Health Policy and Planning - Advance Access

Global health funding: how much, where it comes from and where it goes

McCoy, D., Chand, S., Sridhar, D. — 2009-07-01

Global health funding has increased in recent years. This has been accompanied by a proliferation in the number of global health actors and initiatives. This paper describes the state of global heath finance, taking into account government and private sources of finance, and raises and discusses a number of policy issues related to global health governance. A schematic describing the different actors and three global health finance functions is used to organize the data presented, most of which are secondary data from the published literature and annual reports of relevant actors. In two cases, we also refer to currently unpublished primary data that have been collected by authors of this paper. Among the findings are that the volume of official development assistance for health is frequently inflated; and that data on private sources of global health finance are inadequate but indicate a large and important role of private actors. The fragmented, complicated, messy and inadequately tracked state of global health finance requires immediate attention. In particular it is necessary to track and monitor global health finance that is channelled by and through private sources, and to critically examine who benefits from the rise in global health spending.

Mental health policy in South Africa: development process and content

2009-06-26

Introduction Mental health is increasingly acknowledged as a crucial public health issue in South Africa (SA). However, it is not given the priority it deserves on policy agendas in this and many other low- and middle-income countries. The aim of this analysis is to describe the content of mental health policy and the process of its development in SA.

Methods Quantitative data regarding SA's mental health system were gathered using the World Health Organization (WHO) Assessment Instrument for Mental Health Systems. The WHO Checklist for Mental Health Policy and Plans was completed for SA's 1997 mental health policy guidelines. Semi-structured interviews provided understanding of processes, underlying issues and interactions between key stakeholders in mental health policy development.

Results There is uncertainty at provincial level regarding whether the 1997 policy guidelines should be considered national policy. At national level the guidelines are not recognized as policy, and a new policy is currently being developed. Although the guidelines were developed through wide consultation and had approval through national policy development processes, difficulties were encountered with dissemination and implementation at provincial level. The principles of these policy guidelines conform to international recommendations for mental health care and services but lack clear objectives.

Discussion The process of mental health policy implementation has been hindered by the low priority given to mental health, varying levels of seniority of provincial mental health coordinators, limited staff for policy and planning, varying technical capacity at provincial and national levels, and reluctance by some provincial authorities to accept responsibility for driving implementation.

Conclusion These findings highlight the importance of national leadership in the development of new mental health policy, communication between national and provincial levels, the need for provincial structures to take responsibility for implementation, and capacity building to enable policy makers and planners to develop, monitor and implement policy.

Augmenting frameworks for appraising the practices of community-based health interventions

2009-06-23

This paper aims at augmenting the frameworks proposed by Rifkin in 1996 to distinguish between target-oriented and empowerment approaches to participation in community-based health interventions. In her paper, Rifkin defined three criteria: who makes decisions on resource allocation, expected outcome and outcome assessment. We propose five additional criteria: the definition of community, the characteristics of the capacity-building process, the leadership characteristics, the documentation process, and ethical issues regarding participation. Derived from our analysis of a community-based project, the proposed criteria are discussed in the light of the principles of Popular Education and other literature on community participation. The augmented frameworks are intended to assist health professionals and planners interested in the empowerment approach of community participation to consciously sharpen their practice.

Health needs and health-care-seeking behaviour of street-dwellers in Dhaka, Bangladesh

Uddin, M. J., Koehlmoos, T. L., Ashraf, A., Khan, A I, Saha, N. C., Hossain, M. — 2009-06-17

The study objective was to ascertain the extent to which the need for primary health care services among street-dwellers is being met through existing facilities.

This community-based cross-sectional study was conducted in Dhaka city over a 12-month period from June 2007 to May 2008. The study population included ever-married females and males aged 15–49 years. Data for the study were collected through a community survey and exit interviews. Both bivariate and multivariate analyses were done.

Seventy-two per cent of female and 48% of male street-dwellers interviewed were sick at the time of data collection. Twenty-one per cent of deliveries were conducted on the street. Eighty-nine per cent of the street-dwellers reported that their children aged less than 5 years had more than one symptom associated with acute respiratory infection during the last 2 weeks. Thirty-seven per cent of the females and 34% of the males interviewed reported that their accompanied children had diarrhoea. A few street-dwellers sought services for their health problems, and most went to the nearest pharmacy and to mobile clinics run by a non-governmental organization at night. Eighty-eight per cent of the female and 88% of the male street-dwellers used open space for their defecation.

The street-dwellers are extremely vulnerable in terms of their health needs and health-care-seeking behaviours. There is no health service delivery mechanism targeting this marginalized group of people. Although the health, nutrition and population sector programme of Bangladesh designed programmes to ensure equitable essential services to all, this marginalized group of people was not targeted. The Ministry of Health and Family Welfare and private sectors should, thus, should focus future programmes to meet the needs of this extremely vulnerable group. Mobile and static clinics at night for street-dwellers may be potential programmes. Action research to assess the effectiveness of programmes is essential before large-scale implementation.

Assessing access barriers to maternal health care: measuring bypassing to identify health centre needs in rural Uganda

Parkhurst, J. O, Ssengooba, F. — 2009-06-11

Background In low income countries, several barriers exist to the use of health services for child delivery, including distance, transportation, informal costs or low perceived quality. Yet there is rarely information about which barriers are more or less important to the use of a given health facility. This study assessed the relative importance of different barriers to maternal health facility use in rural Uganda through the use of simple indicators based on locally available data.

