As global leaders prepared for the G-20 Summit in Hamburg, they prioritised efforts to build functioning health systems “as a prerequisite for safeguarding disease outbreaks.” This is vital as the world prepares for the next Ebola-like emergency, but the organizational stress that comes with these shifts in priorities also requires attention if those efforts are going to succeed. Any attempt to strengthen health systems must take seriously well-recognized stressors such as increasing workloads, changing health needs, resource challenges, and less-often identified but routine challenges. Critical amongst these are the stresses posed by managing people and relationships in the uncertain contexts that are the norm for health systems.
Introducing new and revised policies is a major part of this chronic stress, even with the best intentions. The constant, and sometimes unconsidered, imposition of new initiatives and ideas on national health systems places great pressure on those working at the front lines of health care delivery and community engagement. Policy changes may include new treatment guidelines and protocols or quality assurance processes, as well as revised human resource and financial management rules, guidance on management structures such as community committees or new planning processes. New policies are often implemented in a top down manner through the hierarchy of public sector bureaucracy. Often, they are implemented without preparation or adequate information sharing. In addition, new policies frequently come hand in hand with rigid accountability mechanisms — such as those linked to results and performance-based financing or to targets set for health programs, or to finance-linked audit processes that are part and parcel of “good governance” strategies.
These types of accountability mechanisms contribute to creating a “compliance culture" that undermines the managerial flexibility needed to problem-solve and deal with chronic stress or acute challenges. All generally come with yet another new reporting requirement. In fact, the amount of reporting done by frontline health workers in countries such as Kenya and South Africa is simply astounding. As a result, health workers battle to cope with changing demands from managers and communities, whilst remaining poorly supported and resourced.
So, what do global leaders need to do to nurture everyday resilience in the face of chronic stress — and so also strengthen health systems?
First, they need to understand that the "personal" is absolutely integral to a functioning and responsive health system. Without emphasis and acknowledgment of this, efforts to strengthen health systems will be futile. Managing human relations is identified by public health system managers in Kenya and South Africa, including primary care clinics, as a constant challenge in their jobs, and one for which they rarely have adequate training, acknowledgment and resources. Constant policy change can undermine relationships, and is part of the wider organizational change commonly experienced by health systems. From the radical devolution of public management in Kenya in 2013, to the continuing processes of change experienced in South Africa since 1994, organizational change creates an unstable environment that makes managing other challenges — of people and resources — even more difficult.
Second, and most critically, global leaders must pay attention to how they engage with health systems. They should exercise their power much more cautiously than currently and in ways that empower others to lead and take action. They need to support national and local organizational capacity to problem-solve, motivate, and learn. The “Thinking and Working Politically” and “Doing Development Differently” networks call wholeheartedly for global leaders to take heed, by refraining from imposing rigid blueprint approaches and paying “far more attention to issues of power, politics and local context.” Ultimately, strong health systems depend on communities, health workers, managers, researchers and other local stakeholders being empowered to respond to the inevitable, future waves of change we all face. At Health Systems Global, our members represent these multiple groups.
Strengthening everyday resilience demands that we all — governments, donors, researchers, communities, health professionals — work with the resources that health systems already have — their people and relationships. This must be done as we take wider action to confront inequality at all levels. If we do not do that, then efforts to safeguard disease outbreaks will be meaningless.
This oped was originally produced as a blog for the G20 summit in July 2017 and was published on the Devex website and the Resilient & Responsive Health Systems (RESYST) website. For further information on this research programme visit http://resyst.lshtm.ac.uk/.
1. Editorial
2. Latest Equinet Updates
An Essential Health Benefit (EHB) is a policy intervention designed to direct resources to priority areas of health service delivery to reduce disease burdens and ensure equity in health. Mainland Tanzania’s most recent benefit package – the National Essential Health Care Interventions Package-Tanzania (NEHCIP-TZ) – describes the EHB as a minimum or “limited list of public health and clinical interventions.” The package identifies where priorities are set for improved public health. This report shows the challenges of turning a policy ‘wish list’ and package into a reality of services that can be accessed across different facility levels. This report describes the evolution of mainland Tanzania’s EHB; the motivations for developing the EHBs, the methods used to develop, define and cost them; how it is being disseminated, communicated, and used; and the facilitators (and barriers) to its development, uptake or use. Findings presented in this report are from three stages of analysis: literature review, key informant perspectives and a national consultative meeting. The case study on Tanzania was implemented in a research programme of the EQUINET through Ifakara Health Institute and Training and Research Support Centre. The programme is being implemented in association with the East Central and Southern African Health Community, supported by IDRC (Canada).
The Essential Health Benefit (EHB) policy interventions aim to optimize efficiency while extending coverage by increasing equity of access to the defined benefits. Uganda’s EHB is referred to as the Uganda National Minimum Healthcare Package (UNMHCP) introduced in the 1999 Health Policy. The UNMHCP is composed of cost efficient interventions against diseases or conditions most prevalent in the country. This report compiles evidence from published, grey literature and key informants on the UNMHCP since its introduction in Uganda’s health system, and findings were further validated during a one day national stakeholder meeting. It includes information on the motivations for developing the EHBs, the methods used to develop, define and cost them, and how it has been disseminated, used in budgeting, resourcing and purchasing health services and in monitoring health system performance for accountability. It was implemented in an EQUINET research programme through Ifakara Health Institute and Training and Research Support Centre, in association with the ECSA Health Community, supported by IDRC (Canada).
