Zimbabwe’s media has been awash in 2014 with stories of monthly salaries above $50 000 being taken by the executives across a number of public institutions, in a country where the 2011/12 Poverty Income and Expenditure survey found 77% of those in formal employment to be earning less than US$351 and 63% of all households living below the poverty line. A term has been coined for the scandal - "salary-gate".
One of the worst stories of "salary - gate" was in the voluntary health insurance sector. Zimbabwe has about 30 health insurance companies, termed ‘medical aid’, funding health care for about 10% of the population and providing about 80% of the income to private for profit health services. These medical aid societies are private, voluntary organisations and are deemed to be non-profit.
The events of 2014 have shaken these assumptions. The state media, the Herald, on 31st January, 2014 reported that the top fourteen executives of the biggest medial aid society, the Premier Service Medical Aid Society (PSMAS), were getting US$1.1 million monthly in their combined fees and benefits. The chief executive alone was reported in the same media to be paid about a quarter of a million US dollars monthly in direct earnings from PSMAS and from its subsidiary Premier Service Medical Investments (PSMI) and in other benefits and allowances. While the figure remains to be officially verified, other media have made similar report of this figure without it being contested. This is in the context where the majority of PSMAS members- 75% of whom are employed and retired civil servants according to the Civil Service Commission - earn less than US$400 monthly if employed, and significantly less than this if they are pensioners and widows/widowers. While PSMAS paid its managers these huge salaries, they also built up a debt to service providers of US$38 million in unpaid fees. Their failure to pay providers meant that many demanded that PSMAS members pay cash up-front, undermining the financial protection health insurance is supposed to provide.
This was not the first time that PSMAS and some other medical aid societies had come to public attention. PSMAS became the second biggest provider of health services in Zimbabwe after the government in 2003, setting up a subsidiary, PSMI, and using it to acquire and develop private health services. It expanded to accommodate private sector members and became a significant employer of doctors in Zimbabwe. This integration of funder and provider had already raised questions. In 2000 the Competition and Tariff Commission (CTC) raised that such monopolies across all spheres of a sector limited patient choice, and the Medical Aid Societies Statutory Instrument 330 of 2000 regulated such vertical integration. Nevertheless PSMAS and others were given latitude to continue the practice throughout the 2000s, despite beneficiary complaints about restrictions in the providers covered.
The case raises a number of questions, particularly in terms of the effectiveness with which insurers are monitored by their members and regulated by authorities. PSMAS largely covers government as contributors and civil servants members, although it is not a public enterprise. Government as employer nominates four people to the board while six are elected by the members at an annual general meeting, another member is appointed by an affiliated employer organisation and two are nominated by elected members of the board. The chief executive is an ex-officio member. Ironically, civil service members did not elect themselves to the Board. The Board in 2014 included private professionals and heads of several ministries. It was alleged to have been paid US$1million in allowances in 2013 and dissolved itself in February 2014. As na sign of the lack of oversight of the organization the state media citing the Acting Health Minister Dr Mombeshora reported in February that the society’s operating license was not renewed at the end of 2013 for failing to submit audited financial statements. This raises the issue that members of all such insurance schemes should more actively engage with what is happening in their schemes, include through representation on their Boards.
There also seem to be questions about how effectively such schemes are regulated. PSMAS, like other medical aid societies, was regulated as a finance institution by the Ministry of Finance, and as a health institution by the Ministry of Health. Its nature as a society for civil servants additionally brought in the Ministry of Labour and the Public Service Commission. Despite this multitude of regulators, the evidence suggests that there was no effective regulatory control. A number of weaknesses emerge, some of which were pointed out in a 2010 EQUINET Discussion Paper 82 (www.equinetafrica.org/bibl/docs/DIS82zimcapflow.pdf) and at a meeting held on the findings by Training and Research Support Centre (TARSC), SEATINI, in collaboration with Ministry of Health in 2010. The Ministry should play a stewardship and regulatory role given the health insurance and health service role. However regulations were weakly enforced in the 2000s during economic difficulties; and the Ministry oversight role is post hoc, obtaining report of changes to constitutions and practices after they have already been made, without meaningful blocking power to prevent 'bad' behavior. Ironically the Ministry of Health had no representative on the PSMAS board. Regulatory oversight by the Ministry faces challenges in shortages of personnel, ambiguities in the law, lack of reporting from societies and lack of awareness and advocacy by members.
In response to ‘salary-gate’ at PSMAS and a range of public entities Zimbabwe’s Finance minister in March announced that cabinet had set the salary ceiling for chief executive officers of parastatal and public institutions at US$6000. They included PSMAS in this, but there is question over their authority to do so for a private limited company where government has no shareholding.
