The essence of governance in health development

Unveiling the health consequences of air pollution in the world's most polluted nations

Air pollution poses a persuasive threat to global health, demonstrating widespread detrimental effects on populations worldwide. Exposure to pollutants, notably particulate matter with a diameter of 2.5 µm (PM2.5), has been unequivocally linked to a spectrum of adverse health outcomes. A nuanced understanding of the relationship between them is crucial for implementing effective policies. This study employs a comprehensive investigation, utilizing the extended health production function framework alongside the system generalized method of moments (SGMM) technique, to scrutinize the interplay between air pollution and health outcomes. Focusing on a panel of the top twenty polluted nations from 2000 to 2021, the findings yield substantial insights. Notably, PM2.5 concentration emerges as a significant factor, correlating with a reduction in life expectancy by 3.69 years and an increase in infant mortality rates by 0.294%. Urbanization is found to increase life expectancy by 0.083 years while concurrently decreasing infant mortality rates by 0.00022%. An increase in real per capita gross domestic product corresponds with an improvement in life expectancy by 0.21 years and a decrease in infant mortality rates by 0.00065%. Similarly, an elevated school enrollment rate is associated with a rise in life expectancy by 0.17 years and a decline in infant mortality rates by 0.00032%. However, a higher population growth rate is found to modestly decrease life expectancy by 0.019 years and slightly elevate infant mortality rates by 0.000016%. The analysis reveals that per capita greenhouse gas emissions exert a negative impact, diminishing life expectancy by 0.486 years and elevating infant mortality rates by 0.00061%, while per capita energy consumption marginally reduces life expectancy by 0.026 years and increases infant mortality rates by 0.00004%. Additionally, economic volatility shock presents a notable decrement in life expectancy by 0.041 years and an increase in infant mortality rates by 0.000045%, with inflationary shock further exacerbating adverse health outcomes by lowering life expectancy by 0.70 years and elevating infant mortality rates by 0.00025%. Moreover, the study scrutinizes the role of institutional quality, revealing a constructive impact on health outcomes. Specifically, the institutional quality index is associated with an increase in life expectancy by 0.66% and a decrease in infant mortality rates by 0.0006%. Extending the analysis to examine the nuanced dimensions of institutional quality, the findings discern that economic institutions wield a notably stronger positive influence on health outcomes compared to political and institutional governance indices. Finally, the results underscore the pivotal moderating role of institutional quality in mitigating the deleterious impact of PM2.5 concentration on health outcomes, counterbalancing the influence of external shocks, and improving the relationships between explanatory variables and health outcome indicators. These findings offer critical insights for guiding evidence-based policy implications, with a focus on fostering resilient, sustainable, and health-conscious societies.

Health system governance assessment in protracted crisis settings: Northwest Syria

BACKGROUND

Since the withdrawal of government forces from Northwest Syria due to the conflict, several national initiatives have aimed to create alternative governance approaches to replace the central governmental system. One of the recent initiatives was the formulation of so-called 'Central Bodies' as institutional governance structures responsible for thematic planning and service provision; for example, the referral unit is responsible for planning and delivering medical referral services. However, the governance and administrative rules of procedures of these bodies could be immature or unsystematic. Assessing the governance of this approach cannot be condoned, especially with the urgent need for a methodical approach to strategic planning, achieving strategic humanitarian objectives, and efficiently utilizing available resources. Multiple governance assessment frameworks have been developed. However, none were created to be applied in protracted humanitarian settings. This research aims to assess the extent to which the existing health governance structure (central bodies) was capable of performing the governance functions in the absence of a legitimate government in Northwest Syria.

METHODS AND MATERIALS

A governance assessment framework was adopted after an extensive literature review and group discussions. Four principles for the governance assessment framework were identified; legitimacy, accountability and transparency, effectiveness and efficiency, and strategic vision. Focus Group Discussions were held to assess the levels of the selected principles on the governance thermometer scale. Qualitative and quantitative data were analyzed using NVivo 12 and SPSS 22 software programs, respectively.