The new “Participatory Action Research Portal” for resources on Participatory Action Research (PAR) is now live on the EQUINET website. The portal has a homepage and a series of ‘subpages’ for Training, resources - which will provide links to online training courses, whole training guides and reports of training activities; Methods, tools and ethics - which will provide links to online specific papers on PAR methods, to specific examples of tools, and to discussions/ guidelines on ethical issues; PAR work – which will provide links to stories, case studies, briefs, videos, text or photojournalism stories of PAR work, including facilitator reflections; Organisations and networks - which will provide the name, snippet of information, country and link to organisations and networks involved PAR; Publications - which will provide published journal papers and reports on PAR through links to the urls or on the EQUINET database; and Other - which will provide ad hoc information that doesn’t fit anywhere else. The portal is a resource for all those working with PAR and includes resources in any language. There is a form for people to send videos, photojournalism, organisations, journal papers, training guides and other resources for the portal. The url link shown here is in English but there is also a Spanish version at http://www.equinetafrica.org/content/portal-de-recursos-para-la-investigaci%C3%B3n-acci%C3%B3n-participativa-iap
3. Equity in Health
This brief summarizes key findings from the UNRISD research project Towards Universal Social Security in Emerging Economies. The project analysed the efforts of selected emerging economies to move towards universal provision of health care. The brief provides a comparative analysis of the political, economic and social drivers of, and constraints on, the extension of health care service for all and draws out the implications for poverty reduction, equity, growth and democracy. The brief identifies the following factors enabling universalisation: facilitating an empowered civil society, working together with government; political will, institutional capacity and political support for reform to create fiscal space for universal health care; democratic mechanisms to build consensus between different interest groups and maintain reform momentum; strategies to reduce resistance in and from the private sector; comprehensive and coherent national framework for health care, with mechanisms to ensure vertical coherence of policies between different levels of government; and tax- financed health care systems. An overarching finding emerges from the successful cases of the universalisation of health care observed in this UNRISD research: they all adopted integrated approaches that can promote synergies between health and non- health sectors; equally the contestation and consensus that reforms for universal health care entailed were not limited to the health sector alone. Health is interconnected with other areas of social, economic and environmental well- being, so the expansion of health care systems must happen alongside efforts to address the determinants of health that lie beyond the health sector.
Progress in reproductive, maternal, newborn, and child health (RMNCH) in Kenya has been inconsistent over the past two decades, despite the global push to foster accountability, reduce child mortality, and improve maternal health in an equitable manner. This report provides a comprehensive assessment of RMNCH in Kenya from 1990 to 2015, using data from nationally representative Demographic Health Surveys implemented between 1989 and 2014. The authors estimated time trends for key RMNCH indicators, as defined by Countdown to 2015, at both the national and the sub-national level, explored the determinants of change in intervention coverage during the past decade and modelled the effect of intervention scale up by 2030. After an increase in mortality between 1990 and 2003, there was a reversal in all mortality trends from 2003 onwards, although progress was not substantial enough for Kenya to achieve Millennium Development Goal targets 4 or 5. Between 1990 and 2015, maternal mortality declined at half the rate of under-5 mortality, and changes in neonatal mortality were even slower. National-level trends in intervention coverage have improved, although some geographical inequities remain, especially for counties comprising the northeastern, eastern, and northern Rift Valley regions. Disaggregation of intervention coverage by wealth quintile also revealed wide inequities for several health service interventions, such as skilled birth assistance. Maternal literacy and family size were found to be important drivers of positive change in key interventions across the continuum of care. The analysis highlighted the importance of quality of care around birth for maternal and newborn survival, and for targeting poor households and least educated and rural women, through the scale-up of community-level interventions, to improve equity and accelerate progress.
4. Values, Policies and Rights
All roads lead to universal health coverage—and this is the top priority at WHO, Dr Ghebreyesus the WHO director general has asserted. The key question of universal health coverage is an ethical one. Should fellow citizens die because they are poor? Or should millions of families be impoverished by catastrophic health expenditures because they lack financial risk protection? Universal health coverage is a human right. The world has agreed on universal health coverage in Sustainable Development Goal 3.8. He asserts that universal health coverage is ultimately a political choice and responsibility of every country and national government. Countries have unique needs, and tailored political negotiations will determine domestic resource mobilisation. He indicates that WHO will catalyse proactive engagement and advocacy with global, regional, and national political structures and leaders including heads of state and national parliaments. Beyond benchmarking, countries learn from their peers, especially those they see as having similar political or economic contexts. WHO will thus document best practices in universal health coverage at the country level. Once this learning has occurred, countries may request technical assistance and WHO should be prepared to provide technical assistance to countries based on their specific needs, across the full range of health-related Sustainable Development Goals. He further posits that universal health coverage and health emergencies are cousins—two sides of the same coin. Strengthening health systems is the best way to safeguard against health crises. Outbreaks are inevitable, but epidemics are not and strong health systems are the best defence to prevent disease outbreaks from becoming epidemics. Achieving universal health coverage will require innovation. Given that what is measured is managed, data matters and WHO will track progress on how the world is meeting the health-related Sustainable Development Goal indicators. Finally he observes that universal health coverage is not an end in itself: its goal is to improve all health-related Sustainable Development Goals.