Do we expect anything to change? The crisis is an opportunity to raise some critical questions about the private health insurance sector. Is this case the tip of the iceberg? Beyond PSMAS, are members of medical aid societies exercising proper oversight of their insurers? Are the resources being effectively used for their purpose? With the majority of people in two medical aid societies in Zimbabwe, CIMAS and PSMAS, how viable are the other 28 insurers? Are their funding pools large enough to protect the membership against risk? With the benefit packages clearly specified but segmented across schemes, what measures are there for the pooling and cross-subsidy among members needed to ensure viability and equity? Are the monopolies of insurers and private providers not blurring the boundaries of what is for profit and what is not, given that medical aid societies are tax exempt as health funders but earning profits in investments in private health services? Why is the law preventing such integration not being enforced? How are societies earning 'surplus funds' in their service investments, even while service providers are not being paid and beneficiaries not covered for their benefits?
The Zimbabwe story may not be unique within the region, and cost escalation and inappropriate spending may be more common than is being publicly reported. The Zimbabwe experience and the questions raised could provoke those in other countries to do a ‘health check’ of their insurance sector, in a manner that leads to action to address weaknesses identified. The biggest weakness appears to be in the absence of accountability and the checks and balances for this. The state should not be allowed to fall short on its obligation to protect members from predatory behavior, and members expect the state to have adequate competencies to regulate the market. The system needs to be more responsive to the community and the community to be more vigilant and demanding of accountability.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: email@example.com. For more information on the issues raised please visit www.equinetafrica.org and see EQUINET discussion paper 82 at www.equinetafrica.org/bibl/docs/DIS82zimcapflow.pdf and EQUINET discussion paper 82, 87 and 99 on private insurance and their regulation.
2. Latest Equinet Updates
Health Centre Committees (HCCs) have provided one vehicle for social participation and accountability in health systems in east and southern Africa (ESA). Recognising this contribution and building on prior work on HCCs, EQUINET held a regional meeting involving those working with HCCs in ESA countries to exchange experiences and information on the laws, roles, capacities, training and monitoring systems that are being applied to HCCs in the ESA region. The meeting gathered 20 delegates representing seven countries from the region, all involved in training and strengthening HCCs. An interim desk review of existing published literature on HCCs was prepared for the meeting. The desk review covered all 16 ESA countries covered by EQUINET, that is Angola, Botswana, Democratic Republic of Congo (DRC), Kenya, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Delegates validated and added to the evidence presented. This discussion paper combines the evidence from the desk review and the further evidence that was presented at the regional meeting. It covers the legal frameworks, roles, composition, capacities and monitoring of HCCs in ESA countries.
EQUINET will hold a Workshop on ‘Participatory action research in people centred health systems’ immediately after the Global Symposium on Health Systems Research ending 3rd October as a one day post symposium workshop (4th October) and a two day skills training (5-6 October) in Cape Town South Africa. We invite you to send us expressions of interest in participating in the workshop and will post more information on the workshops on the EQUINET website in May.
3. Equity in Health
Action on the social determinants of health is considered a necessary approach to improving health equity. Most of the social determinants of health lie outside the sphere of the health sector and thus collaboration with governmental and non-governmental sectors outside of health are required to develop policies and programs to improve health equity. Case studies of intersectoral action are available, however there is limited information about the impact of intersectoral action on the social determinants of health and health equity. Search and retrieval of literature published between 2001 and 2011 was conducted in 6 databases. A staged screening of titles and abstracts, and later full-text, was conducted by two independent reviewers. Reviewers independently assessed the quality of the articles deemed relevant for inclusion. Data were extracted and synthesized in narrative format for all included studies, conducted by one reviewer and checked by another. 17 articles of varied methodological quality met the inclusion criteria. One systematic review investigating partnership interventions found mixed and limited impacts on health outcomes. Primary studies evaluating the impact of upstream and midstream interventions showed mixed effects. Downstream interventions were generally moderately effective in increasing the availability and use of services by marginalized communities. The literature evaluating the impact of intersectoral action on health equity is limited. The included studies identified reveal a moderate to no effect on the social determinants of health. The evidence on the impact of intersectoral action on health equity is even more limited. The lack of evidence should not be interpreted as a lack of effect. Rigorous evaluations of intersectoral action are needed to strengthen the evidence base of this public health practice.
Improvements in prevention of mother-to-child transmission of HIV (PMTCT) in South Africa are not translating into a reduction in maternal deaths due to HIV infection, according to a 15-year review of a large district referral hospital in Johannesburg, the 21st Conference on Retroviruses and Opportunistic Infections (CROI) heard on Wednesday in Boston. In particular, the audit found that there has been no change in the proportion of maternal deaths caused by HIV since 2007, and over three-quarters of women with HIV who died had never started antiretroviral therapy.The South African review, presented by Coceka Mnyani of University of Witwatersrand, looked at the records of Chris Hani Baragwanath hospital, which serves an urban and periurban population of approximately 2 million people in Johannesburg. The hospital delivered between 17,000 and 23,500 babies a year between 1997 and 2012. HIV prevalence in the maternal population served by the hospital is extremely high: approximately 23% of women who give birth at the hospital were found to be HIV positive in 2012, compared with 30.7% in 2004, the peak year for HIV prevalence among pregnant women giving birth at the hospital.
