This review of the capital flows in the health sector in Zimbabwe was carried out in 2008 and draws from secondary evidence. It presents evidence on the current composition of the health sector, particularly showing the public-private mix; trends over time post-1995 in private capital flows to the health sector showing key entry points for capital and the impact on the health care sector of these flows. The paper explores arguments used to support private flows, the role of trade agreements, and the policy, regulatory, institutional and public responses to the capital flows. It comments on issues arising in relation to methods used to analyse capital flows and their impacts, including data availability and bias. The rapid liberalisation of the health sector in Zimbabwe in the late 1990s created opportunities for private capital. While this was a policy objective of the time, it coincided with cuts in public expenditure during the 1990s and an economic crisis post-2000 that meant that private sector growth was not matched with public sector growth. The marked decline in public health investment reversed the major gains made during the 1980s, and private for-profit health care investments were concentrated in a few urban areas serving a minority of the wealthier population. The absence of a national health insurance system resulted in the 90% uninsured population having difficulties in accessing health services. Private health services were concentrated in a few vertically linked operations, sparking fears of anti-competitive behaviour, especially in the retail pharmaceutical sectors. Incentives given to private-for-profit health care providers did not lever public health gains, and the cost of both public and private health care soared, undermining access. The paper highlights areas for increased policy attention: for government to significantly increase public investment in health and control out of pocket expenditure; for the establishment of social health insurance; for the Ministry of Health to use its powers to monitor and regulate the expansion of private capital so that it serves policy objectives of universal coverage and equity. With powerful national interests gaining from profits in the health sector, including in the medical profession, monitoring and advocacy by communities is essential to engage on policy measures that protect equity and access. The paper further notes the regulatory role of the Competition and Tariff Commission.
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Least developed countries have until 2016 to reform their IP regimes and enact new patent laws in line with Trade-related Aspects of Intellectual Property Rights (TRIPS) Agreement of the World Trade Organisation (WTO). A number of amendments to the TRIPS agreement were made – TRIPS 'flexibilities' – to take care of the health-related concerns of developing countries. Member states have the authority to use these flexibilities when this is necessary to protect public health and to promote access to medicines. The Southern and Eastern African Trade, Information and Negotiations Institute (SEATINI), under the umbrella of the Regional Network for Equity in Health in East and Southern Africa (EQUINET), carried out an assessment of LDCs in East and Southern Africa with regard to their progress towards the new intellectual property (IP) regimes. The study reviewed the situation in sixteen east and southern African countries through a desk review of published and grey literature. The study found that most of the IP regimes currently in ESA countries were in existence before the TRIPS agreement was adopted. These included laws that provide some flexibilities, which were in most cases not being implemented. Only Mauritius and Zambia have formally adopted the protocol amending the TRIPS agreement at the WTO. The December 2009 deadline has been further extended to the end of December 2011 and it is important for all ESA countries to formally adopt the proposal by then to avoid unnecessary renegotiations of the TRIPS amendments. This paper presents a number of recommendations on how ESA countries should apply and implement the TRIPS flexibilities.
This report was commissioned by EQUINET to look at the characteristics and extent of private sector involvement in health financing and provision in East and Southern African countries. It synthesises available information on the private health sector in the following ESA countries: Angola, Botswana, the Democratic Republic of the Congo (DRC), Kenya, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, South Africa, Swaziland, the United Republic of Tanzania, Uganda, Zambia and Zimbabwe. For each country the core health financing issues, including available NHA data, are briefly discussed. As external financial resources play a key role in the funding of private sector initiatives (both for-profit and not-for-profit), the extent of external funding is also considered. Thereafter, an overview is provided of the presence (or not) of private health insurance, and different types of private providers. A trend observed in this review is the expansion of South African private health care organisations into other African countries.
This report was commissioned by the Regional Network for Equity in Health in East and Southern Africa (EQUINET). It highlights areas of concern for gender equity in health in East and Southern Africa (ESA), based on a review of published literature. The report provides examples of key areas of gender equity in health drawn from the literature. It raises dimensions of gender equity in health in relation to the contexts for and social determinants of health; in health outcomes; in health systems and options for acting on gender equity in health. The report does not provide a systematic analysis using household data and is not a comprehensive assessment of all dimensions of gender equity. Rather by presenting key dimensions of gender inequity in health in the region, it raises the argument for more systematic audit and mainstreaming of gender within health systems in ESA countries.