Environmental health risks especially affect women and children, because they are more vulnerable socially and because exposures to environmental contaminants create greater risks for children’s developing bodies and cognitive functions. According to the 2016 World Health Organisation (WHO) estimates, modifiable environmental risk factors cause about 1.7 million deaths in children younger than five years and 12.6 million total deaths every year. The sustainable development goals (SDGs) offer opportunities for countries to create healthier environments for women, children and adolescents. This paper explores how the SDGs can be used to reduce environmental health risks and enhance the health of women, children and adolescents. In particular, the authors focus on drivers for urbanisation and sustainable development (e.g. transport, housing, urban design and energy provision) that can advance the global strategy, but have not traditionally been a focus of health policy-making. They frame the discussion around the three pillars of the global strategy: survive, thrive and transform, while recognising the inevitable overlap between these objectives.
At the 70th World Health Assembly, the “BRICS countries” – Brazil, the Russian Federation, India, China and South Africa – convened a side event sponsored by China. The aim was to share experiences and innovations on people-centred reforms as a means to making progress towards universal health coverage, The Executive Deputy Director, Office of State Council Healthcare Reform Leading Group in China, Dr Liang Wannian highlighted the importance the Chinese government has placed on providing improved primary health services, by transforming the primary service model and enhancing division and cooperation to build an integrated health service system. For Brazil, Mr Ricardo Barros, Minister of Health shared the aspiration that “what we want is to have 80% of problems resolved in primary-level care so that people don’t need to go to the hospital”. He noted that “(delivering) primary-level care is the great challenge that we have” and that although “we have resources available for health, we don’t use them very wisely, so we are trying to improve that.” Dr Veronika Skvortsova, Minister of Health of the Russian Federation also highlighted the important role of designing a patient-focused system for health care based on accessibility and quality. For India, Mr Sanjeev Kumar, Additional Secretary, Ministry of Health and Family Welfare highlighted that the country had adopted a new national policy linked to universal health coverage in March 2017. Dr Aaron Motsoaledi, Minister of Health of South Africa, concluded the series of country presentations by returning the conversation to the importance of reorienting the model of care to focus on primary care. He shared South Africa’s “ideal clinic” innovation, which encourages the development of more attractive primary care clinics to draw patients away from tertiary care centres.
Instead of being locked in crowded camps surrounded by barbed wire, the 1.2 million refugees in Uganda are given large plots of land in sprawling settlements to build homes or, if they like, small farms. If agrarian life isn’t for them, they can move freely around the country, traveling to towns or to the bustling capital of Kampala, which 95,000 refugees call their home. The distinguished scholar and humanitarian activist Noam Chomsky characterizes European attitudes towards refugees “[as] among the signs of the severe moral-cultural crisis of the West that is mislabeled a ‘refugee crisis.’” The five wealthiest countries [the U.S., China, Japan, the U.K. and Germany]— which make up half the global economy — are hosting less than 5 percent of the world’s refugees, while 86 percent of refugees are in poorer developing countries that are often struggling to meet the needs of their own people. The authors argues that Uganda points the way forward and that the country is a good model for compassionate hospitality towards refugees. It is however noted that the country is reaching a breaking point due to increasing demands for accommodation of the large numbers of refugees. What was promised for Uganda from external funders at the 2016 high level summit in New York has not been forthcoming. Supporting viable resettlement programs and working towards durable solutions is argued to be the only way to resolve the crisis. This involves using leverage to promote human rights and good governance in refugee producing countries.
5. Health equity in economic and trade policies
The report Honest Accounts 2017: how the world profits from Africa’s wealth explores how Africa’s wealth is effectively “stolen” from the continent and “calculates the movement of financial resources into and out of Africa and some key costs imposed on Africa by the rest of the world”. Nick Dearden, director of Global Justice Now, writes that although there is money coming into the continent in the form of remittances, there is a larger amount leaving the continent in the form of taxes, “repatriate[d]” profits and illegal trade. A 2014 estimate suggests that rich Africans were holding a massive $500-billion in tax havens. Africa’s people are effectively robbed of wealth by an economy that enables a tiny minority of Africans to get rich by allowing wealth to flow out of Africa. With few exceptions, countries with abundant mineral wealth experience poorer democracy, weaker economic growth, and worse development. The author raises that to prevent tax dodging, governments must stop prevaricating on action to address tax havens.
