This paper presents the findings of research conducted under a wider two-year project (2012-14) that examined the role of African agency in global and south-south health diplomacy in addressing selected key challenges to health and health systems in east and southern Africa (ESA). This research synthesis draws from two desk reviews and a content analysis of three case studies on: (i) the involvement of African actors in global health governance on financing for health systems; (ii) overcoming bottlenecks to local medicine production, including through south-south co-operation; and (iii) health worker migration and the implementation of the World Health Organisation (WHO) Global Code of Practice on the International Recruitment of Health Personnel. Based on the content analysis, the paper reviews evidence on African intervention in four key areas of health diplomacy: agenda setting, policy development, policy selection and negotiation and implementation. The evidence highlights the political and complex nature of global health diplomacy. Effective engagement is enabled in ESA by political leadership and champions with clearly articulated policy positions, regional interaction and unified platforms across African countries and good communication between sectors within countries, between national actors and embassies and with allies in the international community. Negotiators’ understanding of issues and access to credible evidence mattered in policy development and selection. Technical actors, the domestic private sector and civil society appeared to play a weak role relative to the influence of development aid. The case studies suggest there is an opportunity cost in framing health diplomacy in the region within a ‘development aid’ paradigm, if the compromises agreed to lead to a dominance of remedial, humanitarian engagement in African international relations on health, with less sustained attention to structural determinants.
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EQUINET September 2009 Conference Resolutions translated into French: Plus de 200 employés gouvernementaux, parlementaires, membres de la société civile, professionnels de santé, chercheurs, universitaires et décideurs, mais aussi les membres des Nations Unies, d’organisations internationales et non-gouvernementales d’Afrique orientale et Australe se sont rassemblés à la troisième Conférence Régionale de EQUINET sur l’Équité en Matière de Santé en Afrique Orientale et Australe, qui s’est tenue du 23 au 25 septembre 2009 au complexe hôtelier de Munyonyo à Kampala. Les délégués ont reconnu des inégalités significatives, grandissantes, évitables et injustes en matière de santé et de ressources de santé dans nos pays, notre région et notre monde. Comme la Commission de l’Organisation Mondiale de la Santé sur les Déterminants Sociaux de la Santé, nous sommes conscients que cette injustice sociale est en train de décimer certaines populations à une grande échelle. Bien que nous ayons dans notre région les ressources de santé nécessaires, nous notons que beaucoup d’entre elles, dont les professionnels de santé, quittent l’Afrique. Nos ressources restantes atteignent par conséquent rarement les personnes les plus démunies. Ceux qui en ont le plus besoin n’y accèdent pas suite aux contraintes économiques, causée par cette inégalité.
The WHO Global Code of Practice on the International Recruitment of Health Personnel (the Code) provides a global architecture that includes ethical norms and institutional and legal arrangements to guide international co-operation on the management of health worker migration and serves as a platform for continuing dialogue. This paper explores how the policy interests of African countries informed the development of the Code and how east and southern African (ESA) countries have used, implemented and monitored the Code. Data were collected using four approaches: literature review, policy dialogue at the 66th World Health Assembly, a regional questionnaire survey and three country studies in Kenya, Malawi and South Africa. Three years after adoption of the Code, the main concerns relating to human resources for health (HRH) in the region were internal migration and absolute shortages of health professionals, rather than external, or out-, migration. The final version of the Code was not perceived to adequately cover African policy interests on compensation and mutuality of benefits. Concern was also expressed about the voluntary nature of the Code. Dissemination and implementation of the Code was lacking in all countries in the region, and only one country had a designated authority. Beyond the shift in policy concerns, barriers to implementation included lack of champions or designated authorities, poor preparedness, weak mobilisation of stakeholders and low involvement of civil society. The authors recommend that negotiations on international instruments should include provisions relating to their implementation, that deliberate efforts should be made to plan for the mechanisms and resources for their implementation after their adoption, and that the involvement of civil society be promoted at all stages.
This review is part of EQUINETs work on contributions of global health diplomacy to health systems in east and southern Africa. It reviews documented literature to examine the extent to which the policy interests of African countries were carried (or not carried) into the Code in the negotiations around the code and the perceived factors affecting this; the extent to which countries in east and southern Africa view and use the Code as an instrument for negotiating foreign policy interests concerning health workers; and the motivations, capabilities and preparations for monitoring the code to engage in the diplomatic environment on African policy interests concerning health workers. The information was analysed using the policy analysis triangle to capture the changing context, processes, content and major actors in the development of the WHO Code, and documentation on its progress and implementation since its adoption. The review discusses the factors behind the relative lull in efforts on the issue of health worker migration following adoption of the Code.
