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Young people account for 30% of the population in South Africa, with just under 15 million young people aged 10 – 24 years. Adolescence is considered a time of both risk and opportunity: When rapid physical and psychological changes may lead to a rise in risk behaviour, substance abuse, sexual and reproductive health problems, violence and mental illness.2 Adolescent health and behaviour are also key determinants of the adult burden of disease. It is therefore critical to invest in youth friendly services that promote physical and mental health, and enable young people to successfully navigate the challenges of adolescence and take on adult responsibilities.
Young people experience a range of barriers that limit their access to healthcare services including transport costs, clinic hours clashing with school timetables, negative attitudes from healthcare workers and a lack of privacy and confidentiality.
The rapid development of information and communication technology (ICTs) – particularly access to mobile phones – has the potential to address these challenges and improve young people’s access to health-related information and services, especially in poor, remote settings. The World Health Organisation has recognised how mobile health (m-health) programmes have the potential to bring services closer to adolescents by providing 24-hour access and confidential, anonymous and personalised interactions.
While there has been significant investment in m-health initiatives across Africa, little research has been done on how young people actually use mobile phones to seek healthcare – insight that is critical in understanding how the uptake of new ICTs might entrench and/or disrupt health inequalities. This research brief presents key findings from a study led by Durham Universityi to investigate the use of mobile phones amongst youth in Sub-Saharan Africa and considers the implications for policy and practice.
The dominant view within Western biomedicine is that children are vulnerable and in need of adult protection, while medicines are powerful, dangerous and should be controlled by experts, however, a growing literature suggests that children and adolescents (in both Western and developing-country contexts) often take active roles in health-seeking. Here, we consider young people’s health-seeking practices in Ghana: a country with a rapidly changing therapeutic landscape, characterised by the recent introduction of health insurance, mass advertising of medicines, and increased use of mobile phones. Qualitative and quantitative data are presented from eight field-sites in urban and rural Ghana, including 131 individual interviews, focus groups, plus a questionnaire survey of 1005 9-to-17-year-olds.
This paper shows that many young people take active responsibility for their own (and others’) healthcare. However, there is substantial variation in health-seeking practices and associated agency; these processes are shaped by (and also shape) resources available, including economic, social, cultural, psychological, informational and locational forms of capital. Dynamic interactions between resources and health-seeking agency operate within a wider, rapidly-changing therapeutic landscape, which has opened access to a greater range of healthcare possibilities. The paper concludes by considering implications for health and wellbeing, and suggest possible interventions for facilitating young people to seek healthcare safely and effectively.
Changes in Ghana’s therapeutic landscape, which mirror those taking place across the continent, are likely to increase young people’s health-seeking agency over coming years. Regulating rapidly expanding pharmaceutical markets and associated advertising is notoriously difficult, which means that children (and adults) have increasingly easy and cheap access to a range of restricted drugs, without necessarily knowing how to use them appropriately. The pragmatic question is how best to facilitate young people to seek healthcare safely and effectively.
Confidentiality and effective, non-judgmental communication are key features of adolescent-friendly services. Ensuring that existing formal health services in Ghana meet the needs of children and adolescents is an important starting point; this will involve investing resources in training and supporting staff to improve inter-generational communication skills and empathetic approaches.
With dramatic recent rises in schooling in Ghana (and elsewhere in Africa), schools offer an important forum for health education and services, and school-based health education should be extended beyond the usual health promotion messages to cover safe and appropriate use of medicines.
User-fees and health insurance also require careful reflection. Finding here indicate that health insurance, which reduces up-front costs of healthcare, might increase urban adolescents’ independent use of formal, accredited health services. However, many young people are not covered by insurance because their parents cannot afford the premiums. Removing user-fees for under-18s would be an important step to facilitating effective health-seeking and ability to access higher-quality services, in Ghana and elsewhere. However, as we have indicated, user-fees are not the only barrier to health-service use for young people, particularly those living in rural areas. Even with health insurance, for those without effective access to appropriate, affordable services (both formal and informal), good quality healthcare is still as out of reach as ever.
The development literature in the recent past has brought out the stark differences in the social and economic status of Dalits and Adivasis as compared to other social groups in India. Most of these studies tended to focus on the correlates of group identity, material deprivation and poverty of these groups to their development deficit.
Dominant discussions in public health in India have often tended to sideline the questions of discrimination while examining the gap in health status among social groups mainly due to the over influence of more visible issues such as unbalanced resource allocation and spending, poor coverage of services, infrastructure lacuna, human resource shortage, affordability and issues of governance. Whilst not many, there, are evidences that discrimination and resulting deprivation have an impact on health of the people in the Indian context.
The paper examines whether the dalit castes are adequately represented in the health service system in rural India in the context of the already established caste based discrimination in service delivery. Drawing from official data, the paper shows an overall domination of non-dalits in healthcare services. The paper presents two scenarios to understand it further. Fist is the similarities in health disparities between Scheduled Castes (SCs) and non-SC/Scheduled Tribes (STs) of Bihar and Tamil Nadu, which have huge presence of non SC/STs in significant positions of healthcare delivery. Second is the case of Andhra Pradesh (undivided), which has less intergroup disparities and better distribution of health personnel from dalit castes at all levels of health services. These cases confirm the persistence of unfavourable environments for dalits with the domination of non-dalits in health services.
