The national ART scale-up plan contains several measures to promote equity, considering also that there are insufficient resources to cover everyone who is eligible. Thus study focused on four of these covering ART enrolment on an open ‘first-come, first-served’ basis; targeted gender-sensitive health promotion of ART, measures to overcome specific geographical barriers to access for remote populations and prioritisation of people already on ART, pregnant women and young children. Using a case study approach the study analysed the power relations that influenced outcomes on these policy measures on four health facilities in Malawi. The findings indicate that health workers commonly exercise power in relation to patients, and that patient acquiesce with health worker behaviours. In poorly performing facilities, implementation of policy measures is negatively affected by managerial practices that discourage teamwork and de-motivate health workers, while in the two better performing facilities, management practices had a more positive role in supporting positive health worker practices. The study findings highlight that implementing equity policies needs to include measures to orient and involve staff, and address power and resource imbalances that can undermine access.
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Parliaments can play a key role in promoting health and health equity through their representative, legislative and oversight roles, including budget oversight. To better understand and support the practical implementation of these roles, EQUINET (through University of Cape Town (UCT) and its secretariat at Training and Research Support Centre (TARSC) with SEAPACOH implemented a questionnaire survey in September 2008 to explore and document the work and experiences of parliamentary committees on health. This report presents the findings on the general progress on parliament work on health. The survey highlighted a number of areas of current focus of parliament work in health, the potential and experience of positive outcomes, and the limits and constraints to address to support further work. In the budget process parliaments have generally played a role in advocating and engaging on the Abuja commitment, with increasing budget shares to health in a majority of countries, although the target has only been met in two of those included in the survey. Legislative activity is less common, and areas that are of public health concern, such as incorporating TRIPS flexibilities or international commitments into national law are still not well known by parliaments or acted on. Oversight and representative roles are the most frequently reported area of committee action, and parliaments have played an important role in raising debate on and profile of health issues. It appears from the evidence that parliaments can support progress in health equity by enhancing funding for prioritised areas in the budget process, by raising awareness of health issues through parliament debates, by raising public attention to prioritised concerns through media liaison, by gathering evidence and views from communities and communicating issues to communities through constituency visits, and by raising very specific questions to the executive to address.
This report presents a detailed desk review providing the constitutional provisions of the right to health in 15 countries in east and southern Africa (ESA): Angola, Botswana, Congo-Brazzaville, Kenya, Lesotho, Madagascar, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, Zimbabwe and Zambia. The review was carried out within the Regional Network for Equity in Health in East and Southern Africa (EQUINET) by the Center for Health, Human Right and Development. This paper used the six core obligations as spelt out in General Comment 14 to assess the inclusion of the right to health in the constitutional provisions of the ESA countries: to ensure the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalised groups; to ensure access to the minimum essential food which is nutritionally adequate and safe, to ensure freedom from hunger to everyone; to ensure access to basic shelter, housing and sanitation, and an adequate supply of safe and potable water; to provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs; to ensure equitable distribution of all health facilities, goods and services; and to adopt and implement a national public health strategy and plan of action.
This paper outlines the flows of private capital that lie behind the growth of the for-profit pharmaceutical sector in Tanzania. It reports an analysis of the policy, access and equity challenges posed by the shift to increasing private sector participation in the sector. The study was implemented within EQUINET by the Institute of Development Studies, University of Dar es Salaam, in a regional programme co-ordinated by the Institute for Social and Economic Research, South Africa. Strengthening the pharmaceutical sector to produce an adequate supply of medicines in Tanzania, for Tanzanians, is hindered by numerous constraints, including: non inclusion of TRIPS flexibilities in Tanzanian law; lack of skilled staff; financial constraints; poor industrial infrastructure and services; weak local and international pharmaceutical industry links; and counterfeit medicines entering the market. The report recommends that the health ministry step up its own monitoring systems to ensure effective distribution of medicines to health facilities. New legislation is also needed to improve quality standards, implement TRIPS flexibilities in Tanzanian law, and tackle substandard medicines entering the market.
The private health sector in South Africa is substantial. This paper explores the private sector involvement in funding and providing health services in South Africa and the implications for equity and access to health care. Serious challenges face the private health care sector in South Africa, not least of all the very rapid increases in expenditure and, hence, contribution rates in medical schemes. A range of factors underlie these trends; but in recent years, schemes’ spending increases have been driven largely by private for-profit hospitals and specialists, with the number of private hospital beds increasing rapidly and considerable consolidation of beds within three large private hospital groups. The 2007 policy conference of the ruling African National Congress (ANC) resolved to introduce a National Health Insurance (NHI). If successfully implemented, the substantial reforms envisaged will promote health system equity, affordability and sustainability within South Africa. However, there are growing concerns that the introduction of these reforms will contribute to increased activities by South African private for-profit health care companies in other African countries. Private health care firms in South Africa not only have an interest in expanding into other African countries, they will also have access to substantial investment resources. In particular, the World Bank’s International Finance Corporation (IFC) is actively seeking to invest in the private health sector in African countries. The experience of the private health sector in South Africa should be taken into account by policy-makers in other African countries when considering what role they envisage for the private health sector within their country context.