RESULTS

The level of the four principles on the governance thermometer scale was between the lowest and middle quintiles; 'very poor or inactive' and 'fair and requires improvement', respectively. The results indicate that the governance approach of Central Bodies in NWS is underdeveloped and summons comprehensive systematic development. The poor internal mechanisms, poor planning and coordination, and the absence of strategic vision were among the most frequent challenges to developing the approach.

CONCLUSION

Humanitarian actors and donors should pay more attention to health governance approaches and tools in protracted crises. The central bodies must improve coordination with the stakeholders and, most importantly, strategic planning. Establishing or utilizing an independent planning committee, with financial and administrative independence, is crucial to maintain and improving contextual governance mechanisms in Northwest Syria.

An assessment of the performance of the national health research system in Mauritius

BACKGROUND

The goal of universal health coverage (UHC) is that every individual has access to high-quality health services without running the consequences of financial hardship. The World health report 2013 "Research for universal health coverage" states a performant National Health Research Systems (NHRS) can contribute by providing solutions to challenges encountered in advancing towards UHC by 2030. Pang et al. define a NHRS as the people, institutions, and activities whose primary aim is to generate and promote utilization of high-quality knowledge that can be used to promote, restore, and/or maintain the health status of populations. The WHO Regional Committee for Africa (RC) adopted a resolution in 2015 urging member states to strengthen their NHRS to facilitate production and utilization of evidence in policy development, planning, product development, innovation, and decision-making. This study aimed to calculate NHRS barometer scores for Mauritius in 2020, identify the gaps in NHRS performance, and recommend interventions for boosting the Mauritius NHRS in the pursuit of UHC.

METHODS

The study used a cross-sectional survey design. A semi-structured NHRS questionnaire was administered and complemented with a review of documents archived in pertinent Mauritius Government Ministries, universities, research-oriented departments, and non-governmental organizations websites. The African NHRS barometer developed in 2016 for countries to monitor the RC resolution implementation was applied. The barometer consists of four NHRS functions (leadership and governance, developing and sustaining resources, producing and utilizing research, financing research for health [R4H]), and 17 sub-functions, e.g., existence of a national policy on research for health (R4H), presence of a Mauritius Research and Innovation Council (MRIC), existence of knowledge translation platform.

RESULTS

In 2020, Mauritius had an overall average NHRS barometer score of 60.84%. The four NHRS functions average indices were 50.0% for leadership and governance, 77.0% for developing and sustaining resources, 52.0% for producing and utilizing R4H, and 58.2% for financing R4H.

CONCLUSION

The performance of NHRS could be improved through the development of a national R4H policy, strategic plan, prioritized agenda, and national multi-stakeholder health research management forum. Furthermore, increased funding for the NHRS may nurture the human resources for health research capacities, hence the number of pertinent publications and health innovations.

Assessing health governance across countries: a scoping review protocol on indices and assessment tools applied globally

INTRODUCTION

Most global health indices or assessment tools focus on health outcomes rather than governance, and they have been developed primarily from the perspective of high-income countries. To benchmark global health governance for equity and solidarity, it becomes necessary to reflect on the current state of indices or assessment tools evaluating health governance across countries. This scoping review aims to review the existing multicountry indices and assessment tools applied globally with measurable indicators assessing health governance; summarise their differences and commonalities; identify the lessons learnt through analysis of their advantages and gaps; and evaluate the feasibility and necessity to establish a new index or consensus framework for assessing global health governance.

METHODS AND ANALYSIS

This scoping review protocol follows Arksey and O'Malley's methodological framework, the Joanna Briggs Institute guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-analyses methodology for scoping reviews. Key information sources will be bibliographic databases (PubMed, Embase and Web of Science Core Collection), grey literature and citation tracking. The time frame will be from 1 January 2000 to 31 December 2021. Only indices or assessment tools that are globally applicable and provide measurable indicators of health governance will be eligible. A qualitative content analysis will follow the proposed data extraction form to explicate and compare each eligible index or assessment tool. An analysis based on a proposed preliminary evaluation framework will identify the advantages and gaps and summarise the lessons learnt. This scoping review will also discuss the feasibility and necessity of developing a new global health governance index or consensus framework to inform future research and practices.