4. Values, Policies and Rights
WHO has published a draft proposal for a set Framework and set of policies to address its engagement with Non Sate Actors (NSAs). Member States are being invited to discuss these proposals at WHO’s HQ in Geneva on 27th and 28th March. Public Interest NGOs are not invited. IBFAN has been following the process closely and reports finding serious flaws, inconsistencies and contradictions in the proposals. Despite the many statements of WHO’s Director General, Margaret Chan, that WHO’s policies, norms and standards setting processes should be protected from commercial influence, if the new proposals were to be adopted, the corporate influence would increase. IBFAN fears that this would compromise WHO’s integrity, independence and its ability to fulfil its mandate. In particular, the proposals introduce a new risky element, allowing Official Relations status, with all its related privileges, for International Business Associations. Up to now, if businesses wanted to attend governing body meetings in order to lobby Member States delegations, they could wear a public badge, or, if they wanted to speak, inveigle their way onto government delegations. Some, over the years have slipped through WHO’s admission procedures, pretending to be NGOs. The new proposals open the door wide to participation by any business member of these Associations, except tobacco or arms companies. This would, in effect, legitimize businesses lobbying role at WHO’s global policy-setting meetings - the very thing that WHO alleges that it is trying to avoid. In addition to turning WHO governing bodies meetings into multi-stakeholder public-private gatherings, the proposals would also allow businesses greater engagement at programme level, through agreed 3-year plans with WHO. Lida Lhotska, IBFAN NGO Liaison to WHO says: “If these new policy proposals are adopted, IBFAN fears that WHO will be unable to lead and support Member States in taking the bold decisions necessary to tackle global health challenges. For example, irresponsible marketing is a major underlying cause of Non Communicable Diseases (NCDs). In tackling NCDs, acknowledged to be a major threat to public health, will WHO prefer to engage in partnerships with corporations, who would prefer campaigns for promoting ‘slightly better for you products’– or will WHO help Member States bring in legally-binding controls that truly protect right to health of their citizens?”
CEDAW, the Committee on the Elimination of Discrimination against Women, at its recently concluded session, issued a statement (attached) on sexual and reproductive health and rights, which is its contribution to the ICPD@20 review process. The Committee reminds us that it "has observed that failure of a State party to provide services and the criminalisation of some services that only women require is a violation of women's reproductive rights and constitutes discrimination against them." It States that: "the provision of, inter alia, safe abortion and post abortion care; maternity care; timely diagnosis and treatment of sexually transmitted diseases (including HIV), breast and reproductive cancers, and infertility; as well as access to accurate and comprehensive information about sexuality and reproduction, are all part of the right to sexual and reproductive health" and that "every State can and should do more to ensure the full respect, protection and fulfilment of sexual and reproductive rights, in line with human rights obligations."
WHO is launching a public consultation on its draft guideline on sugars intake. When finalized, the guideline will provide countries with recommendations on limiting the consumption of sugars to reduce public health problems like obesity and dental caries (commonly referred to as tooth decay). Comments on the draft guideline will be accepted via the WHO web site from 5 through 31 March 2014. Anyone who wishes to comment must submit a declaration of interests. An expert peer-review process will happen over the same period. Once the peer-review and public consultation are completed, all comments will be reviewed, the draft guidelines will be revised if necessary and cleared by WHO’s Guidelines Review Committee before being finalized.
5. Health equity in economic and trade policies
Many African countries, if not all, are located at the extreme end of what Immanuel Wallerstein thirty years ago termed the core-periphery relationship, a position which impoverishes them to the advantage of rich and industrialised countries in the core. In this paper the author argues that BRICS countries represent sub-imperialists trying to improve their relative location in the world system, perhaps moving toward imperialist power and thereafter even to imperialist superpower status. These countries have different levels of economic development and political influence, vested interests in the African continent and the DRC in particular, and geopolitical positions in world politics. But they all share four characteristics. First, BRICS countries present important opportunities for foreign direct investment that also impoverish people through dispossession of natural resources with little or no compensation, unequal shares of the costs and benefits of mega development projects, repayments of debts incurred to build these projects, and structural exclusion from accessing the outcomes of these initiatives. Second, BRICS countries are argued to share the same modus operandi: accumulation by dispossession. Third, BRICS countries are argued to share the same interests in natural resources including but not limited to mining, gas, oil and mega-dam projects for water and for electricity to meet their increasing demands for cheap and abundant electricity. Fourth, BRICS countries are argued to have poor records of environmental regulation, with virtually no commitment to mitigate climate change and invest in truly renewable energy, to take environmental impact assessments seriously, and to consult with and compensate adversely affected communities.