Climate change has been recognized as both one of the biggest threats and the biggest opportunities for global health in the 21st century. This trend review seeks to assess and characterize the amount and type of scientific literature on the link between climate change and human health.
The authors tracked the use of climate-related terms and their co-occurrence with health terms during the 25 years since the first Intergovernmental Panel on Climate Change (IPCC) report, from 1990 to 2014, in two scientific databases and in the IPCC reports. They investigated the trends in the number of publications about health and climate change through time, by nature of the health impact under study, and by geographic area. Then the authors compared the scientific production in the health field with that of other sectors on which climate change has an impact.
Results: The number of publications was extremely low in both databases from 1990 (325 and 1,004, respectively) until around 2006 (1,332 and 4,319, respectively), which has since then increased exponentially in recent years (6,079 and 17,395, respectively, in 2014). However, the number of climate change papers regarding health is still about half that of other sectors. Certain health impacts, particularly malnutrition and non-communicable diseases (NCDs), remain substantially understudied. Approximately two-thirds of all published studies were carried out in OECD countries (Organization for Economic Cooperation and Development), predominantly in Europe and North America.
There is a clear need for further research on the links between climate change and health. This pertains particularly to research in and by those countries in which health will be mostly affected and capacity to adapt is least. Specific undertreated topics such as NCDs, malnutrition, and mental health should gain the priority they deserve. Funding agencies are invited to take note of and establish calls for proposals accordingly. Raising the interest in this research area in young scientists remains a challenge and should lead to innovative courses for large audiences, such as Massive Open Online Courses.
The ESRC–DFID Joint Fund for Poverty Alleviation Research was established in 2005 in order to ‘provide a robust conceptual and empirical basis for development and enhance the quality and impact of social science research which contributes to the achievement of the Millennium Development Goals (MDGs)’. The scheme has provided funding to a range of research projects examining how poverty may be tackled in a broad range of economic and social contexts.
This report describes how studies funded by the Joint Fund have Direct and Indirect implications for health/ health services and how they can help to understand the links and pathways between poverty and health. It is an analysis based on the screening of all available documentation and outputs from 121 research projects funded by the Joint Scheme, and a subset of 69 studies that were identified as health related. The screening and review of documents was supplemented by discussions and interviews with current grant-holders who are only just beginning to produce outputs.
Chapter 2 presents the research methodology in more detail. Chapter 3 presents the contextual background for health development research starting at the new millennium. Chapter 4 presents a detailed analysis of 69 projects which had a health dimension. It uses basic descriptive statistics to highlight key trends across the projects as well contextualizes the observations. Chapter 5 discusses key gaps in the studies and methodologies used and provides suggestions for further research and future. The Appendices contain an annotated bibliography of outputs from all the health related studies. This is meant to be a resource that makes the research outputs of funded projects accessible to a wider audience.
Health governance has become multi-layered as the combined result of decentralisation, regional integration and the emergence of new actors nationally and internationally. Whereas this has – in principle – enhanced the installed capacity for health response worldwide, this complexity also poses serious challenges for health governance and policy-making.
This paper focuses on one of these challenges, namely the organisation of statistical information flows at and between governance levels, and the emerging role that regional organisations play therein. The authors aim to understand the extent to which statistics are regionally coordinated and the role regional organisations are playing with respect to national health information systems. Specifically, they analysed regional to national-level data flows with the use of two case studies focusing on UNASUR (Bolivia and Paraguay) and SADC (Swaziland and Zambia). Special attention is given to pro-poor health policies, those health policies that contribute to the reduction of poverty and inequities.
Results demonstrate that health data is shared at various levels, to a greater extent at the global-country and regional-country levels, and to a lesser extent at the regional-global levels. There is potential for greater interaction between the global and regional levels, considering the expertise and involvement of UNASUR and SADC in health. Information flows between regional and national bodies are limited and the quality and reliability of this data is constrained by individual Member States’ information systems. Having greater access to better data would greatly support Member States’ focus on addressing the social determinants of health and reducing poverty in their countries.
Oxytocin is a natural hormone with uterine stimulant properties that plays a prominent role in obstetric practice. Clinical guidelines for oxytocin use intrapartum emphasise that injudicious use has serious potential for adverse outcomes for mother and baby. Oxytocin is readily available in South Asia and widely used in ways that flout these guidelines. Yet recommendations for active management of third stage of labour include the administration of oxytocin to prevent post-partum haemorrhage. Troublingly, these proposals seem to ignore oxytocin’s already extensive life independent of policy interventions. Taking oxytocin as an example, the paper argues that policy-makers urgently need to engage with the everyday realities of drug availability and use in South Asia.
Paying for performance (P4P) provides financial incentives for providers to increase the use and quality of care. P4P can affect health care by providing incentives for providers to put more effort into specific activities, and by increasing the amount of resources available to finance the delivery of services.
This paper evaluates the impact of P4P on the use and quality of prenatal, institutional delivery, and child preventive care using data produced from a prospective quasi-experimental evaluation nested into the national rollout of P4P in Rwanda. Treatment facilities were enrolled in the P4P scheme in 2006 and comparison facilities were enrolled two years later. The incentive effect is isolated from the resource effect by increasing comparison facilities’ input-based budgets by the average P4P payments to the treatment facilities. The data were collected from 166 facilities and a random sample of 2158 households.