This article is based upon data gathered during a study conducted in partnership with the World Intellectual Property Organisation on the patent status of products appearing on the World Health Organisation’s 2013 Model List of Essential Medicines (MLEM). It is a statistical analysis aimed at answering: in which developing countries are patents on essential medicines being filed? Patent data were collected by linking those listed in the United States and Canada’s medicine patent registers to corresponding patents in developing countries using two international patent databases (INPADOC and Derwent) via a commercial-grade patent search platform (Thomson Innovation). The respective supplier companies were then contacted to correct and verify their data. The authors tallied the number of MLEM patents per developing country. A subset of 20 of the 375 (5%) products on the 2013 MLEM fit the inclusion criteria. The number of MLEM patents per country was positively associated with human development index (HDI), gross domestic income (GDI) per capita, total healthcare expenditure per capita, population size, the Rule of Law Index, and average education level of the country. Population was a powerful predictor of the number of patent filings in developing countries along with GDI and healthcare expenditure. Broad surveillance and benchmarking of the global medicine patent landscape is valuable for detecting significant shifts that may occur over time. With improved international medicine patent transparency by companies and data available through third parties, the authors suggest that studies such as this will be increasingly feasible.
6. Poverty and health
Gender-based violence (GBV) represents a major cause of psychological morbidity worldwide, and particularly in low- and middle-income countries). Although there are effective treatments for common mental disorders associated with GBV, they typically require lengthy treatment programs that may limit scaling up in low- and middle-income countries. This study tested the effectiveness of a new 5-session behavioural treatment called Problem Management Plus (PM+) that lay community workers can be taught to deliver. In this single-blind, parallel, randomised controlled trial, adult women who had experienced GBV were identified through community screening for psychological distress and impaired functioning in Nairobi, Kenya. Participants were randomly allocated in a 1:1 ratio either to PM+ delivered in the community by lay community health workers provided with 8 days of training or to facility-based enhanced usual care (EUC) provided by community nurses. Participants were aware of treatment allocation, but research assessors were blinded. The primary outcome was psychological distress as measured by the total score on the 12-item General Health Questionnaire (GHQ-12) assessed at 3 months after treatment. Between 15 April 2015 and 20 August 2015, 1,393 women were screened for eligibility on the basis of psychological distress and impaired functioning. Of these, 37% screened positive, of whom 81% were women who had experienced GBV. Of these women, 209 were assigned to PM+ and 212 to EUC. Follow-up assessments were implemented. The study found that among a community sample of women in urban Kenya with a history of GBV, a brief, lay-administered behavioural intervention, compared with EUC, resulted in moderate reductions in psychological distress at 3-month follow-up.
7. Equitable health services
This paper assesses equity in the distribution of health care inputs across public primary health facilities at the district level in Tanzania. It reports a quantitative assessment of equity in the distribution of health care inputs (staff, drugs, medical supplies and equipment) from district to facility level. The study was carried out in three districts (Kinondoni, Singida Rural and Manyoni district) in Tanzania. These districts were selected because they were implementing primary care reforms. The authors administered 729 exit surveys with patients seeking out-patient care; and health facility surveys at 69 facilities in early 2014. The authors found a significant pro-rich distribution of clinical staff and nurses per 1000 population. Facilities with the poorest patients (most remote facilities) have fewer staff per 1000 population than those with the least poor patients (least remote facilities): 0.6 staff per 1000 among the poorest, compared to 0.9 among the least poor; 0.7 staff per 1000 among the most remote facilities compared to 0.9 among the least remote. The negative concentration index for support staff suggests a pro-poor distribution of this cadre but the 45 degree dominated the concentration curve. The distribution of vaccines, antibiotics, anti-diarrhoeal, anti-malarials and medical supplies was approximately proportional (non dominance), whereas the distribution of oxytocics, anti-retroviral therapy (ART) and anti-hypertensive drugs was pro-rich, with the 45 degree line dominating the concentration curve for ART. This study has shown there are inequities in the distribution of health care inputs across public primary care facilities. This highlights the need to ensure a better coordinated and equitable distribution of inputs through regular monitoring of the availability of health care inputs and strengthening of reporting systems.
In some low- and middle-income countries, the national stores and public-sector health facilities contain large stocks of pharmaceuticals that are past their expiry dates. In low-income countries like Uganda, many such stockpiles are the result of donations. If not adequately monitored or regulated, expired pharmaceuticals may be repackaged and sold as counterfeits or be dumped without any thought of the potential environmental damage. The rates of pharmaceutical expiry in the supply chain need to be reduced and the disposal of expired pharmaceuticals needs to be made both timely and safe. Many low- and middle-income countries need to: strengthen public systems for medicines’ management, to improve inventory control and the reliability of procurement forecasts; reduce stress on central medical stores, through liberalisation and reimbursement schemes; strengthen the regulation of drug donations; explore the salvage of officially expired pharmaceuticals, through re-analysis and possible shelf-life extension; strengthen the enforcement of regulations on safe drug disposal; invest in an infrastructure for such disposal, perhaps based on ultra-high-temperature incinerators; and include user accountability for expired pharmaceuticals within the routine accountability regimes followed by the public health sector.