Africa has the highest disease burden in the world and continues to depend on pharmaceutical imports to meet public health needs. As Asian manufacturers of generic medicines begin to operate under a more protectionist intellectual property regime, their ability to manufacture medicines at prices that are affordable to poorer countries is becoming more circumscribed. The Doha Declaration on the TRIPS Agreement and Public Health gives member states of the World Trade Organization (WTO) the right to adopt legislation permitting the use of patented material without authorization by the patent holder, a provision known as "compulsory licensing". For African countries to take full advantage of compulsory licensing they must develop substantial local manufacturing capacity. Because building manufacturing capacity in each African country is daunting and almost illusory, the author argues that an African free trade area should be developed to serve as a platform not only for the free movement of goods made pursuant to compulsory licences, but also for an economic or financial collaboration towards the development of strong pharmaceutical manufacturing capacity in the continent. Most countries in Africa are in the United Nations list of least developed countries, and this allows them, under WTO law, to refuse to grant patents for pharmaceuticals until 2021. Thus, the author argues that there is a compelling need for African countries to collaborate to build strong pharmaceutical manufacturing capacity in the continent now, while the current flexibilities in international intellectual property law offer considerable benefits.
This paper presents a comprehensive mapping of governance efforts by international organizations to address counterfeit medicines, including analysis of related international treaties and conventions that may be applicable to anticounterfeit efforts. The paper reviews governance and global health diplomacy proposals from the literature that addresses counterfeit medicines. A number of international organizations have become active in addressing the global trade of counterfeit medicines. However, governance approaches by international organizations, including the World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC), Interpol and the World Customs Organization (WCO), have varied in scope and effectiveness. The authors argue that treaty instruments with applicability to counterfeit medicines have not been fully leveraged to combat this issue and argue that a formalized and multi-stakeholder governance mechanism is needed to address the issue, and that the UNODC should convene it.
6. Poverty and health
Increasing urbanization will be one of the defining features of the 21st century. This produces particular environmental challenges, but also creates opportunities for urban development that can contribute to broader goals of improving the quality of life for urban residents while achieving greater levels of global sustainability. Focusing on the City Development Strategy (CDS), the report draws on two main sets to determine the effectiveness of using the CDS to integrate environmental issues into city planning processes. Firstly, it draws on an analysis of documentation from 15 cities in Africa, Asia and Latin America that have engaged in the process of developing a City Development Strategy under the auspices of Cities Alliance. Secondly, it incorporates insights from in-depth Learning and Leadership Groups conducted with three additional cities (Metro Manila [Philippines] [specifically Makati City and Quezon City], Kampala [Uganda] and Accra [Ghana]) that have engaged in this process. The report does not present the results of these workshops directly, but rather uses the insights from these to contribute to a broader understanding of the potential for the incorporation of environmental concerns in urban planning and management, the barriers to this, and the opportunities to overcome these. This report is intended primarily to encourage and support urban decision-makers to integrate environmental concerns more centrally in their planning and management activities.
The African continent is currently in the midst of simultaneously unfolding and highly significant demographic, economic, technological, environmental, urban and socio-political transitions. Africa’s economic performance is promising, with booming cities supporting growing middle classes and creating sizable consumer markets. But despite significant overall growth, not all of Africa performs well. The continent continues to suffer under very rapid urban growth accompanied by massive urban poverty and many other social problems. These seem to indicate that the development trajectories followed by African nations since post-independence may not be able to deliver on the aspirations of broad based human development and prosperity for all. This report, therefore, argues for a bold re-imagining of prevailing models in order to steer the ongoing transitions towards greater sustainability based on a thorough review of all available options. That is especially the case since the already daunting urban challenges in Africa are now being exacerbated by the new vulnerabilities and threats associated with climate and environmental change.
7. Equitable health services
The African Health Initiative (AHI) has yielded many lessons about how to support health systems within complex and changing geographic, social and political contexts. This has been organised into a series of essays from the field on “What We’re Learning". The first in this series is reported here, with information to support an understanding of the nuances of how health services that result in improvements in population health are delivered.
Previous studies on vaccination coverage in developing countries focus on individual- and community-level barriers to routine vaccination mostly in rural settings. This paper examines health system barriers to childhood immunisation in urban Kampala Uganda. Mixed methods were employed with a survey among child caretakers, 9 focus group discussions (FGDs), and 9 key informant interviews (KIIs). Poor geographical access to immunisation facilities was reported in this urban setting by FGDs, KIIs and survey respondents. This coupled with reports of few health workers providing immunisation services led to long queues and long waiting times at facilities. Consumers reported waiting for 3–6 hours before receipt of services although this was more common at public facilities. Only 33% of survey respondents were willing to wait for three or more hours before receipt of services. Although private-for-profit facilities were engaged in immunisation service provision their participation was low as only 30% of the survey respondents used these facilities. The low participation could be due to lack of financial support for immunisation activities at these facilities. This in turn could explain the rampant informal charges for services in this setting. There were intermittent availability of vaccines and transport for immunisation services at both private and public facilities. Complex health system barriers to childhood immunisation still exist in this urban setting; emphasizing that even in urban areas with great physical access, there are hard to reach people. As the rate of urbanization increases especially in sub-Saharan Africa, the authors find that governments should strengthen health systems to cater for increasing urban populations.
