Drawing on the analytic framework of the regional analysis, an analysis of equity in health at district level was implemented in Tanzania, through secondary review and field work. We found a clear policy commitment to equity, the administrative means to implement it and a political stability that enables this. A number of features of Tanzania’s context and health system make reducing differentials in health and access to health care possible, including the investment of debt relief resources in health and education, increased public spending in health, methods for managing external funds that pool resources for wider reallocation to areas of need and a resource allocation formula that considers access, poverty and disease burden in the allocation of resources and provides guidelines for spending to protect areas of equity oriented spending.
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In this study, authors aimed to identify the impact of the migration of human resources for health on health services in Kenya. The World Health Organization (WHO) 2004 framework on health systems performance was used. The study concentrated on impacts on resource generation, stewardship and service provision and was limited to doctors and nurses. Despite data limitations, the study shows a general trend in migration both locally, from rural to urban areas and internationally, from Kenya to developed countries, with a high emigration rate of 51% for doctors and 71% of respondents indicating an intention to emigrate. From data collected, authors made a rough estimate of inward remittances of about US$90 million annually for nurses and doctors which, however, are not available to the health system and may not match outflows from the health system. In training doctors (schooling and university) alone, about US$95 million invested was lost in Kenya due to migration. Even if remittances were to be accounted for, there still appears to be a net outflow of capital from the country and its health system due to migration. This loss has negative impacts on workloads, especially at peripheral facilities and in some rural districts, which may impact on health service provision and on the referral chain. Increased workloads caused by understaffing result in stress, burn out and demotivation. These become push factors that lead remaining health workers to leave. There was some improvement in workloads in 2005/6 despite increases in service uptake, suggesting that there has been some policy response to the staff crisis in those facilities surveyed.
The study reviewed existing literature, and held focus group discussions and interviews with key informants to examine the contribution of the AIDS levy in Zimbabwe to national health financing. Two provinces were randomly sampled for the in-depth assessment of spending on AIDS levy. The study revealed that the contribution of the AIDS levy has so far been relatively low and undermined by inflation, with inequities in the allocation of funds by province in relation to HIV prevalence. The provincial and district levels, where most patient care takes place, are severely under-funded. If inflation is controlled for, the study concludes that the AIDS levy is a noble idea but that improvements are needed in the allocation of resources.
This study is a first attempt at gathering evidence on the effects of effects of user fee removal on aspects of utilisation and quality of services. The study was based on data collected from a sample of 23 districts in Zambia. The data included total utilisation, attendance levels at health centre outpatient and inpatient maternal and child health facilities, levels of respiratory infections, skin infections, diarrhoea and supervised deliveries, and the availability of drugs. Utilisation data is categorised by age (under-five years of age and over five years) and according to rural or urban districts. There was a substantial increase in total utilisation of public health services (50% increase in rural populations over 5) and an increase in drug consumption. Districts with a greater proportion of poor people recorded greater increases in utilisation of their facilities. Drug consumption in rural districts was estimated to have increased by about 40%. Staff workloads (calculated as the staff-to-patient ratio per day) in rural districts also showed a slight increase after user fees were removed. Based on patients' perceptions, there was no evidence of deterioration in the quality of care since user fees were removed. However, inadequate numbers of skilled health workers presents a major human resources threat to improving access by all. With sustained budget support from government to the DHMTs, the health system can continue to achieve its desired outcomes without relying on user fees.
This study aimed to assess equity in uptake of antiretroviral therapy in Malawi in 2005, especially according to age (children vs. adults), gender (men vs. women) and income. Particular reference is made to the scaling up of ART and the removal of fees for ART in 2004. Informal interviews were conducted with health sector antiretroviral programme implementers and key policy makers in the Ministry of Health. The researchers also searched both published and grey literature to collect information on the history and operations of the Malawi public sector-led ART programme. Retention rates remain high in Malawi's ART programmes (84%), which compare favourably with those elsewhere on the continent. Rates ranging from 44% to 85% of people remaining on treatment after 24 months of treatment have been reported in ART programmes throughout Africa (Rosen et al, 2007). While there were some reports from key informants that the change from fee-paying ART services to free systems may have improved patient adherence to treatment regimes, the research did not provide conclusive evidence of the impact of cost of patients' medications on their adherence to their treatment regimens. Different adherence rates in different areas and programmes suggest that other determinants may be affecting affect this outcome.