Methods Data from public health facilities performing deliveries in a rural district were used along with census information to construct a set of indicators useful for diagnosing barriers to delivery service use. Indicators included the number of facility-based deliveries per 1000 women served, the proportion of users from a facility's local area, and a new indicator, the ‘bypassing ratio’, defined as the number of women from a facility's local area who delivered in other facilities, divided by the number of local women using the facility itself.

Results Numbers of deliveries varied greatly between facilities of the same level. A few very low use facilities saw over 75% of women come from the local area, while other facilities services attracted a large majority of women from other areas. The phenomenon of bypassing provides additional insight into the relative importance of distance or transport as opposed to internal facility factors preventing use.

Conclusions Simple and easily replicable tools are essential to assist health managers to identify communities and facilities needing improvements in access to delivery care. The methods developed in this paper could be utilized by local officials in other areas to assist planning and improvement of both maternal care and other health services.

Tackling HIV and gender-based violence in South Africa: how has PEPFAR responded and what are the implications for implementing organizations?

Ghanotakis, E., Mayhew, S., Watts, C. — 2009-06-08

South Africa has some of the highest levels of both HIV and gender-based violence (GBV) worldwide. The international literature has highlighted the importance of tackling GBV in the fight against AIDS. Although the link between these epidemics is acknowledged by South Africa's medical and NGO communities, government response has largely dealt with them separately. PEPFAR is South Africa's largest HIV/AIDS donor, representing significant funding potential for programmes seeking to tackle these twin epidemics.

Using a combination of policy document analysis and key informant interviews at national and provincial level (Western Cape), we examined PEPFAR's response to the GBV-HIV link, the extent to which PEPFAR is aligned to national policies and the extent to which implementing agencies have felt able to work with PEPFAR funding.

A number of PEPFAR-South Africa's positions (e.g. on condoms and abortion) stand in contradiction to South Africa's own laws. While PEPFAR-South Africa officials are adamant that PEPFAR addresses the GBV-HIV link, it does not form an explicit strategic goal and there are no indicators for this work. Although some agencies receiving PEPFAR funding do address the links between GBV and HIV, this appeared incidental rather than the reason for their receipt of PEPFAR funding.

Not one implementing agency interviewed agreed with PEPFAR's ideological stance, perceiving it unhelpful and inappropriate in a social context defined by violence and HIV. Nevertheless, many organizations were prepared to apply for funding. Those awarded it found creative ways to work with—or around—PEPFAR's restrictions to ensure delivery of an appropriate range of much needed services to those facing the twin epidemics of HIV and GBV. The recent change in the US administration offers an important opportunity for broader links between HIV and GBV to be supported through PEPFAR. This paper makes recommendations for building a more systematic approach on the current ad hoc experience of PEPFAR in South Africa.

Determinants of health care demand in poor, rural China: the case of Gansu Province

Qian, D., Pong, R. W, Yin, A., Nagarajan, K V, Meng, Q. — 2009-05-08

This paper examines the determinants that influence health care demand decisions in rural areas of Gansu province, China. This represents the first effort to identify and quantify the effect of price of care on choice of provider in China, and is the first quantitative examination of this topic focusing on poor rural areas in China. In the three-tier health care system in rural China, we further distinguish the public village clinics and private village clinics using a mixed multinomial logit model. The results show that price and distance play significant roles in choice of health care provider. The price elasticity of demand for outpatients is higher for low-income groups than for high-income groups. When outpatients have particular concerns about provider quality or reputation, or when their health status is poor, distance tends to matter less, i.e. they are willing to travel further in order to obtain better treatment for their illness. Insurance status has a significant impact on the choice of public village clinics relative to self-treatment. Furthermore, age and the attributes of illness are also statistically significant factors. We discuss the policy implications of the results for meeting the health care needs of the poor in rural China.

Providing information on pregnancy complications during antenatal visits: unmet educational needs in sub-Saharan Africa

Nikiema, B., Beninguisse, G., Haggerty, J. L — 2009-04-28

Introduction Lack of information on the warning signs of complications during pregnancy, parturition and postpartum hampers women's ability to partake fully in safe motherhood initiatives. We assessed the extent to which women in 19 countries of sub-Saharan Africa recall receiving information about pregnancy complications during antenatal care for the most recent pregnancy, and examined the impact of advice receipt on the likelihood of institutional delivery.

Methods A cross-sectional, cross-country analysis was performed on data from the most recent Demographic and Health Surveys (DHS) of 19 countries of sub-Saharan Africa. Multilevel logistic regressions were used to predict the probability of receiving information and delivering in a health centre, by clinical risk factors (age, parity, previous pregnancy termination), social factors (area of residence, education), and the frequency of service utilization (number of visits).

Results The percentage of women recalling information about potential complications of pregnancy during antenatal care varied widely, ranging from 6% in Rwanda to 72% in Malawi, and in 15 of the 19 countries, less than 50% of women reported receiving information. Institutional delivery ranged from 29% (Ethiopia) to 92% (Congo Brazzaville). Teenagers (OR = 0.84), uneducated (OR = 0.65) and rural women (OR = 0.70) were less likely to have been advised, compared with women aged 20–34 years, women with secondary education and urban women, respectively. Likelihood of recalling information increased with the number of antenatal visits. Advice reception interacts with the number of antenatal visits to increase the likelihood of institutional delivery.

Conclusion There is a high level of unmet need for information on pregnancy complications in sub-Saharan Africa, particularly among those who face significant barriers to accessing care if complications occur. Educational interventions are critical to safe motherhood initiatives; health providers must fully use the educational opportunity in antenatal care.