8. Human Resources
The active recruitment of health workers from developing countries to developed countries has become a major threat to global health. In an effort to manage this migration, the 63rd World Health Assembly adopted the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel in May 2010. While the Code has been lauded as the first globally-applicable regulatory framework for health worker recruitment, its impact has yet to be evaluated. The authors offer the first empirical evaluation of the Code’s impact on national and sub-national actors in Australia, Canada, United Kingdom and United States of America, which are the English-speaking high income countries with the greatest number of migrant health workers. Forty two key informants from across government, civil society and private sectors were surveyed. Sixty percent of respondents believed their colleagues were not aware of the Code, and 93% reported that no specific changes had been observed in their work as a result of the Code. 86% reported that the Code has not had any meaningful impact on policies, practices or regulations in their countries. This suggests a gap between awareness of the Code among stakeholders at global forums and the awareness and behaviour of national and sub-national actors. Advocacy and technical guidance for implementing the Code are needed to improve its impact on national decision- makers.
Health worker migration from resource-poor countries to developed countries, also known as ‘brain drain’, represents a serious global health crisis and a significant barrier to achieving global health equity. Resource-poor countries are unable to recruit and retain health workers for domestic health systems, resulting in inadequate health infrastructure and millions of dollars in healthcare investment losses. Using acceptable methods of policy analysis, the authors first assess current strategies aimed at alleviating brain drain and then propose our own global health policy based solution to address current policy limitations. Although governments and private organizations have tried to address this policy challenge, brain drain continues to destabilise public health systems and their populations globally. Most importantly, lack of adequate financing and binding governance solutions continue to fail to prevent health worker brain drain. In response to these challenges, the establishment of a Global Health Resource Fund in conjunction with an international framework for health worker migration could create global governance for stable funding mechanisms encourage equitable migration pathways, and provide data collection that is desperately needed.
9. Public-Private Mix
Lesotho has a new hospital – built and operated under the first public-private partnership (PPP) of its kind in any low-income country. The IFC advice and promise was that it would cost the same as the public hospital it replaced. Instead the PPP hospital is costing the government 51% of their total health budget while providing 25% returns to the private partner and a success fee of $723,000 for the IFC. This report explains how the Lesotho health PPP was developed under the advice of the International Finance Corporation (IFC – the private sector investment arm of the World Bank) and now costs the government $67 million per year, or at least three times the cost of the old public hospital. The hospital is reported by the IFC to be delivering better outcomes in some areas. But the biggest concern is that as costs escalate for the PPP hospital in the capital, fewer and fewer resources will be available to tackle serious and increasing health problems in rural areas where three quarters of the population live.
Days after the Council for Medical Schemes in South Africa announced it had ordered a forensic investigation into its registrar, Monwabisi Gantsho, for allegedly soliciting a R3m kickback, an earlier report has come to light raising further questions about his conduct.Dr Gantso heads the agency charged with overseeing the R110bn medical schemes industry. In November 2012, the council’s acting chairman Trevor Bailey instructed law firm Bell Dewar to investigate a series of allegations made by senior staff against the registrar. The law firm’s report, according to Business Day, concluded that the registrar:
• Ignored recommendations made by a council task team for the appointment of independent curators to three different medical schemes — Bonitas, Sizwe and Medshield — and had instead appointed curators "with whom he appear(ed) to have a relationship";
• Delayed an investigation into troubled medical scheme Medshield "without justification";
• Refused to approve the merger of Nampak Medical Scheme and Discovery Health Medical Scheme for "no justifiable reason";
• Appointed staff without following due process; and
• Put pressure on a junior staff member to reveal confidential minutes of meetings of the medicine pricing committee.
The article provides further report on the follow up actions according to Business Day.
On 6 January 2014, South Africa’s Competition Commission began a market inquiry (an investigation)into the private health sector. The Commission was concerned about high prices in private health care and will use its wide powers to investigate the general state of competition in this sector to determine what can be done to achieve accessible, affordable, high quality and advanced private health care in South Africa. According to the Commission, there are indications that the private health care market is not working well for consumers. The market inquiry will examine the causes of why the market may not be working effectively, and will make recommendations as to how they might be made to work better in order to promote and protect consumer interests, while ensuring that markets
are fair and competitive. As such the Commission will specifically look into the increases in prices in private health care and determine the factors that are driving prices. This fact sheet outlines the terms of the Commission inquiry. It points to the opportunity to address inequality in the health system in South Africa. SECTION27, together with its partners, report that they will closely monitor the inquiry and ensure that the voice of ordinary users of private health services.