ETHICS AND DISSEMINATION

This scoping review does not require ethics approval. Dissemination will include a peer-review article, policy briefs and conference presentations. This protocol has been registered in the Open Science Framework (osf.io/y93mj).

Assessing the governance of the health policy-making process using a new governance tool: the case of Lebanon

Background

In the international agenda, it has become common to assert that the assessment of health system governance using a practical tool is crucial. This approach can help us better understand how health systems are being steered as well as to identify gaps in the decision-making process and their causes. The authors developed a new assessment tool, the Health Policymaking Governance Guidance Tool (HP-GGT), that was designed to be conceptually sound and practical. This tool enables policy-makers and stakeholders to systematically review and assess health system governance at policy-making level. This article presents first use of the HP-GGT in Lebanon, together with generated results, recommendations, and discusses how these results improve governance practices when initiating new health policy formulation processes.

Methods

The HP-GGT, which is a multidimensional structured tool, was used retrospectively to assess and review the process used to develop a new mental health strategy; this process was compared against consensus-based good governance principles, focusing on participation, transparency, accountability, information and responsiveness. The assessment was conducted through face-to-face interviews with 11 key informants who were involved in the development of the strategy.

Results

The HP-GGT enabled policy-makers to reflect on their governance practices when developing a mental health strategy and was able to identify key areas of strengths and weaknesses using good governance practice checklists given by the questions. The insights generated from the assessment equipped the national policy-makers with a better understanding of the practice and meaning of policy-making governance. Identifying weaknesses to be addressed in future attempts to develop other national health policies helped in this regard. Using the tool also increased awareness of alternative good practices among policy-makers and stakeholders.

Conclusions

Assessing a health policy formulation process from a governance perspective is essential for improved policy-making. The HP-GGT was able to provide a general overview and an in-depth assessment of a policy formulation process related to governance issues according to international good practices that should be applied while formulating health policies in any field. The HP-GGT was found to be a practical tool that was useful for policy-makers when used in Lebanon and awaits applications in other low- and middle-income countries to further show its validity and utility.

Determinants of geographical inequalities for DTP3 vaccine coverage in sub-Saharan Africa

Childhood immunization is one of the most effective health interventions, making it a key indicator of progress towards universal health coverage. In the last decade, improvements in coverage have been made globally, however, slow progress has been documented in sub-Saharan Africa with considerable subnational variations. We explore potential drivers of equitable immunization services based on subnational DTP3 coverage estimates. Using vaccine coverage at the 5 by 5 km area from 2000 to 2016, we quantify inequality using three measures. We assess the shortfall inequality which is the average deviation across subnational units from that with the highest coverage for each country. Secondly we estimate the threshold index, the proportion of children below a globally set subnational coverage target, and lastly, a Gini coefficient representing the within-country distribution of coverage. We use time series analyses to quantify associations with immunization expenditures controlling for country socio-economic and population characteristics. Development assistance, maternal education and governance were associated with reductions in inequality. Furthermore, high quality governance was associated with a stronger relationship between development assistance and reductions in inequality. Results from this analysis also indicate that countries with the lowest coverage suffer the highest inequalities. We highlight growing inequalities among countries which have met national coverage targets such as South Africa and Kenya. In 2016, values for the shortfall inequality ranged from 1% to 43%, the threshold index from 0% to 100% and Gini coefficient from 0.01 to 0.37. Burundi, Comoros, Eswatini, Lesotho, Namibia, Rwanda, and Sao Tome and Principe had the least shortfall inequality (<5%) while Angola, Ethiopia and Nigeria had values greater than 40%. A similar picture was noted for the other dimensions of inequality among these particular countries. Immunization program investments offer promise in addressing inequality, however, domestic mechanisms for resource implementation and accountability should be strengthened to maximize gains in coverage.