This study analysed factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries. The authors pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006-2014). Based on World Health Organisation protocols, the authors created indices of process quality for antenatal care (first visits) and for sick-child visits. They assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service. Data were available for 2594 and 11 402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% of eight recommended antenatal care actions and 54.5% of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined. The quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care
8. Human Resources
Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the difficulty in retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians, medical licentiates, trained initially to the level of a higher diploma and from 2013 up to a Bachelor of Science degree. Medical licentiates have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations. This qualitative study aimed to describe the role, contributions and challenges surgically active medical licentiates have experienced. Based on 43 interviewees, it includes the perspective of medical licentiates, their district hospital colleagues—medical officers, nurses and managers; and surgeon-supervisors and national stakeholders. In Zambia, medical licentiates play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with medical officers, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, medical licentiates often face professional recognition problems and tensions around relationships with medical officers that impact their ability to utilise their surgical skills. The paper provides new evidence concerning the benefits of ‘task shifting’ and identifies challenges that need to be addressed if medical licentiates are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use non-physician clinicians to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.
Uganda’s national community health worker program involves volunteer Village Health Teams (VHTs) delivering basic health services and education. Evidence demonstrates their positive impact on health outcomes, particularly for Ugandans who would otherwise lack access to health services. Despite their impact, VHTs are not optimally supported and attrition is a growing problem. In this study, the authors examined the support needs and existing challenges of VHTs in two Ugandan districts and evaluated specific factors associated with long-term retention. The authors reported on findings from a standardised survey of VHTs and exploratory interviews with key stakeholders and draw conclusions that inform efforts to strengthen and sustain community health care delivery in Uganda. A mixed-methods approach was employed through a survey of 134 individual VHT members and semi-structured interviews with six key stakeholders. Descriptive and bivariate regression analysis of quantitative survey data was performed along with thematic analysis of qualitative data from surveys and interviews. In the regression analysis, the dependent variable is 10-year anticipated longevity among VHTs, which asked respondents if they anticipate continuing to volunteer as VHTs for at least 10 more years if their current situation remains unchanged. VHTs desire additional support primarily in the forms of money (for example transportation allowance) and material supplies (for example rubber boots). VHTs commonly report difficult working conditions and describe a lack of respect from their communities and other health workers. If their current situation remains unchanged, 57% of VHTs anticipate remaining in their posts for at least 10 years. Anticipated 10-year longevity was positively associated with stronger partnerships with local health centre staff and greater ease in home visiting. The authors note that supporting and retaining Uganda’s VHTs would be enhanced by building stronger partnerships between VHTs and other health workers and regularly providing supplies and transportation allowances. Pursuing such measures would likely improve equity in access to healthcare for all Ugandans.
Studies have shown the contribution that supportive supervision can make to improving job satisfaction amongst over-stretched health workers in in resource-constrained settings. The Support, Train and Empower Managers study designed and implemented a supportive supervision intervention and measured its’ impact on health workers using a controlled trial design with a three-arm pre- and post-study in Niassa Province in Mozambique. Post-intervention interviews with a small sample of health workers were also conducted. The quantitative measurements of job satisfaction, emotional exhaustion and work engagement showed no statistically significant differences between end-line and baseline. The qualitative data collected from health workers post the intervention showed many positive impacts on health workers not captured by this quantitative survey. Health workers perceived an improvement in their performance and attributed this to the supportive supervision they had received from their supervisors following the intervention. Reports of increased motivation were also common. An unexpected, yet important consequence of the intervention, which participants directly attributed to the supervision intervention, was the increase in participation and voice amongst health workers in intervention facilities.
9. Public-Private Mix
The author argues that social protection systems that are based on solidarity, sharing of risks, and built on collective bargaining and social dialogue, democratic structures and long-term strategies are needed to combat poverty and address inequalities and inequity. Universal social protection is essential to achieve gender equality, given a strong link between the provision of public services and the ability of women to enter the labour market, to address unpaid care work responsibilities and to ensure that children have access to health and social services. The push for the individualisation of social protection is reported to have had a major impact on the delivery of these services, including on the provision of health and social care, pensions and unemployment benefits, to which austerity programmes have added perverse effects that lead to social exclusion or risk exposure – instead of inclusion and protection. Genuine support for universal social security and healthcare could thus, he argues, make important contributions to the achievement of decent work and reduced inequality. However, the international financial institutions (IFIs) continue to promote social protection reforms that focus on targeting, which is less efficient and more costly, rather than broad coverage. Reforms promoted by the World Bank, IFC and Regional Development Banks, including marketisation, decentralisation and corporatization of the public sector, provide opportunities for multinational companies to enter the public health care sector. In addition, public health spending is coming under increasing scrutiny across the world, particularly since the 2008-2009 global financial and economic crisis. Cuts to public sector funding often penalise health workers and lead to reduced services at a time when demand for such services is increasing, as the economic crisis impacts on the wider economy. The author thus argues that the main policy tools in the orthodox approach to health sector financing risk being counter-productive. Efforts to reduce costs by increasing competition have created fragmented structures that work against the integration and coordination of healthcare. Bringing in the private sector is likely to accentuate this silo mentality in provision, in the name of commercial confidentiality and profit maximisation.