The document found that:
The authors conclude that P4P financial performance incentives can improve both the use of and the quality of health services.
This paper is part of a collection forming A Special Issue, which covers selected themes from a larger project on child mobility in Ghana, Malawi and South Africa. The themes are those which individual members of the Ghana research team identified as of particular interest and on which they have reflected, drawing on material collected and analysed by the team as a whole. In this paper the authors take a broader view, first presenting the background history and context of the three-country study in which the Ghana research is set (country selection, project design and methods), then focusing on the research process in Ghana.
The two research strands pursued in the study present different entry points through which we can explore children’s mobility and access to services. One strand comprises relatively conventional academic research: the first part of this is qualitative (in-depth interviews with children, parents and other key informants; focus groups; life histories; accompanied walks), the second part consists of a large-scale quantitative questionnaire survey directed at children aged c. 9-18 years (N= 1000). The second main research strand, less conventionally, is based in young people’s own research, in which (following some preliminary training) they have selected their research methods and directly undertaken research with their peers. Findings from this second strand, which was undertaken at a relatively early stage in the project, by young people aged between about 11 and 20 years, also helped shape questions in the adult academic qualitative and quantitative elements.
Key findings from the project include:
Paying for performance provides financial rewards to medical care providers for improvements in performance measured by specific utilisation and quality of care indicators. In 2006, Rwanda began a paying for performance scheme to improve health services delivery, including HIV/AIDS services. This study examines the scheme’s impact on individual and couples HIV testing and counseling and using data from a prospective quasi-experimental design.
The study finds a positive impact of paying for performance with an increase of 6.1 percentage points in the probability of individuals having ever been tested. This positive impact is stronger for married individuals: 10.2 percentage points. The results also indicate larger impacts of paying for performance on the likelihood that the respondent reports both partners have ever been tested, especially among discordant couples (14.7 percentage point increase) in which only one of the partners is HIV positive.
Community health workers (CHWs) are used increasingly in the world to address shortages of health workers and the lack of a pervasive national health system. However, while their role is often described at a policy level, it is not clear how these ideals are instantiated in practice, how best to support this work, or how the work is interpreted by local actors. CHWs are often spoken about or spoken for, but there is little evidence of CHWs’ own characterisation of their practice, which raises questions for global health advocates regarding power and participation in CHW programmes. This paper addresses this issue.
A case study approach was undertaken in a series of four steps. Firstly, groups of CHWs from two communities met and reported what their daily work consisted of. Secondly, individual CHWs were interviewed so that they could provide fuller, more detailed accounts of their work and experiences; in addition, community health extension workers and community health committee members were interviewed, to provide alternative perspectives. Thirdly, notes and observations were taken in community meetings and monthly meetings. The data were then analysed thematically, creating an account of how CHWs describe their own work, and the tensions and challenges that they face.
The way that these CHWs described their work was as healthcare generalists, working to serve their community and to integrate it with the official health system. Their work involves referrals, monitoring, reporting and educational interactions. Whilst they face problems with resources and training, their accounts show that they respond to this in creative ways, working within established systems of community power and formal authority to achieve their goals, rather than falling into a ‘deficit’ position that requires remedial external intervention. Their work is widely appreciated, although some households do resist their interventions, and figures of authority sometimes question their manner and expertise. The material challenges that they face have both practical and community aspects, since coping with scarcity brings community members together. The implication of this is that programmes co-designed with CHWs will be easier to implement because of their relevance to their practices and experiences, whereas those that assume a deficit model or seek to use CHWs as an instrument to implement external priorities are likely to disrupt their work
Obtaining a diagnosis of tuberculosis (TB) is a prerequisite for accessing specific treatment, yet one third of estimated new cases are missed worldwide by National Programmes. This study investigated economic, geographical, socio-cultural and health system factors hindering adults’ attendance and completion of the TB diagnostic process in Yemen, to inform interventions designed to improve patient access to services.
The study found that the majority of patients surveyed were disadvantaged and had poor literacy (61% illiterate), had travelled from rural areas (47%) and attended with companions (84%). Key barriers for attendance identified were clinic and transport costs (augmented by companions), distance from home, a preference for private services, strong social stigma and a lack of understanding of the diagnostic process.
The authors conclude that strategies to bring TB diagnostic services closer to communities and address the multiple barriers patients face to attend, will be important to increase access to TB diagnosis and care.
This Helpdesk Report responds to the following query: What are the areas of likely comparative advantage of the private sector in delivery of health care services for public health goals particularly in the areas of MNCH and SRH including work with adolescents and SGBV?
It finds that there is a considerable body of evidence on the private provision of healthcare in low- and middle-income countries, often focusing on SSA. However, the evidence base is not robust. Evidence is often mixed and sometimes conflicting and policy implications are unclear.
The arguments in favour of private healthcare suggest it is more responsive and efficient, while arguments in favour of public services suggest they are more equitable and better equipped than the market to respond to health needs. Some studies find that the private sector is unregulated, has financial incentives for inappropriate healthcare, and is expensive.