10. Resource allocation and health financing
After a decade of high growth, a new narrative of optimism has taken hold about Africa and its economic prospects. Despite this, there is a broad
consensus that progress in human development has been limited given the volume of wealth created. There is growing concern that the high levels of
income inequality in sub-Saharan Africa are holding back progress. This report investigates the issue of income inequality in eight sub-Saharan African countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, South Africa, Zambia and Zimbabwe). While there is growing public recognition that inequality is the issue for our time - both globally and in sub-Saharan Africa – there is little definitive analysis of income inequality trends on the continent. This report seeks to contribute in this area, looking at whether income inequality is, in fact, rising and in what context this is occurring. In particular, this report seeks to locate an analysis of tax systems in sub-Saharan Africa in the context of these economic inequalities, given the primary importance of national tax systems in redistributing wealth. A central contention of this report is that rising income inequality is going hand in hand with – and is ultimately caused by – the current growth model, illicit financial flows and the the inability of governments to tax the proceeds of growth, because a large part of sub-Saharan Africa’s income and wealth has escaped offshore. This report also finds many shortcomings in direct taxation in the countries studied. The personal income tax (PIT) systems lack equity as the bulk of the burden is on employees. The self-employed rarely pay tax. The visible lack of equity erodes citizens’ trust in the system. While the report notes some signs of progress, such as some mineral taxation reforms, there is also a clear gap between rhetoric and reality. There is national and international consensus that it is urgent to address issues such as tax incentives, extractives taxation, the taxation of HNWI, tax evasion and illicit financial flows. However, countries are struggling to introduce new direct taxes and to enforce tax compliance against companies and elites. Support to make such transformational changes is reported to be inadequate.
The last decade has seen widespread retreat from user fees with the intention to reduce financial constraints to users in accessing health care and in particular improving access to reproductive, maternal and newborn health services. This has had important benefits in reducing financial barriers to access in a number of settings. If the policies work as intended, service utilization rates increase. However this increases workloads for health staff and at the same time, the loss of user fee revenues can imply that health workers lose bonuses or allowances, or that it becomes more difficult to ensure uninterrupted supplies of health care inputs. This research aimed to assess how policies reducing demand-side barriers to access to health care have affected service delivery with a particular focus on human resources for health. The authors undertook case studies in five countries (Ghana, Nepal, Sierra Leone, Zambia and Zimbabwe). In each the authors reviewed financing and HRH policies, considered the impact financing policy change had made on health service utilization rates, analysed the distribution of health staff and their actual and potential workloads, and compared remuneration terms in the public sectors. The authors question a number of common assumptions about the financing and human resource inter-relationships. The impact of fee removal on utilization levels is mostly not sustained or supported by all the evidence. Shortages of human resources for health at the national level are not universal; maldistribution within countries is the greater problem. Low salaries are not universal; most of the countries pay health workers well by national benchmarks. The interconnectedness between user fee policy and HRH situations proves difficult to assess. Many policies have been changing over the relevant period, some clearly and others possibly in response to problems identified associated with financing policy change. Other relevant variables have also changed. However, as is now well-recognised in the user fee literature, co-ordination of health financing and human resource policies is essential. This appears less well recognised in the human resources literature. This coordination involves considering user charges, resource availability at health facility level, health worker pay, terms and conditions, and recruitment in tandem. All these policies need to be effectively monitored in their processes as well as outcomes, but sufficient data are not collected for this purpose.
11. Equity and HIV/AIDS
There is a huge interest by faith-based organizations (FBOs) in sub-Saharan Africa and elsewhere in HIV prevention interventions that build on the religious aspects of being. Successful partnerships between the public health services and FBOs will require a better understanding of the conceptual framing of HIV prevention by FBOS to access for prevention intervention, those concepts the churches of various denominations and their members would support or endorse. This paper reports the findings of a study on the conceptual framing of HIV prevention among church youths in Botswana. The findings suggest the church youth to conceptually frame their HIV prevention from both faith-oriented and secular-oriented perspectives, while prioritizing the faith-oriented concepts based on biblical teachings and future focus. In their secular-oriented framing of HIV prevention, the church youths endorsed the importance to learn the facts about HIV and AIDS, understanding of community norms that increased risk for HIV and prevention education. However, components of secular-oriented framing of HIV prevention concepts were comparatively less was well differentiated among the youths than with faith-oriented framing, suggesting latent influences of the church knowledge environment to undervalue secular oriented concepts. Older and sexually experienced church youths in their framing of HIV prevention valued future focus and prevention education less than contrasting peer cohorts, suggesting their greater relative risk for HIV infection.
There is growing interest in expanding public health approaches that address social and structural drivers that affect the environment in which behaviour occurs. Half of those living with HIV infection are women. The sociocultural and political environment in which women live can enable or inhibit their ability to protect themselves from acquiring HIV. This paper examines the evidence related to six key social and structural drivers of HIV for women: transforming gender norms; addressing violence against women; transforming legal norms to empower women; promoting women’s employment, income and livelihood opportunities; advancing education for girls and reducing stigma and discrimination. The paper reviews the evidence for successful and promising social and structural interventions related to each driver. This analysis contains peer-reviewed published research and study reports with clear and transparent data on the effectiveness of interventions. Structural interventions to address these key social and structural drivers have led to increasing HIV-protective behaviours, creating more gender-equitable relationships and decreasing violence, improving services for women, increasing widows’ ability to cope with HIV and reducing behaviour that increases HIV risk, particularly among young people.