The author raises that South Africa has limited data on what grant making takes place and on the size and scope of the civil society sector, despite a a dependency on international funding and support from private philanthropic foundations. According to Nedbank Private Wealth’s Giving Report III, however, only 5% of the high net worth individuals surveyed had actually established a giving trust or foundation. That meant that the balance were giving money on an ad hoc basis. The same report indicated that South African givers “demonstrated a long-term commitment to the causes they support. Nearly half had supported beneficiaries for longer than five years (and) 22% had been supporting them for their entire lives. The author suggests that in principle, philanthropy should be focusing on organisations that are involved in systemic change and government should be supporting those organisations that deal with basic human requirements. In that case, non-profits are unlikely to be greatly affected by recession. However, that does not apply in South Africa where philanthropy is being stretched to its limits by the high level of needs not being met by the state. The choice of where limited resources can go is a hard one, but it is argued that those donating funds will support those organisations that are aligned with their individual passions for specific causes and their values, combined with effective and efficient outcomes.
10. Resource allocation and health financing
Total domestic and international funding for malaria is inadequate to achieve WHO global targets by 2030. The authors describe the trends of investments in malaria-related research in sub-Saharan Africa and compare investment with the national disease burden to identify areas of funding strength and potentially neglected populations, including that for malaria control. Research funding data related to malaria for 1997–2013 were sourced from existing datasets, from 13 major public and philanthropic global health funders, and from funding databases. Investments (reported in US$) were considered by geographical area and compared with data on parasite prevalence and populations at risk in sub Saharan Africa. 45 sub-Saharan African countries were ranked by amount of research funding received. The authors found 333 research awards totalling US$814.4 million. Public health research covered $308.1 million (37.8%) and clinical trials covered $275.2 million (33.8%). Tanzania ($107.8 million [13.2%]), Uganda ($97.9 million [12.0%]), and Kenya ($92.9 million [11.4%]) received the highest sum of research investment and the most research awards. Malawi, Tanzania, and Uganda remained highly ranked after adjusting for national gross domestic product. Countries with a reasonably high malaria burden that received little research investment or funding for malaria control included Central African Republic (ranked 40th) and Sierra Leone (ranked 35th). Congo (Brazzaville) and Guinea had reasonably high malaria mortality, yet received little investment. Some countries receive reasonably large investments in malaria-related research (Tanzania, Kenya, Uganda), whereas others receive little or no investments (Sierra Leone, Central African Republic). Research investments are typically highest in countries where funding for malaria control is also high. The authors suggest that investment strategies should consider more equitable research and operational investments across countries to include currently neglected and susceptible populations.
The purchasing function of health financing is gaining increasing attention and traction in global health systems and universal health coverage (UHC) debates, which have, in the past, focused predominantly on revenue collection and pooling. A recent workshop convened by the World Health Organisation on strategic purchasing. In the blog, the author summarises seven key messages from the workshop that are likely to feature in future discussions on strategic purchasing. Purchasing refers to the process by which funds are allocated to healthcare providers to obtain services on behalf of identified groups. Strategic purchasing is a continuous search for the best ways to maximise health system performance, by deciding which interventions should be purchased, how, and from whom. It is typically considered from the point of view of the purchaser. However, by looking at it from the perspective of healthcare facilities, a complex picture of multiple purchasers and funding flows emerges. A key responsibility of healthcare purchasers is in deciding what to include in the benefit package for health. However, decisions about priority setting are often neglected in this process. The governance boards of many purchasing organisations, such as social health insurers, include representatives from the government, employers (e.g. an umbrella employer association) and employees (labour unions). However, in most low and middle income countries, a significant proportion of the population work in the informal sector. They do not belong to the labour unions, and do not have formal employers to represent them on such boards. A further governance issue is the perennial problem regarding oversight of purchasers that are separate entities from the Ministry of health, such as social health insurers. Strategic purchasing cannot occur in the absence of good quality data. Often information systems are fragmented, presenting a partial view of the system. While it was appreciated that Results Based Financing (RBF) can contribute to strategic purchasing and act as a catalyst for health system reform, there is a need to ensure that RBF mechanisms are embedded and integrated within the wider health system. Strategic purchasing is argued to be not just a technical issue, but also a political issue.
The SDG Health Price Tag estimates the costs and benefits of progressively expanding health services in order to reach 16 Sustainable Development Goal (SDG) health targets in 67 low- and middle-income countries that account for 75% of the world’s population. The analysis shows that investments to expand services towards universal health coverage and the other SDG health targets could prevent 97 million premature deaths globally between now and 2030, and add as much as 8.4 years of life expectancy in some countries. While most countries can afford the investments needed, the poorest nations will need assistance to reach the targets. The SDG Health Price Tag models two scenarios: an “ambitious” scenario in which investments are sufficient for countries to attain the health targets in the SDGs by 2030, and a “progress” scenario in which countries get two thirds or more of the way to the targets. These investments would boost health spending as a proportion of gross domestic product across all 67 countries from an average of 5.6% to 7.5%. The global average for health spending as a proportion of GDP is 9.9%. Although higher spending does not necessarily translate to improved health, making the right investments at the right time can. The SDG Health Price Tag does not prescribe what countries should spend on health, but is intended as a tool to inform further research. It also highlights that achieving universal health coverage and the other health targets requires not only funding but political will and respect for human rights. WHO plans to update the estimates every five years and will include other health-related targets and diseases as more evidence becomes available.