There is very little evidence on the comparative cost-effectiveness of the private sector. This varies considerably across country contexts and types of services. There is no conclusive evidence that the private sector is more cost-effective or more efficient than the public sector. The literature warns that increased use of private services may crowd out or decrease the funding available to the public sector.
The major criticism of private sector services is that their higher user fees create inequality of access, limiting their use by the poor. The literature is quite clear that private for-profit health services create inequality. Private non-profit, or services run by NGOs, appear to mitigate some of the inequality effects.
In practice, boundaries can be blurred between public and private; both formal and informal cost recovery schemes operate at public facilities. NGOs providing healthcare are generally seen as private, although they may not charge for their services. The difference between free-at-the-point-of-use NGOs and out-of-pocket-expenditure on private doctors can be enormous, and it is important to differentiate between the types of providers when reviewing the evidence on private
The private sector has a large and growing role in health systems in low-income and middle-income countries. The goal of universal health coverage provides a renewed focus on taking a system perspective in designing policies to manage the private sector. This perspective requires choosing policies that will contribute to the performance of the system as a whole, rather than of any sector individually.
The private for-profit sector's prominence in health-care delivery, and concern about its failures to deliver social benefit, has driven a search for interventions to improve the sector's functioning. The authors review evidence for the effectiveness and limitations of such private sector interventions in low-income and middle-income countries.
Although the private sector is an important health-care provider in many low-income and middle-income countries, its role in progress towards universal health coverage varies. Studies of the performance of the private sector have focused on three main dimensions: quality, equity of access, and efficiency. The characteristics of patients, the structures of both the public and private sectors, and the regulation of the sector influence the types of health services delivered, and outcomes. Combined with characteristics of private providers — including their size, objectives, and technical competence — the interaction of these factors affects how the sector performs in different contexts.
Private health care in low-income and middle-income countries is very extensive and very heterogeneous, ranging from itinerant medicine sellers, through millions of independent practitioners — both unlicensed and licensed — to corporate hospital chains and large private insurers. Policies for universal health coverage (UHC) must address this complex private sector. However, no agreed measures exist to assess the scale and scope of the private health sector in these countries, and policy makers tasked with managing and regulating mixed health systems struggle to identify the key features of their private sectors.
In this report, the authors propose a set of metrics, drawn from existing data that can form a starting point for policy makers to identify the structure and dynamics of private provision in their particular mixed health systems; that is, to identify the consequences of specific structures, the drivers of change, and levers available to improve efficiency and outcomes. The central message is that private sectors cannot be understood except within their context of mixed health systems since private and public sectors interact. The authors develop an illustrative and partial country typology, using the metrics and other country information, to illustrate how the scale and operation of the public sector can shape the private sector's structure and behaviour, and vice versa.
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"As a result of the campaign, couples were motivated to communicate about health, and men and women were more likely to seek reproductive health services together."
This was one of the key results of the Vunja Ukimya. Zungumza na Mwenzio (Break the Silence. Talk to your partner) campaign in Tanzania. The campaign was launched in 2010 as part of the CHAMPION project, a six-year initiative (2008-2014) to increase men's positive involvement in preventing the spread of HIV in Tanzania. The 5-month national social and behaviour change communication (SBCC) campaign was designed to encourage couples to communicate more effectively for healthier, more equitable relationships and to prevent the spread of HIV. "Campaign messages focused on the role of gender equity in ensuring health, and targeted individuals, couples, and communities in promoting dialogue around HIV, gender equality, and positive health-seeking behavior." The brief forms part of a series of CHAMPION briefs to highlight some of the project's achievements.
The brief explains the campaign approach, which used radio, television, national newspapers, billboards, and outreach events and activities to reach audiences of adult men and women over the age of 25 and in established, longer-term relationships. The roll-out occurred in phases, beginning with a teaser phase, followed by a two month "problem phase" that also incorporated a World Cup sub-campaign, and then a "how to" phase, highlighting and demonstrating the health benefits of effective communication between partners. The messages focused on positive couple communication and used food as a metaphor for relationships, "indicating that both (dinner and happiness) require preparation and care to achieve the desired results."
The following are a selection of lessons learned:
Overall, the assessment of the Vunja Ukimya campaign was that it was widely well received, with community members responding positively to the promotion of couples being close and the concept of "transparency" within relationships.
This literature review was produced to inform how social and behaviour change communication (SBCC) programmes can contribute to improving services provided by community health workers (CHWs) and strengthen their ability to effectively deliver quality health care to community members. Produced as part of the Health Communication Capacity Collaborative (HC3) project, the literature review examines barriers and facilitating factors for CHWs in three areas: knowledge and competency, structural and contextual barriers (systemic and environmental factors), and motivational barriers (such as social norms and attitudes that effect CHWs willingness to provide services). Findings revealed that "CHWs face significant barriers, ranging from lack of materials and high workloads to ingrained attitudes and insufficient training." The report shares results and recommendations that can be used to anticipate and respond to potential barriers and promote facilitators to service provision through SBCC programmes for CHWs.
Based on a literature review, which included both peer-reviewed journals and grey literature on the topic of CHWs (with a particular focus on CHWs abilities, performance and attitudes), limited to resources published in the last 10 years focussing on middle- and lower-income countries, the report outlines a number of key findings.