This literature review, implemented within an EQUINET programme of theme work on health workers at the University of Limpopo, presents published evidence on the recruitment and retention of skilled healthcare workers in rural areas of east and southern Africa. It reviewed published documents in English with a focus on east and southern Africa from 2000-2017. From the literature reviewed the following strategies emerged as key for health worker retention: Education and training of healthcare workers; review of regulations and policies regarding provision of healthcare services in rural areas; provision of financial incentives; and personnel and professional support of healthcare workers. The report identified strategies relating to: Reviewing admission policies and criteria for health worker education; including rural practice issues and skills in health worker training and exposing students to rural areas during training; improving access to continuing professional development (CPD) in rural areas; ensuring that compulsory measures are accompanied by relevant support and incentives; ensuring that mitigatory strategies such as task shifting are not ‘task dumping’, do not replace more substantive solutions and that they are accompanied by suitable regulatory systems, training and management support; using financial and non-financial incentives to address issues prioritised by health workers, in a way that does not motivate some while demotivating others, and not as a substitute for a more substantive review of working conditions of healthcare workers and strategies to reduce the disparities in salaries between different health professionals; and improving health worker management and support, and the skills of HRH managers.
This article examines how national health actors in South Africa, Tanzania and Zambia perceive the participatory quality of negotiation processes associated with the performance‐based funding mechanisms of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank. Through analysis of qualitative fieldwork consisting of 101 interviews within the case countries as well as in Geneva and Washington DC, the research results show that African actors within national governments generally set and negotiate performance targets of performance‐based funding schemes. Nevertheless, the results also show that the quality of those negotiations with external funders were inconsistent, suggesting the existence of asymmetrical power and influence in relation to the quality of those negotiations. This raises questions about the level of power and influence being exerted by external funders and how much leverage African political actors have available to them within global health diplomacy. It also provides evidence that certain key aspects of these negotiated processes are closed off from negotiation for African actors, therefore undermining African participation in significant ways.
Zindaba Yiwombe of the Malawi Health Equity Network is the winner of the award for the best EQUINET student grant proposal. Zindaba, who is studying journalism, presented a proposal to do a content analysis of debates on health in the Malawi National Assembly. The proposal by Zindaba aims to identify the extent to which debates in parliament take up health equity issues, the key areas debated and the trends in such debates. The work is relevant to EQUINET work with GEGA in the region on strengthening and supporting parliamentary oversight, legislative, representation and budget roles in promoting health equity. Malawi Health Equity Network has built close links with the Malawi Parliamentary committee on health in promoting health equity. The award was presented to Zindaba at the EQUINET June Conference.
This case study is produced by the Kenya Legal and Ethical Issues Network on HIV and AIDS (KELIN), working with Charles Dulo as a contributor, in the theme work on health rights and law of the Regional Network for Equity in Health in East and Southern Africa (EQUINET). This Paper’s objective is to answer the question, “What difference have constitutional rights to health made in practice and what have been the issues affecting the capacity to claim and deliver on the rights in Kenya?” It is a follow up on the results of work on the right to health that highlighted a need to do further studies in countries that do not have expressed provision on the rights to health. It is a desk review of literature that explores the historical background on the right to health before the current constitution that was promulgated in 2010. This is followed by a review of the legislative framework after 2010 and jurisprudence on the right health, and concludes by highlighting key challenges in the realization of the right to health in Kenya.
The Regional Network for Equity in Health in Southern Africa (EQUINET) and Health Systems Trust South Africa (HST) successfully held a review meeting on Equity in the Distribution of Personnel in Southern Africa. This meeting is part of the two-year research and advocacy programme of work in this area that aims to promote the equitable distribution of health personnel in southern Africa. Watch the site www.equinetafrica.org for a report of the meeting.
A regional meeting (hosted by EQUINET/Oxfam working with SADC in February 2004) identified the need to monitor equity in access and health systems issues as critical to supporting visibility, policy dialogue and programme planning on these issues of equity and health system strengthening. EQUINET, through Training and Research Support Centre, carried out work to assess the existing monitoring taking place in relation to expanding ART coverage and contracted the Equi-TB Knowledge Programme – now REACH Trust - Malawi, to write a paper on the area of monitoring equity and health systems impacts of ART expansion at subnational and national level, with recommendations for regional level monitoring.