Small fish in a big pond? External aid and the health sector in South Africa

The National Strategic Plan of South Africa: what are the prospects of success after the repeated failure of previous AIDS policy?

Hitherto, the story of HIV/AIDS in South Africa is, to a large extent, one of lost opportunities. Whereas the country has one of the worst epidemics in the world, consecutive national AIDS strategies have been repeatedly marked by failure over almost three decades. Understandably, South Africa's most recent HIV/AIDS policy, the HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011 (NSP), has been greeted with general acclaim. However, what are its real prospects of success against the backdrop of the repeated failures of the past? The first objective of this review is to systematically identify the core reasons for past policy failures. Using a comprehensive analytical framework, this article presents a systematic review of the literature on postapartheid AIDS policy in South Africa. The analysis demonstrates that a complex interplay among the content, context, actors and process of AIDS policy created a gap between policy making and policy implementation, which rendered near-ideal AIDS policies ineffective. Secondly, we evaluate the chances of success of the current NSP by examining both the policy-making phase and the resulting policy document in light of the reasons for past policy failures. Our analysis shows that the NSP contains dynamic and comprehensive policy content, sensitive to the socio-economic and cultural dimensions of HIV/AIDS. However, many of the political actors that hampered treatment implementation in the past, and who deepened the gap between government and civil society, are still in office. Monetary and human resource shortages also create a policy context that is infertile for the implementation of a comprehensive HIV/AIDS strategy, as envisaged in the NSP. Finally, these health system restrictions have a clear negative impact on the process of policy implementation. Without the mobilization of people living with HIV/AIDS and their communities, the NSP will be ineffective in bridging the gap between policy intentions and policy implementation. The strength of this article lies in its systematic analysis of previous policy responses, as a basis for appraising current AIDS policy. Although such an approach tends to simplify the complexities of the actual policy environment, it nonetheless draws to the attention of policy participants the importance of and the complex interrelationships among the different dimensions of AIDS policy.

Reducing user fees for primary health care in Kenya: Policy on paper or policy in practice?

BACKGROUND

Removing user fees in primary health care services is one of the most critical policy issues being considered in Africa. User fees were introduced in many African countries during the 1980s and their impacts are well documented. Concerns regarding the negative impacts of user fees have led to a recent shift in health financing debates in Africa. Kenya is one of the countries that have implemented a user fees reduction policy. Like in many other settings, the new policy was evaluated less that one year after implementation, the period when expected positive impacts are likely to be highest. This early evaluation showed that the policy was widely implemented, that levels of utilization increased and that it was popular among patients. Whether or not the positive impacts of user fees removal policies are sustained has hardly been explored. We conducted this study to document the extent to which primary health care facilities in Kenya continue to adhere to a 'new' charging policy 3 years after its implementation.

METHODS

Data were collected in two districts (Kwale and Makueni). Multiple methods of data collection were applied including a cross-sectional survey (n = 184 households Kwale; 141 Makueni), Focus Group Discussions (n = 12) and patient exit interviews (n = 175 Kwale; 184 Makueni).

RESULTS

Approximately one third of the survey respondents could not correctly state the recommended charges for dispensaries, while half did not know what the official charges for health centres were. Adherence to the policy was poor in both districts, but facilities in Makueni were more likely to adhere than those in Kwale. Only 4 facilities in Kwale adhered to the policy compared to 10 in Makueni. Drug shortage, declining revenue, poor policy design and implementation processes were the main reasons given for poor adherence to the policy.

CONCLUSION

We conclude that reducing user fees in primary health care in Kenya is a policy on paper that is yet to be implemented fully. We recommend that caution be taken when deciding on how to reduce or abolish user fees and that all potential consequences are carefully considered.

Good governance and sustainability: a case study from Pakistan

OBJECTIVE

On the basis of a case study in Pakistan, the paper argues that good governance, characterized by transparency, accountability and meaningful community participation, plays a critical role in the sustainability of donor-funded health systems projects in the public health sector.

METHODS

The Family Health Project (FHP) (1992-1999), funded by the World Bank, has been used as a case study. Critical analysis of secondary data mainly obtained from the Department of Health (DoH) in the province of Sindh in Pakistan is the major tool used for the study. Data from other sources including the World Bank have also been used.

RESULTS

The analysis reveals that the existing health care system could not fully absorb and sustain major "sociopolitical" thrusts of the project, meaningful community participation and "democratic" decision-making processes being the most important ones. The hierarchical structure and management process made it difficult to produce a sense of ownership of the project among all managers and the rank and file staff. The Provincial Health Development Center (PHDC) and District Health Development Centers (DHDCs) established by the FHP did not receive adequate financial and political support from DoH and the Ministry of Health to have much control of the project at the local level. Consequently, these Centers largely failed to institutionalize a continuing training program for district level health officials/professionals. Due to lack of political support, the District Health Management Teams (DHMTs) could not be institutionalized. Community participation in the DHMTs was symbolic rather than forceful. Improved coordination among all stakeholders, more stable and competent leadership, more meaningful community participation, greater devolution of project management to the district level, and better management of resources would have resulted in more effective and efficient implementation of the project. Based on these findings, the paper introduces a Sustainable Management Approach (SMA) as a tool that can be used to ensure the sustainability of health systems projects, particularly those funded by international organizations in developing countries.

CONCLUSIONS

Good governance and a conducive organizational culture are important prerequisites for incorporating any new project within an existing system. This includes prior consensus building among all stakeholders, a meaningful and inclusive participatory planning, implementation and evaluation process involving communities, political commitment, and the identification and use of appropriate leadership for project management.

A comparison of single- and multi-payer health insurance systems and options for reform

A major choice confronting many countries is between single-payer and multi-payer health insurance systems. This paper compares single-payer models in the areas of revenue collection, risk pooling, purchasing, and social solidarity. Single-payer and multi-payer systems each have advantages which may meet countries' priorities for their health insurance system. Single-payer systems are usually financed more progressively, and rely on existing taxation systems; they effectively distribute risks throughout one large risk pool; and they offer governments a high degree of control over the total expenditure on health. Multi-payer systems sacrifice this control for a greater ability to meet the diverse preferences of beneficiaries. Several major reforms of single-payer insurance systems--expansion of the role of private insurance and transformation to a multi-payer system--are then described and illustrated using specific country examples. These reforms have been implemented with some success in several countries but face several important challenges.