The report concludes that "while identifying and understanding barriers can assist in the design and implementation of SBCC programs, additional research is needed to evaluate the actual impact of SBCC programs in overcoming these barriers. Some knowledge and attitudinal barriers may be easily addressed through communication strategies, however, more serious systemic barriers may prove more challenging to resolve."
Couple connectedness is defined as the quality of the emotional bond between partners that is both mutual and sustained over time. For couple connectedness to exist, it must be experienced by both partners in the relationship who are committed to practicing these behaviors..."
This was the core principle underlying CoupleConnect, a gender-transformative curriculum developed by the CHAMPION Project in Tanzania to help couples communicate more effectively about relationship challenges as a way to foster improved sexual and reproductive health and prevent HIV. Created in 2011, the CoupleConnect curriculum was used to guide group education workshops designed to provide couples with insights, information, and skills needed to increase their "connectedness," considered an important determinant of healthy sexual and reproductive health (SRH) behaviour.
The brief explains that "couple connectedness is operationalized by nine determinants of sexual behavior focused on mutual trust and support, communication, financial planning and management, shared goals, love and affection, joint decision making, achievement and maintenance of RH, and conflict resolution." The 15-session CoupleConnect curriculum was designed specifically for Tanzania through a process that included stakeholder meetings and key informant interviews, followed by a pilot project in nine districts. Couples participated in sessions using interactive teaching methodologies, such as large-group and knee-to-knee couple discussions, fishbowls, and other adult learning games. Workshop results were assessed through a comparison of questionnaires to assess attitudes, beliefs, and knowledge related to "couple connectedness."
The brief offers a number of recommendations:
This fifth volume of the mHealth Compendium, produced by the African Strategies for Health Project for the United States Agency for International Development (USAID), is a collection of 41 case studies submitted by various implementing partners which document a range of mHealth applications being implemented mainly throughout Africa, but also in other regions of the world. The majority of case studies focus on maternal, newborn and child health issues and HIV/AIDS, with some also looking at mHealth used to address tuberculosis, Ebola and malaria.
The case studies in this compendium have been organised into five programmatic areas where mHealth is being implemented: 1) Behaviour Change Communication; 2) Data Collection; 3) Finance; 4) Logistics; and 5) Service Delivery. Each two-page case study includes an introduction to the health area or problem; a description of the mHealth intervention highlighted; a description of any important results or evaluation findings; lessons learned; and a conclusion. In addition, the second page includes a summary of the geographic coverage, implementation partners, and donors, as well as contact information for the implementing partner and donor.
The mHealth Compendium Special Edition 2016: Reaching Scale presents ten in-depth profiles of mHealth programmes that have grown in scale over time. This edition follows on from a series of five mHealth Compendiums which were produced by the United States Agency for International Development (USAID)’s Africa Bureau project, African Strategies for Health (ASH), to help USAID missions, governments, and health implementing organisations access information on a range of mHealth example programmes. The series (see Related Summaries below) features over 150 case studies of mHealth programmes and applications being implemented mainly throughout Africa, but also in other regions of the world.
Each case study includes details of the process, challenges, and lessons learned in growing an mHealth programme. The featured programmes are:
The dominant nutrition discourse concerns access to adequate food and its quality. It now includes food security, food rights and justice, governance and agriculture. Despite many initiatives to assure food access, and growing economies, high levels of undernutrition persist in much of Asia. It is increasingly suggested that much of this ‘Asian enigma’ can now be explained by open defecation (OD) combined with population density. However, the insight that ‘shit stunts’ remains a widespread blind spot. The persistence of this blind spot can in part be explained by factors which are institutional, psychological and professional. Reductionist focus on the diarrhoeas, which are serious, dramatic, visible and measurable, has led to the relative neglect of many other often subclinical and continuously debilitating faecally-transmitted infections (FTIs) including environmental enteropathy (EE), other intestinal infections, and parasites. These are harder to measure but together affect nutrition much more: the diarrhoeas are only the tip of the much larger sub-clinical iceberg.
How OD and FTIs, poverty and undernutrition reinforce each other is illustrated in this paper by looking at the case of India, which has about 60 per cent of the OD in the world, around a third of the undernourished children, and approximately a third of the people living in poverty. Through OD, FTIs and in other ways, lack of sanitation leads to losses, which may be estimated, in the range of 1 to 7 per cent of GDP in various countries.
To reframe undernutrition for a better balance of understanding and interventions, the authors propose two inclusive concepts: the FTIs and the 5 As. The first two As – availability and access – are oral, about food intake, while the last three As – absorption, antibodies and allopathogens – are novel categories, anal and internal, about FTIs and what happens inside the body. These concepts have implications for research, professional teaching and training, and policy and practice. While other countries make rapid progress towards becoming open-defecation free, India remains obstinately stuck, making undernutrition in India one of the great human challenges of the twenty first century.
The concepts of FTIs and the 5 As reframe more inclusively how undernutrition is perceived, described and analysed. The authors hope is that this reframing will contribute however modestly to a cleaner, healthier and happier world in which all children and adults are well-nourished and can grow and live to their full potential.
It took the threat of a global health crisis to illustrate the failings of Africa’s health systems. Resilient health systems, free at the point of use, are evidently a global public good. They are essential for the provision of universal health coverage and for a prompt response to outbreaks of disease.
