the needs, the capacities and the available funding situation of each country. There was also agreement on the need to interact with existing initiatives, such as EVIPNet and make use of existing tools and platforms as starting blocks for new and innovative frameworks.
Despite the growing focus on health systems, the largest global health initiatives continue to have a disease specific focus. In response, the Doris Duke Charitable Foundation launched the African Health Initiative (AHI) to catalyse significant advances in strengthening health systems by supporting Population Health and Implementation Training (PHIT) Partnerships in five diverse sub-Saharan African contexts. Each Partnership is addressing key health systems constraints to improve service delivery and health outcomes. The authors of this article identify a number of overarching lessons from the first three and a half years of implementation, which include the need for a multipronged approach to systems, with the result that most of the teams ultimately included activities in each of six areas identified as health system building blocks by the World Health Organisation. Despite relatively modest funds for the scope of planned activities, teams garnered substantial interest and support at high levels of the Ministries of Health, reflective of the need to plan comprehensively for health systems without the constraint of a single disease focus.
In this study, researchers report on linking data with improved decision-making. Mozambique, Ghana, and Tanzania focus on improving the quality and use of the existing Ministry of Health health information, while Zambia and Rwanda have introduced new information and communication technology systems or tools. All have a flexible, iterative approach in designing and refining the development of new tools and approaches for HIS enhancement, as well as improving decision making through timely feedback on health system performance. The differences are found in the level of emphasis of data collection (patient versus health facility), and consequently the level of decision making enhancement (community, facility, district, or provincial leadership).
Public health today enjoys commitment, resources, and powerful interventions but the power of these interventions is not matched by the power of health systems to deliver them to those in greatest need, on an adequate scale and in time. According to this document, this arises, in part, from the fact that research on health systems has been so badly neglected and underfunded. In the absence of sound evidence, we will have no good way to compel efficient investments in health systems. Outlined in this document are a number of options for action by stakeholders to facilitate evidence-informed decision-making and the strengthening of health systems. These complementary options are intended to support the embedding of research within decision-making processes and promote a steady programme of national and global investment in HPSR. Member States of WHO may opt to pursue some or all of these actions, based on their individual context . 1. Embed research within decision-making processes. 2. Support demand-driven research. 3. Strengthen capacity for research and use of evidence. 4. Establish repositories of knowledge. 5. Improve the efficiency of investments in research. 6. Increase accountability for actions.
The Mozambique Population Health Implementation and Training (PHIT) Partnership focuses on improving the quality of routine data and its use through appropriate tools to facilitate decision making by health system managers; strengthening management and planning capacity and funding district health plans; and building capacity for operations research to guide system-strengthening efforts. This seven-year effort covers all 13 districts and 146 health facilities in Sofala Province. The Mozambique PHIT Partnership expects to provide evidence on the effect of efforts to improve data quality coupled with the introduction of tools, training, and supervision to improve evidence-based decision making. This contribution to the knowledge base on what works to enhance health systems is highly replicable for rapid scale-up to other provinces in Mozambique, as well as other sub-Saharan African countries with limited resources and a commitment to comprehensive primary health care.
14. Useful Resources
Health Equity Impact Assessment (HEIA) tool has four key objectives: 1. Help identify unintended potential health equity impacts of decision-making (positive and negative) on specific population groups. 2. Support equity-based improvements in policy, planning, programme or service design. 3. Embed equity in an organisation’s decision-making processes. 4. Build capacity and raise awareness about health equity throughout the organisation. The HEIA tool includes a template and a workbook that provides users with step by step instructions on how to conduct an HEIA. The workbook walks users through five steps: scoping, potential impacts, mitigation, monitoring and dissemination. The results are recorded in the HEIA template. The tool may be used by organisations both inside and outside the health care system whose work can have an impact on health outcomes.
This is an interactive online platform and one-stop resource centre for civil society practitioners who want to work on improving the impact and quality of their development work. Whether you are starting to plan your work, or already have some tools and best practices to share, on this site you can access, share and rate tools, case studies and best practices from CSOs around the world, on implementing each of the eight Istanbul Principles and advocating for an enabling environment.
Participatory mapping, commonly used in participatory development, plays an important role in helping marginalised groups by making visible the association between land and local communities, highlighting important social, historical and cultural knowledge as well as presenting geographical feature information. This review is intended to provide a broad background in the use of participatory mapping processes and the range of tools available to practitioners. It is not exhaustive but aims to give readers a greater appreciaion of how participatory mapping has involved from a relatively simplistic participatory rural appraisal (PRA) tool into a community of practice spanning a range of sophisticated technologies and processes. It draws on a number of examples from around the world, with special attention given to projects supported by the International Fund for Agricultural Development (IFAD), as this organisation commissioned the review. However, it contains useful insights, lessons and pitfalls in both the processes and tools available for participatory mapping.
15. Jobs and Announcements
The MPH at the University of the Western Cape aims to equip health professionals to: quantify and prioritise health needs; design, implement and evaluate Comprehensive Primary Health Care Programmes; and manage District Health Systems. The Programme is designed for a range of health and welfare professionals and managers from middle to senior level, at district, provincial or national levels, staff of NGO’s and academic research contexts. The Programme may be taken over two to three years. Admission requirements: A four year degree (Honours Degree) or its equivalent in any discipline, or in exceptional cases, five years of relevant experience assessed by the university through a Recognition of Prior Learning (RPL) process. Contact Mrs Janine Kader at the email address given.
The next Global HSR Symposium will be held in Cape Town, 30 September-3 October 2014. The South African Local Organising Consortium (SA-LOC) consists of the Universities of Cape Town, Stellenbosch and Western Cape as well as the Health Systems Trust and the SA Medical Research Council. The organisers are seeking to gather your views on African ideas and experiences to share in the Symposium. The Symposium theme is Health Systems Research: the science and practice of people-centred health systems. Kindly submit ideas on the Symposium and its theme via the open, global survey now available – go to the webpage address provided. In addition, if you have any specific thoughts about excellent African speakers and experiences of relevance to the theme, who/which might be considered for inclusion in the Symposium, or specific proposals for activities in and around the Symposium, please send an email to Funke Alaba at the email address given.
The Department of Health and Rehabilitation Sciences at the University of Cape Town, South Africa, is holding its first Rehabilitation Conference in September 2013. The conference will host speakers from diverse disciplinary fields on a range of themes such as: policy: influencing development and implementation; evidence for action: a research agenda; responsive rehabilitation service delivery; and optimising human resourcing for rehabilitation.
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