11. Equity and HIV/AIDS
This guide is one of a series of good practice guides, and contains information, strategies and resources to help HIV programmers implement HIV programming for adolescents. Adolescents are now included as a separate target group in global and national strategies. Increased access to HIV testing and treatment means that, more than ever, adolescents living with HIV know their status and are living longer on antiretroviral therapy (ART). Much more work is needed, however, to meet adolescents’ needs for prevention, care, treatment and support services. Barriers to access, poor uptake of both prevention and treatment services, stigma and discrimination, as well as challenges with adherence to treatment contribute significantly to HIV-related morbidity and mortality among adolescents. This Good Practice Guide contains information, strategies and resources to help programmers meet the standards for Alliance HIV programming for adolescents. Implementing these standards is one of the ways that the Alliance, our partners and other organisations define and promote a unified and quality-driven approach to HIV programming.
Couples’ HIV testing and counselling (CHTC) is associated with greater engagement with HIV prevention and care than individual testing and is cost-effective, but uptake remains suboptimal. The authors aimed in this work to determine the impact of incentives for CHTC on uptake of couples testing and HIV case diagnosis in rural Zimbabwe. 68 rural communities (the clusters) in four districts receiving mobile HIV testing services were randomly assigned to incentives for CHTC or not. Allocation was not masked to participants and researchers. Randomisation was stratified by district and proximity to a health facility. Within each stratum random permutation was done to allocate clusters to the study groups. In intervention communities, residents were informed that couples who tested together could select one of three grocery items worth US$1·50. Standard mobilisation for testing was done in comparison communities. The primary outcome was the proportion of individuals testing with a partner. Analysis was by intention to treat. 3 months after CHTC, couple-testers from four communities per group individually completed a telephone survey to evaluate any social harms resulting from incentives or CHTC. The study indicated that small non-monetary incentives, which are potentially scalable, were associated with significantly increased CHTC and HIV case diagnosis. Incentives did not increase social harms beyond the few typically encountered with CHTC without incentives. The authors suggest that the intervention could help achieve UNAIDS 90-90-90 targets.
12. Governance and participation in health
This study explored how community-based initiatives address the critical health literacy of older adults and their communities. A systematic literature search was conducted. Two reviewers independently screened titles and abstracts, as well as the quality of the methodological and community-based elements of the studies. In addition, a meta-synthesis was carried out, consisting of a qualitative text analysis of the results sections of the 23 included studies. The authors identified two main themes, which are practices that contribute to the critical health literacy of older adults as well as their communities: collaborative learning, and social support. In these practices they identified reciprocity as a key characteristic of both co-learning and social support. This study provides the first overview of community-based initiatives that implicitly address the critical health literacy of adults and their community. The results demonstrate that in the context of one’s own life collaborative learning and social support could contribute to people’s understanding and ability to judge, sift and use health information. The authors therefore suggest to add these two practices to the definition of critical health literacy.
The Forum on Internet Freedom in Africa convened stakeholders in end September 2017 from the internet governance and online rights arenas in Africa and beyond to deliberate on gaps, concerns and opportunities for advancing the right to privacy, access to information, free expression, non-discrimination, and the free flow of information online. The Forum gathered human rights defenders, journalists, government officials, private sector players, global information intermediaries, bloggers, developers, the arts community, law enforcers and regulators – all of whom have a role to play in advancing internet freedom in Africa. Highlights at FIFAfrica include the launch of the annual State of Internet Freedom in Africa research report, as well the commemoration of the International Day for Universal Access to Information (IDUAI), which falls on September 28. Further information, thoughts and ideas can be found at the #InternetFreedomAfrica hashtag.
Citizen-based accountability strategies to improve the lives of the poor and marginalised groups are increasingly being used in efforts to improve basic public services. The latest thinking suggests that broader, multi-pronged, multi-level, strategic approaches that may overcome the limitations of narrow, localised successes, hold more promise. This paper examines the challenges and opportunities, in theory and practice, posed by the integration of two such citizen-based accountability strategies—social accountability and legal empowerment. It traces the foundations of each of these approaches to highlight the potential benefits of integration. Consequently it examines whether these benefits have been realised in practice, by drawing upon five cases of organisations pursuing integration of social accountability and legal empowerment for health accountability in Macedonia, Guatemala, Uganda, and India. The cases highlight that while integration offers some promise in advancing the cause of social change, it also poses challenges for organisations in terms of strategies they pursue.