Mitigating The Burden Of Diabetes In Sub-Saharan Africa Through An Integrated Diagonal Health Systems Approach

Diabetes is a chronic non-communicable disease (NCD) presenting growing health and economic burdens in sub-Saharan Africa (SSA). Diabetes is unique due to its cross-cutting nature, impacting multiple organ systems and increasing the risk for other communicable and non-communicable diseases. Unfortunately, the quality of care for diabetes in SSA is poor, largely due to a weak disease management framework and fragmented health systems in most sub-Saharan African countries. We argue that by synergizing disease-specific vertical programs with system-specific horizontal programs through an integrated disease-system diagonal approach, we can improve access, quality, and safety of diabetes care programs while also supporting other chronic diseases. We recommend utilizing the six World Health Organization (WHO) health system building blocks - 1) leadership and governance, 2) financing, 3) health workforce, 4) health information systems, 5) supply chains, and 6) service delivery - as a framework to design a diagonal approach with a focus on health system strengthening and integration to implement and scale quality diabetes care. We discuss the successes and challenges of this approach, outline opportunities for future care programming and research, and highlight how this approach can lead to the improvement in the quality of care for diabetes and other chronic diseases across SSA.

Strengthening non-communicable disease policy with lessons from Bhutan: linking gross national happiness and health policy action

There is growing global interest in Gross National Happiness (GNH) as a metric to capture population well-being and economic development. Empirical evidence suggests that health is necessary for achievement of happiness. The growing epidemic of non-communicable diseases (NCDs) threatens to undermine the achievement of GNH. We analyze synergies between current policy priorities and the institutional mechanism for GNH and the Global NCD Action Plan 2013-2020 that has informed Bhutan's approach to NCDs. We identify strategic policy opportunities to strengthen outcomes for both policy areas. Lessons from Bhutan also suggest strategic opportunities to address NCDs in other countries where happiness is on the national agenda, or where action on NCDs could be improved through engagement between health and other sectors, especially where ways to promote and measure GNH (population well-being) already exist.

Health and human development in Kenya

Purpose

This paper aims to critically analyze the empirical literature on health and human development in high-, middle- and low-income countries to develop a sustainable model for investing in human health. The model is critical in building a comprehensive health-care system that fosters the stakeholders’ financial stability, economic growth and high-quality education for the local community.

Design/methodology/approach

A comprehensive literature review was carried out on health, human development and sustainable health investment. After thoroughly examining theoretical frameworks underlying the strategies of successful human health systems, a summary of empirical articles is created. Summaries provided in this paper represent relevant health-care strategies for Kenya.

Findings

Based on the empirical review of literature, a Nexus Health Care model focusing on human development, social and cultural development, economic development and environmental development in high-, middle- and low-income countries is proposed. The goal of this model is to enhance sustainable development where wealth creation is accompanied with environmental uplifting and protection of social and material well-being.

Research limitations/implications

This paper is limited to a comprehensive literature review presenting empirical evidence of human development and sustainability.

Originality/value

Kenya like other developing nations aspires to contribute significantly in improving health through development of health products but the approaches used have been limiting. In most cases, the use of Western theories, lack of empowering the community and dependence on donor support have hindered the country from achieving comprehensive health and human development. This papers seeks to develop a model for health-care investment and provide strategies, operations and structure of successful health systems and human development for a developing country, such as Kenya.