Resilient health systems require long-term investment in the six key elements that are required for a resilient system:
Six foundations for resilient health systems:
• an adequate number of trained health workers, including non-clinical staff and CHWs
• available medical supplies, including medicines, diagnostics and vaccines
• robust health information systems (HIS), including surveillance
• an adequate number of well-equipped health facilities (infrastructure), including access to clean water and sanitation
• adequate financing
• a strong public sector to deliver equitable, quality service
The HPSR database has been developed as a result of a study undertaken by the Teaching and Learning Health Policy and Systems Research Thematic Working Group. Commissioned by the Alliance for Health Policy and Systems Research, the study did a global mapping of current teaching and training programmes focused on HPSR relevant to low- and middle-income countries. It intended to assess their reach and diversity in terms of content and modalities, identifying major gaps and opportunities to expand HPSR teaching capacity.
The database includes:
Repositories of courses and course materials
Tools and libraries from HPSR-related multi-partner collaborations
Like other countries seeking a progressive path to universalism, Peru has attempted to reduce inequalities in access to healthcare by granting the poor entitlement to tax-financed basic care without charge. The authors identify the impact of this policy by comparing the target population’s change in healthcare utilization with that of poor adults already covered through employment-based insurance. There are positive effects on receipt of ambulatory care and medication that are largest among the elderly and the poorest. The probability of getting formal healthcare when sick is increased by almost two fifths, while the likelihood of being unable to afford treatment is reduced by more than a quarter. Consistent with the shallow cover offered, there is no impact on use of inpatient care. Mean out-of-pocket (OOP) expenditure on healthcare is unaffected but spending is reduced by up to one quarter at some points of the distribution. Among healthcare users, medical spending is reduced across much of the distribution and in relative terms falls most at lower quantiles, which is consistent with limited nominal and effective coverage of expensive treatments.
There are two main types of diabetes. Type 2 accounts for over 90 per cent of diabetes worldwide. It results from the body’s ineffective use of insulin, leading to raised glucose levels in the blood. One of the four leading global NCDs2, diabetes is a major cause of chronic illness and morbidity:
Key messages fromthis factsheet:
Access to health care gained the spotlight on national and international development agendas when the 1978 Alma Ata Declaration outlined a strategy for achieving universal access to primary health care by the year 2000 (World Health Organization, 1978). The Millennium Development Goals (MDGs) set targets for improving health-care delivery by 2015, and the United Nations’ new Sustainable Development Goals (SDGs), which took effect in January 2016, extend and supplement those with ambitious targets aimed at ensuring healthy lives for all.
Despite significant gains under these initiatives, Africans fully support health care’s continued prominence on development agendas: In Afrobarometer surveys across 36 African countries in 2014/2015, citizens rank health as the second-most-important problem (after unemployment) that their governments need to address, as well as the No. 2 priority (after education) requiring additional government investment.
While the proportion of Africans going without needed health care has decreased over the past decade, citizens’ perceptions highlight some of the challenges that still stand between current reality and “health for all,” including:
The health sector assumes special importance in India-Africa development cooperation. It is the major component of the broad-ranging collaborative effort envisaged under the rubric of India-Africa cooperation in social development and capacity building. India is playing a crucial role in extending healthcare cooperation to the African region to fight the scourge of fatal diseases like HIV/AIDS, malaria, TB, and pandemics.
India-Africa development cooperation in healthcare sector assumes added importance in view of the Sustainable Development Goal 3 that calls for ensuring healthy lives and promoting well-being for all.
Apart from the traditional trade and investment route, India has taken some major initiatives in the health care sector in Africa through the Pan-Africa e-Network Project (PAENP). Medical practitioners at the patient end locations in Africa can consult on-line with Indian medical specialists in various disciplines and specialties selected by African Union for its Member States. India’s is the third largest pharmaceutical formulation supplier to Africa.
Considering the current state of global economies, the governments will have to play the role of a facilitator than that of a doer. This could take the form of incentives. Some possible areas for such incentives are:
Government initiatives can also be for:
On the African governments’ side, faster drug marketing approval for generic pharmaceuticals, speedier measures for various clearances required for setting up new ventures in the pharmaceutical sector and also in the health care sector are required.
Indian private and public sector as well as non-governmental agencies could also consider taking initiatives in bringing together philanthropists to contribute towards Africa’s determination to achieve health for all in the shortest possible period.
The establishment of the India-Brazil-South Africa Trilateral Cooperation Forum (IBSA), formalised by the Brasilia Declaration in 2003 is a distinctive international trilateral development initiative to promote South- South cooperation among these countries.
In order to assess the overall status of social sectors in IBSA countries since its inception, this paper analyses the select Communiqués and Declarations pertaining to social sectors issued from time to time. In this context, it evaluates the status and performance of social development in each of the IBSA countries and analyses the progress achieved in terms of poverty reduction, health and education towards achievement of MDGs targets. The paper presents an insight from the policy initiatives taken for inclusive growth followed by analysis of their serious commitments into concrete actions to strengthen trilateral cooperation and finally suggests the way forward.
Ghana’s National Health Insurance Scheme (NHIS) is an innovative attempt to extend social protection to informal workers, and, as such, it may hold important policy lessons for other countries where the informal economy is large and growing and where informal workers are excluded from existing social protection mechanisms.