This study was undertaken by University of Zambia within the Health Financing theme work of the Regional Network for Equity in Health in East and Southern Africa (EQUINET) within a regional programme that is exploring progress in integrating equity into resource allocation. The study was undertaken to update the experiences and progress on the design, review and implementation of an equity-based resource allocation formula in the Zambian health sector. The author found that the formula has only been implemented in partial form, and that second and third generation formulae have not been adjusted in the implementation process. A severe lack of funding for the public health system, whose funding is smaller than the financing for specific health programmes like HIV and AIDS, remains a significant concern. The study makes a number of recommendations. The author calls for more research evaluating the changes in health outcomes, outputs or processes as a consequence of implementing resource allocation formulae. He calls for integration of financing and expansion of the pooled funding for the health sector to raise possibilities for a realistic implementation of the resource allocation formula. Richer districts should not have to risk a revenue reduction. The way to achieve the formula should rather use limited revenue growth in these districts relative to accelerated revenue growth for the poorer districts. A clear time line should be established with regard to the transformation of resource allocation and this should be updated based on emerging evidence. A monitoring and evaluation process should track performance of both resource allocation and health and health care outcomes. Finally, the Ministry of Health should evaluate the effect of structural changes with regard to resource management and performance so as to ensure optimum implementation.
This study was undertaken by University of Zambia within the Health Financing theme work of the Regional Network for Equity in Health in East and Southern Africa (EQUINET) within a regional programme that is exploring progress in integrating equity into resource allocation. The study was undertaken to update the experiences and progress on the design, review and implementation of an equity-based resource allocation formula in the Zambian health sector. The author found that the formula has only been implemented in partial form, and that second and third generation formulae have not been adjusted in the implementation process. A severe lack of funding for the public health system, whose funding is smaller than the financing for specific health programmes like HIV and AIDS, remains a significant concern. The study makes a number of recommendations. The author calls for more research evaluating the changes in health outcomes, outputs or processes as a consequence of implementing resource allocation formulae. He calls for integration of financing and expansion of the pooled funding for the health sector to raise possibilities for a realistic implementation of the resource allocation formula. Richer districts should not have to risk a revenue reduction. The way to achieve the formula should rather use limited revenue growth in these districts relative to accelerated revenue growth for the poorer districts. A clear time line should be established with regard to the transformation of resource allocation and this should be updated based on emerging evidence. A monitoring and evaluation process should track performance of both resource allocation and health and health care outcomes. Finally, the Ministry of Health should evaluate the effect of structural changes with regard to resource management and performance so as to ensure optimum implementation.
The 52nd Health Ministers Conference of the East, Central and Southern African Health Community that took place from 25-29 October 2010 in Harare, Zimbabwe, under the theme: Moving from Knowledge to Action: Harnessing Evidence to Transform Healthcare. The meeting recognised the limited production and use of locally generated evidence to influence policy within the region, and resolved to promote use of evidence in decision making and policy formulation within the region and make more effective links with existing resources and institutions within the region for this. This report provides information to support the connections particularly between regional institutions and regional policy forums. It provides summary information from desk review, internet sites and email follow up on the 25 institutions and networks in East and Southern Africa (ESA) identified that are local to the region and that undertake health policy, strategy, and health systems work at regional level. The report further presents the perceptions from key informant interview of six regional policy institution personnel of the current links with technical institutions in the region, and how they can be improved. The evidence gathered is used to suggest implications for strengthening links between regional technical institutions and regional policy forums. The recommendations identify actions that can be taken with current resources, and those that call for additional investment or re-orientation of resources. The authors welcome feedback and comment on the issues raised, as well as information on other institutions from within the region working at regional level on health policy issues to add to the database compiled.
This review was commission by EQUINET to explore the implications of expansion of the private for profit health sector for equitable health systems in East and Southern Africa. It summarises the rationale behind the IFC’s recommendations. It then explores whether there are signs of increasing for-profit private sector activity in the region, along the lines suggested by the IFC. The report then identifies issues of concern on private for profit activity in the health sector. It is an initial scoping exercise based on a desk review of predominantly grey literature. It suggests from the evidence presented that Ministries of Health need to highlight both benefits and pitfalls of encouraging for-profit private sector provisioning in economic growth policies and assess the opportunity costs of supporting the for-profit private health sector as opposed to developing the public health system. Comprehensive policies on the private sector need to be developed, together with a robust regulations and state capacities to monitor private sector activity and enforce regulations and sanctions.
This publication reports from stakeholders the information and knowledge gaps and research priorities on global health diplomacy (GHD) in Africa to inform regional discussion on a research agenda for GHD. The findings indicate that research on GHD should identify factors that support the effectiveness of GHD in addressing selected key challenges to health strengthening systems in Eastern and Southern Africa, in a way that strengthens the capacity of key African policy actors and stakeholders within processes of health diplomacy. . The findings indicate a preference from officials and policy makers to do this in three broad areas: i. Firstly, to explore the implementation of existing global commitments in the region, to learn lessons from the current experience, generate evidence for input to monitoring and review of the commitments, and to inform future health negotiations. ii. Secondly, to explore the extent to which African interests are advanced in areas under global health negotiation, to assess the implications, costs and benefits of specific issues for the diverse countries in the region, and the different negotiating positions of countries in and beyond the region. iii. Thirdly to explore how effectively interests in the region are being represented in the current global architecture and governance, including of the global initiatives that fund health, to inform African engagement on global governance reforms.