Guidelines, policies, and barriers to kidney care: findings from a global survey

An international survey led by the International Society of Nephrology in 2016 assessed the current capacity of kidney care worldwide. To better understand how governance and leadership guide kidney care, items pertinent to government priority, advocacy, and guidelines, among others, were examined. Of the 116 responding countries, 36% (n = 42) reported CKD as a government health care priority, which was associated with having an advocacy group (χ2 = 11.57; P = 0.001). Nearly one-half (42%; 49 of 116) of countries reported an advocacy group for CKD, compared with only 19% (21 of 112) for AKI. Over one-half (59%; 68 of 116) of countries had a noncommunicable disease strategy. Similarly, 44% (48 of 109), 55% (57 of 104), and 47% (47 of 101) of countries had a strategy for nondialysis CKD, chronic dialysis, and kidney transplantation, respectively. Nearly one-half (49%; 57 of 116) reported a strategy for AKI. Most countries (79%; 92 of 116) had access to CKD guidelines and just over one-half (53%; 61 of 116) reported guidelines for AKI. Awareness and adoption of guidelines were low among nonnephrologist physicians. Identified barriers to kidney care were factors related to patients, such as knowledge and attitude (91%; 100 of 110), physicians (84%; 92 of 110), and geography (74%; 81 of 110). Specific to renal replacement therapy, patients and geography were similarly identified as a barrier in 78% (90 of 116) and 71% (82 of 116) of countries, respectively, with the addition of nephrologists (72%; 83 of 116) and the health care system (73%; 85 of 116). These findings inform how kidney care is currently governed globally. Ensuring that guidelines are feasible and distributed appropriately is important to enhancing their adoption, particularly in primary care. Furthermore, increasing advocacy and government priority, especially for AKI, may increase awareness and strategies to better guide kidney care.

The monetary value of human lives lost due to neglected tropical diseases in Africa

BACKGROUND

Neglected tropical diseases (NTDs) are an important cause of death and disability in Africa. This study estimates the monetary value of human lives lost due to NTDs in the continent in 2015.

METHODS

The lost output or human capital approach was used to evaluate the years of life lost due to premature deaths from NTDs among 10 high/upper-middle-income (Group 1), 17 middle-income (Group 2) and 27 low-income (Group 3) countries in Africa. The future losses were discounted to their present values at a 3% discount rate. The model was re-analysed using 5% and 10% discount rates to assess the impact on the estimated total value of human lives lost.

RESULTS

The estimated value of 67 860 human lives lost in 2015 due to NTDs was Int$ 5 112 472 607. Out of that, 14.6% was borne by Group 1, 57.7% by Group 2 and 27.7% by Group 3 countries. The mean value of human life lost per NTD death was Int$ 231 278, Int$ 109 771 and Int$ 37 489 for Group 1, Group 2 and Group 3 countries, respectively. The estimated value of human lives lost in 2015 due to NTDs was equivalent to 0.1% of the cumulative gross domestic product of the 53 continental African countries.

CONCLUSIONS

Even though NTDs are not a major cause of death, they impact negatively on the productivity of those affected throughout their life-course. Thus, the case for investing in NTDs control should also be influenced by the value of NTD morbidity, availability of effective donated medicines, human rights arguments, and need to achieve the NTD-related target 3.3 of the United Nations Sustainable Development Goal 3 (on health) by 2030.

Frameworks to assess health systems governance: a systematic review

Governance of the health system is a relatively new concept and there are gaps in understanding what health system governance is and how it could be assessed. We conducted a systematic review of the literature to describe the concept of governance and the theories underpinning as applied to health systems; and to identify which frameworks are available and have been applied to assess health systems governance. Frameworks were reviewed to understand how the principles of governance might be operationalized at different levels of a health system. Electronic databases and web portals of international institutions concerned with governance were searched for publications in English for the period January 1994 to February 2016. Sixteen frameworks developed to assess governance in the health system were identified and are described. Of these, six frameworks were developed based on theories from new institutional economics; three are primarily informed by political science and public management disciplines; three arise from the development literature and four use multidisciplinary approaches. Only five of the identified frameworks have been applied. These used the principal–agent theory, theory of common pool resources, North’s institutional analysis and the cybernetics theory. Governance is a practice, dependent on arrangements set at political or national level, but which needs to be operationalized by individuals at lower levels in the health system; multi-level frameworks acknowledge this. Three frameworks were used to assess governance at all levels of the health system. Health system governance is complex and difficult to assess; the concept of governance originates from different disciplines and is multidimensional. There is a need to validate and apply existing frameworks and share lessons learnt regarding which frameworks work well in which settings. A comprehensive assessment of governance could enable policy makers to prioritize solutions for problems identified as well as replicate and scale-up examples of good practice.