The paper concentrates on the interactions between three groups of women informal workers (traders, headload porters, and indigenous caterers) and the scheme, focusing particularly on the barriers to accessing the scheme and to participating in its development and management.
The major factor for poorer workers was the cost of the premiums, which often sit well above the mandated minimum in urban areas. For better off workers, the major barrier was the chaotic administration of the district schemes, which meant that a significant amount of time had to be spent trying to register with the NHIS. It was also discovered that there has been very little direct involvement of informal workers in either the design or the ongoing management of the scheme, with the result that it does not take into account the particular needs of informal workers.
The paper concludes that, as the NHIS reflects the wider inequalities of Ghanaian society, systemic changes in social and economic policy are necessary for it to truly promote the ideal of universal access to healthcare. It then offers shorter term recommendations for changes that would allow the scheme as it exists at present to become more responsive to the needs of informal workers.
Summary adapted from source.
In recent years, the government of India has made attempts to address its notorious health inequities by providing health protection to poor and vulnerable citizens. This paper presents an overview of India’s health care system and some key demographic indicators. Then, the paper analyses some of India’s most prominent health protection schemes, from the perspective of poor informal women workers. The analysis addresses the following issues: inclusiveness and access for informal workers; the quality of services being provided; awareness of the scheme among its intended beneficiaries; the scheme’s impact on reducing out-of-pocket expenditure on health care; and the scheme’s ability to provide access to women.
The study finds that health schemes that are rooted in highly unequal societies are likely to reproduce that inequality. However, it is also finds that the institutional reproduction of inequality can to some extent be mitigated if health schemes are integrated into programmes that seek to improve living and working conditions more generally. The paper argues that without a comprehensive approach to raising the living standards of poor workers, including the provision of primary healthcare and preventive health services, health inequities are unlikely to decline.
Adapted from author’s summary.
While in many low- and middle-income countries, urban women have had better opportunities to join growing formal economies, rural women are often stuck in harsh living and working conditions in informal economies. The aim of this report is to examine and provide evidence of inequalities in social health protection experienced by rural women. Due to questions of data availability, the report focuses on two aspects of health: utilization of maternal health care and antiretroviral treatment. Further, the report examines the specific barriers to utilization of health services for women in rural areas, and the systemic weaknesses for rural women, such as gender-blind financing mechanisms. Because the root causes of the identified inequities are complex and cannot be addressed by social protection alone, the authors argue that effectively eliminating issues of access for women in rural areas requires a coherent policy approach in health, social and economic sectors.
Access to health protection is crucial for both good health of the population and for boosting the economy. Ensuring that everyone can attend quality health care is a prerequisite for sustainable development based on equity and inclusiveness. This policy paper examines the dimensions magnitude of the global health crisis at the global, regional and national level as well as urban/rural divergences within countries. Dimensions include gaps in legal health coverage, availability, affordability and financial protection of quality services.
Using the framework of national social protection floors, the paper suggests policy responses to address the crisis, focusing on inclusive legislation and adequate financing as well as making quality services available and providing financial protection. Finally, the paper concludes that progressing towards universal health protection is possible by developing a three-step approach that yields highest rates of returns in terms of sustainability, economic growth and equity.
Adapted from available summary.
This report addresses the role of employment in efforts to reduce poverty in the context of increased globalisation and its impacts on labour markets. Worldwide, countries are experiencing a decline of jobs with secure and lasting contracts and work-related social benefits. As a consequence, for many, employment fails to provide the opportunity to escape poverty and even contributes to vulnerability. While the importance of employment for poverty reduction is gaining recognition in development agencies, less attention has been given to occupationally related injury and illness as a major source of worker vulnerability. This study investigates the impact of occupational injury and illness on poverty and uses three case studies to explore possible interventions to reduce these work-related risks in capacity constrained environments.
The report considers conceptual and measurement issues in establishing the relationship between work-related health risks and poverty and reviews the mainstream regulatory mechanisms for occupational health and safety (OHS). The report identifies these mechanisms’ failure to adapt to the changing nature of work and worker vulnerability as a major limitation, and presents case studies of interventions to improve OHS for informal workers. This leads to a range of lessons and recommendations and a call for improving quantitative and qualitative data about OHS and the informal economy.
Adapted from authors' summary.
In the last ten years, the Department of Health (DOH) has actively assumed a new form of leadership in the health sector in response to changes in the policy environment. It has reexamined the focus of the public delivery system, improved targeting of public spending reconsidered better protection of consumers, sought out alternative sources of health care financing, decentralized the system and relied more on private market solutions. Thus, the rapidly changing policy environment has led the Department to rethink and recast its roles as provider, financier, regulator and coordinator of an increasingly decentralized and private health care system.
This brief includes have two major features. One dissects the key economic issues that the new Philippine president faces as a new six-year term unfolds after the May presiden tial election. The other talks about two top Philippine export industries and their use of a "common" factor input— unskilled labor—as they work to occupy the top slot in the list of the country's exporters. While the focus of the two articles' exposition may, at first glance, differ from one another, a closer look reveals that one running theme pervades in the two articles— that of leadership and the difficult yet necessary decisions that need to be made to assert such leadership and give it real meaning.