This report provides an overview of resource-allocation decision making in South Africa as it impacts on the distribution of health budgets. It also looks at changes in the allocation of public health care resources since the early 1990s across provinces. Finally, it considers whether resources are allocated equitably between health districts. The report finds that while considerable progress has been made towards the equitable allocation of public sector health care resources among provinces, substantial disparities in spending on primary health care (PHC) services remain among health districts. It is critical that provincial health departments pay more attention to the equitable allocation of resources for PHC services among the districts within their province, the author argues. In the absence of such efforts, many South Africans will continue to be disadvantaged in their access to PHC services simply because of their place of residence.
This annotated literature review was prepared as a resource for the policy research programme led by EQUINET that is examining the role of global health diplomacy (GHD), including south–south diplomacy, in addressing selected key challenges to health and strengthening health systems. This review provides an annotated bibliography and a summary of key features of peer-reviewed articles, books, book chapters and academic reports published between 1998 and 2004 on three case study areas: research on GHD, particularly in the areas of the World Health Organisation's Code on International Recruitment of Health Workers; access to essential drugs through south-south partnerships; and involvement of African actors in global health governance. It focuses on the theoretical and conceptual frameworks used in peer-reviewed literature on global health diplomacy and on the authors’ methodological choices to reach their conclusions. The report highlights theories that guided the research, the types of conceptual frameworks used and the research strategy and research tools employed in the publications reviewed.
EQUINET has supported the development of needs-based resource allocation formulae in a number of east and southern African countries in the past, and the methods for developing such a formula are summarised in this paper. EQUINET's work in the region has persuaded us that it is necessary to supplement the development of a formula with other initiatives to support the successful implementation of equity in resource allocation. We believe that for real progress to be made the equity target allocations calculated through a formula must be linked explicitly to planning and budgeting processes to facilitate the gradual shifting of resources. EQUINET through UCT HEU has been developing such an approach in collaboration with the Ministry of Health in Mozambique. A broad overview of this approach, which may be of value to other countries, is outlined in this paper. A needs-based formula is used to identify the provinces and districts that are furthest from their equity targets and that should receive priority for the allocation of additional budgetary resources. A detailed ‘gap analysis’ focuses on comparing the current physical and human resources in each of these provinces and districts to national norms (developed by the Mozambique Ministry of Health based on what is regarded as the ideal or good practice).
This review assesses the resource mobilisation and allocation performance and challenges faced by the MoHCW in meeting the target set out in its Investment Case. As the Investment Case was meant to complement the annual government budget and resource mobilisation efforts by other players, the review took these resources into account in assessing the level and direction of funding. The review specifically looked at the response from funders of the health sector to the Investment Case, in terms of what resources were raised and the successes and challenges associated with raising the intended resources. It assesses the resources raised and some of the health outputs from these resources. The study included interviews with key informants in the Ministry, review of policy documents and analysis of financial data from government and external funders.
In this paper, the author considers elements of the design of health systems and how these relate to moving towards universal care in the context of Africa. She focuses particularly on health financing issues (revenue collection, pooling and purchasing), but also raises health service delivery and management issues. In relation to revenue collection, the global consensus is that in order to pursue universal coverage, it is critical to reduce reliance on out-of-pocket payments as a means of funding health services. The author notes that the key focus in moving towards universal coverage should be on mandatory prepayment mechanisms and discusses the options for these. The common assumption of limited fiscal space for increased government spending on the health sector should be challenged and the fiscal space envelop pushed. While mandatory health insurance schemes can also contribute to generating additional revenue for health services, these funds should be pooled with funds from government revenue. Although there is limited evidence in relation to purchasing in east and southern African countries, introducing active purchasing of services, as well as addressing service delivery and management challenges, will be essential if universal access to services of appropriate quality is to be achieved.
In this paper, the author considers elements of the design of health systems and how these relate to moving towards UC in the context of Africa. She focuses particularly on health financing issues (revenue collection, pooling and purchasing), but also raises health service delivery and management issues. In relation to revenue collection, the global consensus is that in order to pursue universal coverage, it is critical to reduce reliance on out-of-pocket payments as a means of funding health services. The author notes that the key focus in moving towards universal coverage should be on mandatory prepayment mechanisms and discusses the options for these. The common assumption of limited fiscal space for increased government spending on the health sector should be challenged and the fiscal space envelop pushed, she argues. While mandatory health insurance schemes can also contribute to generating additional revenue for health services, these funds should be pooled with funds from government revenue. Although there is limited evidence in relation to purchasing in ESA countries, introducing active purchasing of services, as well as addressing service delivery and management challenges, will be essential if universal access to services of appropriate quality is to be achieved.