Sub-national assessment of aid effectiveness: A case study of post-conflict districts in Uganda

Background

In post-conflict settings, many state and non-state actors interact at the sub-national levels in rebuilding health systems by providing funds, delivering vital interventions and building capacity of local governments to shoulder their roles. Aid relationships among actors at sub-national level represent a vital lever for health system development. This study was undertaken to assess the aid-effectiveness in post-conflict districts of northern Uganda.

Method

This was a three district cross sectional study conducted from January to April 2013. A two stage snowball approach used to construct a relational-network for each district. Managers of organizations (ego) involved service delivery were interviewed and asked to list the external organizations (alters) that contribute to three key services. For each inter-organizational relationship (tie) a custom-made tool designed to reflect the aid-effectiveness in the Paris Declaration was used.

Results

Three hundred eighty four relational ties between the organizations were generated from a total of 85 organizations interviewed. Satisfaction with aid relationships was mostly determined by 1) the extent ego was able to negotiate own priorities, 2) ego’s awareness of expected results, and 3) provision of feedback about ego’s performance. Respectively, the B coefficients were 16%, 38% and 19%. Disaggregated analysis show that satisfaction of fund-holders was also determined by addressing own priorities (30%), while provider satisfaction was mostly determined by awareness of expected results (66%) and feedback on performance (23%). All results were significant at p-value of 0.05. Overall, the regression models in these analyses accounted for 44% to 62% of the findings.

Conclusion

Sub-national assessment of aid effectiveness is feasible with indicators adapted from the global parameters. These findings illustrate the focus on “results” domain and less on “ownership” and “resourcing” domains. The capacity and space for sub-national level authorities to negotiate local priorities requires more attention especially for health system development in post-conflict settings.

Developing the African national health research systems barometer

Background

A functional national health research system (NHRS) is crucial in strengthening a country’s health system to promote, restore and maintain the health status of its population. Progress towards the goal of universal health coverage in the post-2015 sustainable development agenda will be difficult for African countries without strengthening of their NHRS to yield the required evidence for decision-making. This study aims to develop a barometer to facilitate monitoring of the development and performance of NHRSs in the African Region of WHO.

Methods

The African national health research systems barometer algorithm was developed in response to a recommendation of the African Advisory Committee for Health Research and Development of WHO. Survey data collected from all the 47 Member States in the WHO African Region using a questionnaire were entered into an Excel spreadsheet and analysed. The barometer scores for each country were calculated and the performance interpreted according to a set of values ranging from 0% to 100%.

Results

The overall NHRS barometer score for the African Region was 42%, which is below the average of 50%. Among the 47 countries, the average NHRS performance was less than 20% in 10 countries, 20–40% in 11 countries, 41–60% in 16 countries, 61–80% in nine countries, and over 80% in one country. The performance of NHRSs in 30 (64%) countries was below 50%.

Conclusion

An African NHRS barometer with four functions and 17 sub-functions was developed to identify the gaps in and facilitate monitoring of NHRS development and performance. The NHRS scores for the individual sub-functions can guide policymakers to locate sources of poor performance and to design interventions to address them.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-016-0121-4) contains supplementary material, which is available to authorized users.

Space and place for WHO health development dialogues in the African Region

BACKGROUND

Majority of the countries in the World Health Organization (WHO) African Region are not on track to achieve the health-related Millennium Development Goals, yet even more ambitious Sustainable Development Goals (SDGs), including SDG 3 on heath, have been adopted. This paper highlights the challenges - amplified by the recent Ebola virus disease (EVD) outbreak in West Africa - that require WHO and other partners' dialogue in support of the countries, and debate on how WHO can leverage the existing space and place to foster health development dialogues in the Region.