This introductory paper to a series suggests that rather than seeing governance as a normative health system goal addressed through the architecture and design of accountability and regulatory frameworks, it should be located in the real-world decision-making of health policy and system actors. Their multiple, routine decisions translate policy intentions into practice - and are filtered through relationships, underpinned by values and norms, influenced by organizational structures and resources, and embedded in historical and socio-political contexts. These decisions are also political acts - in that they influence who accesses benefits and whose voices are heard in decision-making, reinforcing or challenging existing institutional exclusion and power inequalities. In other words, the everyday practice of governance has direct impacts on health system equity. Analysis of governance can be viewed through diverse health policy and system issues, considers actors located at multiple levels of the system and draws on multi-disciplinary perspectives. This article introduces papers that present detailed examination of experiences in a range of African and Indian settings, led by authors who live and work in these settings, providing an empirical and embedded research perspective on governance and equity in health systems.
13. Monitoring equity and research policy
It is 20 years since an international consultation in Lejondal, Sweden, highlighted the need for more and better research “to understand and improve how societies organize themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes to contribute to policy outcomes.” One outcome was the creation of the Alliance for Health Policy and Systems Research. There have since been several important milestones on the path towards more and better health systems research. Such encouraging developments need to be carefully balanced against areas where progress has not met expectations. The development of national capacity for financing and institutional leadership of health policy and systems research has been slow. The authors ask: how can health policy and systems research seize this favourable context and contribute more effectively to universal health coverage, greater health security, improved value in health and effective engagement of citizens? First, they propose that there is a need a comprehensive review of the progress that has been made and the progress that might be anticipated in the future. Second, there is a need to accelerate the development of capacity and opportunity for health policy and systems research in low- and middle-income countries. Lastly, they suggest that there is a need for a revitalised approach to stewardship that reflects the pluralistic reality of contemporary health systems and prioritises health policy and systems research across all countries.
This report aims to provide guidance to governments, institutions, and development partners on how to approach the provision of advanced information and communication technology (ICT) services to the higher education and research community in Africa. It coincides with a transformation in the telecom infrastructure and services on the continent as fibre optic connectivity, both undersea and on land, is expanding at a rapid pace. The report suggests that the organisation of ICT services and connectivity is best provided by a dedicated organisation called the National Research and Education Network (NREN) based on international best practice and the current plans of the stakeholders in the region. The nature of NRENs and the case for their establishment is outlined and the story of their development in Africa to their current status is described. The report also provides guidance on how to establish or strengthen an NREN, with recommendations to the government, the private sector, institutions, development partners.
14. Useful Resources
This guide includes case studies, tips, photographs, training materials and an accompanying video on implementing community-based HIV-prevention services. Each chapter focuses on a different aspect of implementation, from engaging with stakeholders and communities to how to set up teams and conduct HIV testing services that integrate important other services including screening for TB, sexually transmitted infections and non-communicable diseases.
This manual provides an accessible, practical reference to encourage and strengthen the practice of health inequality monitoring. It aims to foster regular reporting of inequalities across diverse health topics, and promote greater integration of health inequality considerations in policies, programmes and practices. It is organised according to a flow chart, showing the steps and sub-steps of the health inequality monitoring cycle, with key questions and itemised checklists of data requirements, analysis/reporting activities and/or decision points. The steps include firstly, determining the scope of monitoring, obtaining data, then analysing and reporting results before implementing changes. Relevant examples and resources, including sample table templates and recommended readings, are provided for further exploration. While the manual focuses on health at the national level, the step-by-step approach may be applied to monitor inequalities within any defined population, ranging from a community context to a multi-country context.
15. Jobs and Announcements
A 2 day Master class will be held on Defending Medical Malpractice and professional Negligence Cases scheduled for 29-30 November, 2017 in Randburg, Johannesburg, RSA. Medical malpractice liability is incurred when patients suffer damages, which may be attributed to sub-standard care provided by health practitioners or hospital personnel involved in their treatment. This master class aims to provide a sound knowledge of the legal rules applicable to the practice and administration of healthcare. The master class covers legal relationships of physicians and patients down to legal terms, professional attitudes, and the principles and basic concepts of laws involved in providing medical services. For further information contact SECOLO. For further information contact info@secolo.co.za.
The Global Symposium on Health Systems Research is organised every two years by Health Systems Global to bring together the full range of players involved in health systems and policy research and practice. The Alma Ata vision of ‘Health for All’ remains as compelling today as it was in 1978, as reflected in goal 3 of the Sustainable Development Goals (SDGs). But the world has changed in forty years. Despite improved health outcomes, there remain extraordinary challenges for health equity and social inclusion, such as demographic and disease transitions, conflicts and their subsequent migrations, pluralistic health systems and markets, and climate change. Political systems still marginalise those most in need. Yet there are new opportunities for health systems to achieve universal coverage. The Fifth Global Symposium will advance conversations and collaborations on new ways of financing health; delivering services; and engaging the health workforce, new social and political alliances, and new applications of technologies to promote health for all.
SolidarMed is a leading non-profit organization working to improve the health of people in rural Sub Saharan Africa. Working together with national partners to strengthen health systems and community capacities, it is committed to scientific evidence and policy dialogue. They are offering an position for an experienced Project Manager as Child Health Project Manager Ancuabe, Moçambique in the Moçambique team. For this key position, they are looking for a well-grounded and experienced professional with strong interpersonal and management skills and an academic background in medical sciences and/or public health.
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