12. Governance and participation in health
Social capital is important to disadvantaged groups, such as sex workers, as a means of facilitating internal group-related mutual aid and support as well as access to broader social and material resources. Studies among sex workers have linked higher social capital with protective HIV-related behaviors; however, few studies have examined social capital among sex workers in sub-Saharan Africa. This cross-sectional study examined relationships between two key social capital constructs, social cohesion among sex workers and social participation of sex workers in the larger community, and HIV-related risk in Swaziland using respondent-driven sampling. Relationships between social cohesion, social participation, and HIV-related risk factors were assessed using logistic regression. HIV prevalence among the sample was 70.4%. Social cohesion was associated with consistent condom use in the past week and with fewer reports of social discrimination, including denial of police protection. Social participation was associated with HIV testing and using condoms with non-paying partners and was inversely associated with reported verbal or physical harassment as a result of selling sex. Both social capital constructs were significantly associated with collective action, which involved participating in meetings to promote sex worker rights or attending HIV-related meetings/ talks with other sex workers. Social- and structural-level interventions focused on building social cohesion and social participation among sex workers could provide significant protection from HIV infection for female sex workers in Swaziland.
Although infrastructure typically refers to physical characteristics, in this article it refers to social-cultural properties within which health decisions and communication may occur. An understanding of agency and identities is incomplete without situating them in social-cultural networks of relationships that give meaning to health behaviors and sociocultural practices. Airhihenbuwa (2007) describes social-cultural infrastructure as systems and mechanisms of culture that nurture social strengths by rendering them assets in containing epidemics. The focus on physical infrastructure in addressing the development levels offers a useful perspective on the nature and relationship people have with themselves, their people, and their environment (Beune, Haafkens, Schuster, & Bindels, 2006), but does not adequately explain how choices are made and have social impact. Understanding how choices are made offers insight into how individuals are able to maintain optimum health and function in spite of limitations on their social and cognitive capabilities. In this commentary, the authors offer a perspective on the continually changing and conflicting global agenda to reduce the disease burden by improving health and health care practices in Africa (Sambo et al., 2011). They argue for a discourse that can accommodate complexity, plurality, and contradictions and is anchored in sociocultural rather than physically referenced impulses in a framework for future strategies for African health and development.
13. Monitoring equity and research policy
Despite increasing investment in health research capacity strengthening efforts in low and middle income countries, published evidence to guide the systematic design and monitoring of such interventions is very limited. Systematic processes are important to underpin capacity strengthening interventions because they provide stepwise guidance and allow for continual improvement. The authors aimed to use evidence to inform the design of a replicable but flexible process to guide health research capacity strengthening that could be customized for different contexts, and to provide a framework for planning, collecting information, making decisions, and improving performance. They used peer-reviewed and grey literature to develop a five-step pathway for designing and evaluating health research capacity strengthening programmes, tested in a variety of contexts in Africa. The five steps are: i) defining the goal of the capacity strengthening effort, ii) describing the optimal capacity needed to achieve the goal, iii) determining the existing capacity gaps compared to the optimum, iv) devising an action plan to fill the gaps and associated indicators of change, and v) adapting the plan and indicators as the programme matures. The five-step pathway starts with a clear goal and objectives, making explicit the capacity required to achieve the goal. Strategies for promoting sustainability are agreed with partners and incorporated from the outset. The pathway for designing capacity strengthening programmes focuses not only on technical, managerial, and financial processes within organisations, but also on the individuals within organisations and the wider system within which organisations are coordinated, financed, and managed.
To identify priority policy issues in access to medicines (ATM) relevant for low- and middle-income countries, to identify research questions that would help address these policy issues, and to prioritize these research questions in a health policy and systems research (HPSR) agenda. The study involved i) country- and regional-level priority-setting exercises performed in 17 countries across five regions, with a desk review of relevant grey and published literature combined with mapping and interviews of national and regional stakeholders; ii) interviews with global-level stakeholders; iii) a scoping of published literature; and iv) a consensus building exercise with global stakeholders which resulted in the formulation and ranking of HPSR questions in the field of ATM. A list of 18 priority policy issues was established following analysis of country-, regional-, and global-level exercises. Eighteen research questions were formulated during the global stakeholders’ meeting and ranked according to four ranking criteria (innovation, impact on health and health systems, equity, and lack of research). The top three research questions were: i) In risk protection schemes, which innovations and policies improve equitable access to and appropriate use of medicines, sustainability of the insurance system, and financial impact on the insured? ii) How can stakeholders use the information available in the system, e.g., price, availability, quality, utilization, registration, procurement, in a transparent way towards improving access and use of medicines? and iii) How do policies and other interventions into private markets, such as information, subsidies, price controls, donation, regulatory mechanisms, promotion practices, etc., impact on access to and appropriate use of medicines?The authors' HPSR agenda adopts a health systems perspective and will guide relevant, innovative research, likely to bear an impact on health, health systems and equity.
Almost any major problem in global health – from discovering new drugs to developing vaccines, to finding solutions to environmental changes that can affect health in vulnerable countries – requires research and innovation solutions that are beyond the scope of individual countries, organisation, or companies. In the case of research and innovation for health, there are few, if any, functional platforms where multiple players can negotiate towards creating constructive solutions, or share global resources better. COHRED outlines opportunities to play a role in the complex array of partners, with attention to Africa, enabling sustainable and usually complex solutions for complex global health problems.
