In the study, the researchers explore how policies are shaped and transformed in the process of implementation, using as a case study the implementation of two community health workers policies in a rural sub-district in South Africa. The researchers investigated how role players at different levels of the implementation process interacted with each other and the policy and how they used power at their disposal in this process. Rather than focusing on the gap between policy formation and policy outcome, with implementation being a mere administrative follow-on, the researchers took a 'bottom-up' perspective, which allows one to view implementation as an integral and continuing part of the policy process. Within this, the researchers particularly explored the use of discretionary power by front-line implementers, finding that selective communication and lack of information led to a 'thinning down' of a complex and comprehensive policy. While ftontline implementers did not have the power to change the rules that were set by the provincial actors, they used their knowledge of local conditions, control over local knowledge and distance from the provincial capital to shape implementation at the service level.
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This paper investigates the impact of the framework and strategies to retain critical health professionals (CHPs) that the Zimbabwean government has put in place, particularly regarding non-financial incentives, in the face of continuing high out-migration. The study investigated and reports on the causes of migration of health professionals; the strategies used to retain health professionals, how they are being implemented, monitored and evaluated and their impact, in order to make recommendations to enhance the monitoring, evaluation and management of non-financial incentives for health worker retention. The field survey results showed that Zimbabwe is losing experienced CHPs, but that even newly qualified staff aspire to migrate to gain experience. The major factor driving out-migration is the economic hardship that CHPs face due to deterioration in the country’s economy. Other factors identified include poor remuneration, unattractive financial incentives and poor working conditions. The Zimbabwe Health Service Board (ZHSB) has implemented a retention package but constraints in its adequacy and coverage appear to have limited its impact, whilethe ZHSB itself has limited autonomy to decide on health worker incentives.
This report provides an overview of the status of health care financing in seven East and Southern African (ESA) countries (Malawi, Namibia, South Africa, Tanzania, Uganda, Zambia, Zimbabwe). It draws on country case-studies and a collaborative cross-country analysis undertaken at an EQUINET workshop. Health care financing issues are considered through an equity lens, with a focus on revenue collection, pooling of funds and purchasing. There remains a heavy dependency on donor funding in several countries. While debt relief initiatives are translating into increased government funding for health care in some countries, in other countries, the health sector has not benefited much from reduced debt servicing. Due to high levels of out-of-pocket payments in many ESA countries and a heavy emphasis in the tax system on VAT, individual households carry a heavy burden. Health insurance is growing in popularity, particularly community-based health insurance which has placed the financing burden on relatively poor rural communities and those living in informal urban areas. All the countries under review have poor fund pooling with little in the way of risk equalisation mechanisms, which severely limits the potential for income and risk cross-subsidies. To achieve equitable health care financing it is necessary to: eliminate, or at least reduce out-of-pocket payments; increase the funding of health services from tax revenue; and introduce mechanisms to integrate all forms of pre-payment (i.e. tax funding and health insurance).
Have non-financial incentives been successful in retaining health workers in Swaziland? This study reviewed health policy and programme documents in Swaziland relevant to health workers and found that only one that mentioned non-financial incentives, suggesting that the value of these incentives is under-rated in policy. In contrast, a field study interviewing health workers at different levels of the health system revealed that most workers in Swaziland consider non-financial incentives to be more important than salary in determining whether or not they will remain in their jobs or join the 'medical brain drain' overseas.
This study, commissioned by EQUINET, ECSA-HC and WHO, aimed to review and critically analyse the literature and secondary evidence on the impact of HIV and AIDS programmes on health care worker (HCW) retention in east and southern Africa. Early studies reported negative effects of HIV and AIDS and the delivery of HIV and AIDS services on HCW morale with stigma, burn-out, resignation and deaths due to HIV and AIDS, while more recent ones speak of hope, high prestige, high motivation and better retention of HCWs in HIV and AIDS programmes, largely due to effective antiretroviral therapy (ART) which has improved the prognosis of AIDS. Global Health Initiatives have contributed to the expansion of HCW numbers through training, higher salaries or salary supplements, such as better furnished facilities or appointment at higher levels, often to the exclusion of other HCWs. Selectively applied incentives tend to demoralise and discourage those who are excluded; as illustrated by examples from programmes in South Africa, Tanzania and Guyana. But well funded HIV and AIDS programmes are attractive to HCWs and may contribute to internal brain drain. In contrast, more inclusive approaches, such as in Malawi where MSF supplemented salaries of all health workers in the operational districts, and Namibia where the Ministry of Health and Social Services applied uniform terms and conditions of service for all HCWs, reportedly experienced no problems. Some countries have an ‘emergency response’ approach to HIV and AIDS; hence they accept any help, usually on the funders’ terms, leading to fragmented vertical programmes. The lack of integration of HIV and AIDS services into other health programmes is a problem in many countries. Where successfully integrated programmes do exist - such as HIV and TB, HIV and sexual and reproductive health, and even those where HIV and AIDS services are fully integrated into the public health system - integrated programmes benefited the whole system. There have been fears that existing inequalities in health care may be intensified in scaling up HIV and AIDS services. There are, however, reports showing that a public health and equitable approach to the roll-out of ART is possible across all socio-economic groups with similar outcomes. HIV and AIDS programmes have the potential to benefit the health system by attracting and retaining HCWs in the health system; and indeed, innovations such as task shifting and the integrated management of adult and adolescent illness have been applied to more efficiently use available HCWs. Many vertical programmes recruit their own HCWs, especially counsellors and home-based caregivers. This can increase the pool of HCWs. By relying on the health system for the more skilled health professionals, however, HIV and AIDS programmes may also undermine other health programmes. We recommend that country-level case studies be undertaken to document the various approaches, such as engagement between countries and funding agencies, country perspective on NGO roles, the implementation of the ‘Three Ones’, SWAP and public health approach; and the impact of national and project specific initiatives on HCWs.