In Uganda, community-based health insurance started in 1995; however, the number of schemes has remained small with very low coverage levels. This study examines issues of equity and sustainability in these prepayment schemes; if they are to contribute significantly to health sector financing, the schemes must be equitable and sustainable. A descriptive cross-sectional study employing qualitative techniques was carried out. Key informant interviews, focus group discussions and documents review were used. Data was tape-recorded, transcribed, typed, manually analysed thematically using a master sheet. Abolition of user fees did not have a big effect on enrolment into the schemes. People went for higher quality services, which were perceived to be provided in private health facilities rather than government services. Schemes were perceived to directly contribute towards health financing by providing funds for the procurement of drugs and equipment, allowing people to contribute to their own health care. An indirect benefit is that they would ease the pressure on public facilities by diverting patients from the public health sector. Whereas some thought the contribution of CHI schemes was insignificant due to low enrolment, others felt the schemes needed to be strengthened to build confidence in social health insurance. The researchers recommend that government increase funding to maintain the improvement in quality of health care in public facilities. Future health policy needs to address whether or not CHI has a role to play in the Ugandan context and in institutionalising SHI.
African Heads of State committed themselves at a meeting in Abuja in 2001 to devoting a minimum of 15% of government funds to the health sector in order to address the massive burden of ill-health facing countries in Africa, particularly within the context of a growing burden of HIV, AIDS, TB and malaria, This report considers progress towards this target and is based on information provided by researchers in seven east and southern African countries. Of the countries reviewed, only Zambia and Malawi have made considerable progress towards the Abuja target, with the health sector’s share of total government expenditure increasing consistently from 8% and 5% respectively in 1997 to nearly 11% and 7% in 2000 and almost 18% and 11% in 2003 (thus exceeding the Abuja target in the case of Zambia). Although Namibia has not achieved the Abuja target, it has made good progress from 10% in 1997 to nearly 14% in 2003. Kenya is the furthest from the Abuja target, with only 5% of government resources going to health services in 2006 and with no consistent increase in government spending. Some seven years after the Declaration, many countries are still lagging well behind the target, although there are promising signs of increases in allocations towards the health sector in some.
The Tanzanian public health sector is losing workers to internal and external migration. This paper examines the implementation of policies to govern non-financial incentives to retain health workers. It examines a range of non-financial incentives, including training; leave; promotion; housing; and a safe and supportive working environment. It also examines the systems for managing personnel and the implementation of incentives as a factor in retention, including the participatory personnel appraisal system; worker participation in discussing their job requirements and welfare; supervision; recognition and respect. Drawing on a review of policy, published and grey literature and on a field stidy of seven districts, including five underserved districts, the paper finds that while a number of incentives exist in policy, their sustainability is eroded by the absence of special earmarked funding for their implementation. Decentralised districts also lack adequate powers and authority to manage health workers weakening their ability to implement non-financial incentives. There was general consensus from health workers and managers that interventions such as training and education, promotion and the provision of safe working and living environments, can be strong motivators if implemented in an effective and sustainable manner. In contrast, health workers interviewed pointed to the demotivating effect of poor implementation of available non-financial incentives. The management and resource barriers to implementing non financial retention incentives are further explored in the paper and recommendations made to strengthen the implementation of incentives. The authors conclude that analysis of issues driving retention needs to take into account both individual and structural factors that shape individual health workers' preference structures and the complex nature of the health care labour market. A trivialised pull and push factors framework in analysing complex problems like retention, will not guide sustainable solutions, which need to be based on an understanding of factors that not only guide the design of incentive regimes, but also the resources, management systems and other factors that enable their implementation in practice.
In Kenya, internal migration of workers, from rural/poor areas to urban/rich areas, is just as serious a problem as international migration. Shortages in the health workforce are aggravated by the unequal distribution of health workers as a result of economic, social, professional and security factors. This report is of a literature review and field research on strategies for the retention of health workers in Kenya. It examines trends in health worker recruitment and retention; existing policies, strategies and interventions to retain health workers; and assesses their implementation and the factors affecting this. The study data suggests that better organised facilities, often in higher-income areas, are more successful in providing incentives. Yet it is at the lower levels of the health system (in rural and poorer areas) where incentives are more urgently needed to counteract the strong push factors that force workers out of these areas. Recommendations are proposed for measures to retain health workers in rural areas, in lower-income districts and at lower levels of the health system to ensure that all areas reach minimum standards with regard to numbers of personnel per population. Such incentives are not only financial. A number of non-financial incentives are highly valued: improved working conditions; training and supervision; and good living conditions, communications, health care and educational opportunities for themselves and their families.
This report presents a review of the public health laws in Kenya, Uganda and Tanzania that impact on equity in health, to assess the extent to which the current legal framework addresses public health and health equity. Public health law has perhaps not had adequate profile in academic and professional practice, but is a critical area of work if countries in east and southern Africa are to protect public health and health equity in an environment increasingly influenced by global challenges and policies. Various areas of law are provided for in all countries, and it is more in their application that there may be deficits. Some areas of law are provided for in some laws but not in all relevant laws, or not in all countries. This calls for measures to harmonise the legal frameworks within countries to ensure consistency, and across the three countries to protect health across the region as a whole. In some cases there are policy commitments but omissions or gaps in law to reflect these policy commitments and ensure their application at national level across all sectors. The authors suggest that these areas be reviewed by health authorities, parliamentary committees, health professional associations and health civil society.