14. Useful Resources
WHO has released a handbook ‘Arguing for UHC', made to support CSOs' advocacy work on health financing for universal health coverage. WHO is happy to share with you the handbook ‘Arguing for UHC', made to support CSOs' advocacy work on health financing for universal health coverage. 'Arguing for Universal Health Coverage' includes basic principles on health financing, country examples and evidence-based arguments to support Civil Society Organizations advocating for health funding policies that promote equity, efficiency and effectiveness, and ensure that the rights of the most vulnerable are not forgotten.
includes basic principles on health financing, country examples and evidence-based arguments to support Civil Society Organizations advocating for health funding policies that promote equity, efficiency and effectiveness, and ensure that the rights of the most vulnerable are not forgotten.
This internal webinar co-hosted by IDS and FHS as part of the FHS webinar series looks at a number of social media tools to support both research and research uptake.
In the Zones Rouges of southern Madagascar, economic opportunities are scarce, as is any presence of the state: the police are particularly absent from most villages. But there are lots of zebu - the country’s distinctive breed of humpbacked cattle. Millions of them. Each worth several hundred US dollars. This walking wealth makes for easy prey for rustlers known as dahalo, who rob and kill with virtual impunity. With no one to turn to for protection, civilians are forming their own vigilante units, called zama. Armed only with crude weapons and denied training or support from the government, they are no match for the dahalo, but this does little to dent their zeal. IRIN’s latest film, The Zebu and the Zama - Bounty and Bloodshed in Southern Madagascar, explores a vicious cycle of violence in which the dahalo murder those who get in the way and the zama mete out deadly “justice” on those they suspect of banditry.
15. Jobs and Announcements
The 10th anniversary of the Public Health Association of South Africa (PHASA) conference will be celebrated with the hosting of the conference in Polokwane (Limpopo) from 3 to 6 September 2014. The workshops will take place on the 3rd, the actual conference on the 4th and 5th, and the student symposium on the 6th of September.
The Third Global Symposium on Health Systems Research (HSR) is to be held from 30 September – 3 October 2014 in Cape Town, South Africa (http://hsr2014.healthsystemsresearch.org/). This is the first time this Symposium has been held in Africa. The theme of the 2014 symposium is: the science and practice of people–centred health systems. The involvement of people both in their own health decisions and in those concerning the development of a health system is a vital platform for effective service delivery and for ensuring the health system offers wider value in society.
The opening plenary (on 30th September 2014) will have a specific African focus – and its theme is governance and health in Africa. As part of this opening ceremony the organisers would like to feature different voices from the African continent and provide African stakeholders with an opportunity to share their perspective on the theme of the symposium. They would like you to identify a stakeholder whose voice you feel would be important to feature in the opening plenary and to record a short interview with them. It could be someone you work closely with – such as a health worker, a researcher, a community member or a client or user of the health service. Someone that you feel represents a critical constituency from the African continent. Depending on the volume and quality of material received we will seek to project the clips at other moments during the conference, and also post them on the conference website.
AAPS 2014 will focus on the central themes and problems of African urbanization. While the conference is focused on sub-Saharan Africa, the discussion will be extended to other contexts in the global South. The AAPS 2014 Conference will feature keynote presentations from a number of international experts on cities and urbanization in Africa and the global South, including Edgar Pieterse (African Centre for Cities) and Colin MacFarlane (Durham University). The conference is aimed at urban planning educators, researchers and practitioners seeking to enhance their knowledge of the contemporary issues and debates surrounding African and Southern cities and urbanization. It will also appeal to other built environment professionals, as well as academics in related disciplines with an interest in urban issues.
The Council for the Development of Social Science Research in Africa (CODESRIA) is pleased to announce the 2014 session of its annual Democratic Governance Institute. The theme is: Building more resilient societies: human security and risk management in Africa. CODESRIA researchers to submit their applications for participation in this institute.
The Council for the Development of Social Science Research in Africa (CODESRIA) is pleased to announce the 2014 session of an initiative targeted at those members of the African social research community who, in their universities, are responsible for teaching social science research methods at the undergraduate and graduate levels. In cognisance of the multi-faceted crises confronting the African higher education system in general and the universities in particular, CODESRIA has invested itself in offering platforms for postgraduate students and mid-career professionals to be offered opportunities for training in quantitative and qualitative research methods. The first tranche of such training opportunities centred on quantitative research methods. Over the last few years, the accent was shifted to qualitative research methods. Organised as advanced research seminars at which participants were exposed to various methodological techniques and their roots in the history and philosophy of science. CODESRIA organises five research methodology workshops every year on the basis of one per sub-region, one specially dedicated to Nigeria and English-speaking countries of West and Central Africa, and one for trainers. This last one brings together researchers who have responsibility for imbuing others with the basic skills they require in order to be successful researchers.
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