This paper aims to provide a detailed analysis of the options for protecting universal comprehensive and equitable health services within the framework of the EU-ESA EPA and other EPAs in the region through the services negotiations. The paper notes a number of commitments that the ESA-EU countries have already made in relation to public health. It proposes issues for negotiators in the services negotiations in the EPA to take into account to protect health in these agreements.
Parliaments can play a key role in promoting the right to health in east and southern Africa. To better understand and support the practical implementation of this role, this report presents the findings of a questionnaire administered to parliamentary committees on health from 12 countries in the region. Knowledge of international human rights and related laws pertaining to the right to health was found to be limited. Parliamentarians were more likely to be familiar with Trade-related Aspects of Intellectual Property Rights (TRIPS) applications and with the provisions of the Abuja Declaration than with rights agreements such as the International Covenant on Economic, Social and Cultural Rights (ICESCR), its General Comment 14 or the African Charter on Peoples and Human Rights. Important gains could be made if parliamentarians were able to analyse, interpret and integrate these agreements into their work.
The main challenges facing parliamentarians appear to be: how to deal with policy choices under conditions of severe resource constraints and, particularly, the application of the concept of progressive realisation of the right to health; how to balance individualist concepts of rights with rights claims that benefit groups so that it is not simply a question of those who shout the loudest getting access to decision making processes; and how to structure engagement with civil society to preference groups who are most marginalised – a pro-poor application in human rights practice.
This paper was commissioned under the umbrella of the Regional Network for Equity in Health in east and southern Africa (EQUINET), led by the Institute of Social and Economic Research, Rhodes University (ISER) to map and review documented (secondary) evidence on capital flows in the health sector and their implications for equitable access to health care services between 1995 and 2007 in South Africa. The paper finds that private intermediaries channel more funds than the public ones, yet a significant proportion of the population meets health service costs through out-of-pocket payments, and for many this is catastrophic expenditure. There have been successful pro-equity measures to increase access to both public and private health care services e.g. through removal of barriers, such as user fees at primary health care (PHC) facilities, increased coverage of medical aid and through regulation of the private sector. However, inequities in access persist, as do geographical barriers to access. The period reviewed is one where expansion of both public and private sectors has taken place. The challenge remains to translate this into equitable use of available resources, or increased access to health services, especially for those with higher health need. Improved monitoring of health systems impacts of trends described in this paper is urged, given the significant share of private sector services in the public-private mix in health in South Africa.
While there is much promotion of private capital flows into the health sector in Southern Africa in reality these flows have been minimal. Private health is the fifth most promoted sector in African after tourism, hotels and restaurants, energy, and computer services. To understand flows of private capital behind the growth of the for-profit health care sector in SADC, EQUINET working through Rhodes University Institute of Social and Economic Research (ISER) and other institutions in the region are examining health sector capital flows in ESA. Despite the minor movements of capital in the ESA health sector, Mauritius, South Africa, Botswana and Namibia appear as the growth points for big capital, with the rest of the region relegated to the margins in terms of large investments. Investment potential exists in the pharmaceutical, hospital and hospital services sectors, but most of new FDI in health is in the pharmaceutical sector often for the production of ARVs to absorb large donor funds. The pharmaceutical sector has also had the most significant amounts of overt privatisation of all health-related sectors, either through selling fixed assets or transfer of equity. The report argues that South Africa is likely to be the biggest destination for investment in health care, and the major regional source of private FDI flows to the health sector in ESA countries.
This paper presents a summary of the regional programme on incentives for health worker retention in the Regional Network for Equity in Health in East and Southern Africa (EQUINET) in co-operation with the East, Central and Southern Africa Health Community (ECSA-HC). The studies sought to investigate the causes of migration of health professionals, the strategies used to retain health professionals, how they are being implemented, monitored and evaluated, as well as their impact, to make recommendations to enhance the monitoring, evaluation and management of non-financial incentives for health worker retention. They aimed to have some comparability in design to share learning. The findings revealed that all four countries studied (Swaziland, Zimbabwe, Tanzania, Kenya) have put in place strategies to improve morale and retain staff in the public health sector. They were designed after some assessment of the drivers of attrition, often through prior surveys of push/pull factors. All the countries studied were applying a mix of non-financial incentives according to their strategies and plans, although implementation was not always uniform at all levels or for all cadres, or reached all those cadres intended. All implement non-financial incentives, together with some form of financial incentives. All studies indicated the presence of policies providing for non-financial incentives. The country studies observed that incentives were not uniformly applied to all health workers, and did not always reach all in the target category. The studies indicated a need to intensify focus on issues of operationalising and implementing non-financial incentives: moving from inserting incentives in policies and strategies to ensuring their application across all providers; moving from focused application for specific cadres of health workers to sector wide application of incentives for all health workers; and moving from experiments within the health sector to more sustained multi-sectoral policies that involve other sectors, including public service, finance, public works, education and housing. The results of the work were reviewed at a regional meeting to review the findings from this body of work and to explore the implications for policies and measures aimed at valuing and retaining health workers in ESA, develop proposals and guidelines for policy and action relevant to health worker deployment and retention, and identify knowledge gaps for follow up work. The recommendations from this meeting are presented.