If agriculture has historically been the engine of economic growth of the Philippines, it looks like a new engine is driving it these days—services. Services is where the real growth is actually coming as this issue’s banner article discusses. Not only does it contribute significantly to economic output, it also creates millions of jobs. Services is also where substantial amounts of foreign direct investment are being poured in.
Articles inthis brief include:
In the light of increased demand for basic services and sanitation facilities due to urbanisation, devolution facilitates the smooth and fast delivery of social services. In the health sector, however, the strongest opposition, due to issues of tenure, the sustainability of devolved facilities and the politics of health services, has met devolution. Various local officials have complained over the delay and insufficiency of funds that deter the immediate implementation of health programs. However, there are LGU’s where health sector devolution has reaped appreciation. The focus of this paper is to highlight the model cities recommended by NEDA regional offices, which are winners of various competitions such as Galing Pook and Health and Management System Awards. This is in the hope of setting examples in overcoming the limitations entailed by devolution in the health sector.
This paper is one of eight case studies in the health sector conducted under the project 'Population and Urbanization: Managing the Urbanization Process Under the decentralized Governance Framework' jointly undertaken by the Philippine Institute for Development Studies, National Economic and Development Authority and Development Academy of the Philippines. This paper is a case study on Cotabato City recommended by NEDA-Region XII as a model city for health. The city has come up with the Special Project on Health and Sanitation that won a silver Award in the 1997 Health and Management Information System Contest.
This paper estimates a discrete choice model of outpatient care using data drawn from a household survey covering four regions and seven provinces in the Philippines. The choice alternatives include home care and formal care which consists of hospital outpatient clinics, independent private clinics, and public or charity clinics. Both simple logit model and nested logit specifications were estimated. Unlike the results in Gertler and van deer Gaag (1990), the data did not support rejection of the simple logit in favor of the nested logit model specification. The paper found that, contrary to early results (e.g., Akin et al. 1985), prices or user fees and income are important determinants of health care choice. The price elasticities, however, are small in magnitude compared to those in Ching (1995). However, just like the result in Ching (1995) there is a clear tendency for bigger price elasticities among lower income households compared to high income households.
The capital stock of public health facilities in the Philippines has been stagnant for decades. The number of hospitals remained the same since the mid-1990s and the ratio of hospital beds per 10,000 population has declined from 18 in the 1970s to 13 in the late 2000s. To arrest the deteriorating stock and quality of public health facilities, the Department of Health launched the Health Facilities Enhancement Program (HFEP) in 2007. This Policy Note presents the key findings of field surveys conducted by PIDS between December 2014 and April 2015 in several provinces to assess the HFEP implementation. Lack of service delivery network plan for expansion and upgrading of facilities, and non-use of commissioned contracting were some of the major problems found in the assessment. To address these problems, this Note provides some recommendations. They include, among others, formulating an overall national/regional health facilities strategic plan and organizing the health facilities to be upgraded or constructed into sets or tranches under a commissioned contracting approach.
By design, the PhilHealth Customer Assistance, Relations and Empowerment Staff (CARES) project provides a member/patient-focused service that mediates between the individual and the huge government machinery as well as with stakeholders such as hospitals and health-care providers.
This Policy Note describes the overall goals and objectives of the program and how these are understood by the program managers and staff in selected areas in the National Capital Region. It evaluates the extent to which these goals and objectives were met, as well as the strengths, weaknesses, opportunities, and threats as perceived by the CARES managers and staff. Helping patients obtain benefits and hospitals process their claims were some of the strengths and opportunities of CARES. The challenges posed by poor technical and logistical support, lack of efficient monitoring and evaluation systems, and the absence of job tenure were among the weaknesses and threats that PhilHealth has to contend with.
Catastrophic illnesses can impoverish a household due to unmanageable expenditures that arise from their treatment or management. The Z Benefits program of PhilHealth aims to protect Filipinos from financial catastrophe due to certain medical conditions. The cases included in the Z benefits program, however, are few, and only selected government hospitals provide the Z benefits. Using the private sector to address the limitations of the current Z benefits packages will enable the government to provide financial protection to more Filipinos.
This Policy Note finds that a supplemental fund from the private sector for catastrophic illness financing is currently not feasible. One of the recommendations in this Note to further involve the private sector is to enhance the current situation. The private sector provides supplemental insurance through health maintenance organizations (HMOs), insurance companies, and self-insured companies by providing Z benefits in private hospitals. This can be a common ground for PhilHealth, HMOs, and self-insured companies to serve their clients or employees for catastrophic illnesses.
Although free services and drugs are available in various Directly Observed Treatment Short Course (DOTS) units, many tuberculosis (TB) patients still prefer to go to private health facilities due to proximity and better quality of service.
This Policy Note discusses the strategies recommended for a more active and sustainable involvement and engagement of the private sector as an important partner in controlling TB. In particular, strong and dedicated support of the government to the private sector is crucial for the partnership to continue. It is also important to develop and pilot a short messaging service-based information system to assist in the referral, tracking of patients and defaulters, and facilitate the referral and feedback system among DOTS facilities and private service providers. There is also a need to review the procurement and distribution system to ensure steady supply of anti-TB drugs. The conduct of information and education campaign to promote the availability of quality-assured DOTS services is also warranted.