DISCUSSION

To realise SDG 3 on ensuring healthy lives and promoting well-being for all at all ages, the African Region needs to tackle the persistent weaknesses in its health systems, systems that address the social determinants of health and national health research systems. The performance of the third item is crucial for the development and innovation of systems, products and tools for promoting, maintaining and restoring health in an equitable manner. Under its new leadership, the WHO Regional Office for Africa is transforming itself to galvanise existing partnerships, as well as forging new ones, with a view to accelerating the provision of timely and quality support to the countries in pursuit of SDG 3. WHO in the African Region engages in dialogues with various stakeholders in the process of health development. The EVD outbreak in West Africa accentuated the necessity for optimally exploiting currently available space and place for health development discourse. There is urgent need for the WHO Regional Office for Africa to fully leverage the space and place arenas of the World Health Assembly, WHO Regional Committee for Africa, African Union, Regional economic communities, Harmonization for Health in Africa, United Nations Economic Commission for Africa, African Development Bank, professional associations, and WHO African Health Forum, when it is created, for dialogues to mobilise the required resources to give the African Region the thrust it needs to attain SDG 3.

CONCLUSIONS

The pursuit of SDG 3 amidst multiple challenges related to political leadership and governance, weak health systems, sub-optimal systems for addressing the socioeconomic determinants of health, and weak national health research systems calls for optimum use of all the space and place available for regional health development dialogues to supplement Member States' efforts.

Towards understanding governance issues in integration of mental health into primary health care in Uganda

BACKGROUND

There is a growing burden of mental illness in low income countries. The situation is further worsened by the high poverty levels in these countries, resulting in difficult choices for their health sectors as regards to responding to the burden of mental health problems. In Uganda, integration of mental health into primary health care (PHC) has been adopted as the most vital strategy for ensuring mental health service delivery to the general population.

OBJECTIVES

To identify governance related factors that promote/or hinder integration of mental health into PHC in Uganda.

METHODS

A qualitative research design was adopted at national and district level. A total of 18 Key informant interviews were conducted at both levels. Content thematic analysis was the main method of data analysis.

FINDINGS

There were positive gains in working on relevant laws and policies. However, both the mental health law and policy are still in draft form. There is also increased responsiveness/participation of key stakeholders; especially at national level in the planning and budgeting for mental health services. This however seems to be a challenge at both district and community level. In terms of efficiency, human resources, finances, medicines and technologies constitute a major drawback to the integration of mental health into PHC. Ethics, oversight, information and monitoring functions though reported to be in place, become weaker at the district level than at national level due to limited finances, human resources gaps and limited technical capacity. Other governance related issues are also reported in this study.

CONCLUSIONS

There is some progress especially in the legal and policy arena to support integration of mental health into PHC in Uganda. However, adequate resources are still required to facilitate the effective functioning of all governance pillars that make integration of mental health into PHC feasible in Uganda.

Health workforce governance: Processes, tools and actors towards a competent workforce for integrated health services delivery

A competent health workforce is a vital resource for health services delivery, dictating the extent to which services are capable of responding to health needs. In the context of the changing health landscape, an integrated approach to service provision has taken precedence. For this, strengthening health workforce competencies is an imperative, and doing so in practice hinges on the oversight and steering function of governance. To aid health system stewards in their governing role, this review seeks to provide an overview of processes, tools and actors for strengthening health workforce competencies. It draws from a purposive and multidisciplinary review of literature, expert opinion and country initiatives across the WHO European Region's 53 Member States. Through our analysis, we observe distinct yet complementary roles can be differentiated between health services delivery and the health system. This understanding is a necessary prerequisite to gain deeper insight into the specificities for strengthening health workforce competencies in order for governance to rightly create the institutional environment called for to foster alignment. Differentiating between the contribution of health services and the health system in the strengthening of health workforce competencies is an important distinction for achieving and sustaining health improvement goals.

Indirect costs associated with deaths from the Ebola virus disease in West Africa

BACKGROUND

By 28 June 2015, there were a total of 11,234 deaths from the Ebola virus disease (EVD) in five West African countries (Guinea, Liberia, Mali, Nigeria and Sierra Leone). The objective of this study was to estimate the future productivity losses associated with EVD deaths in these West African countries, in order to encourage increased investments in national health systems.

METHODS

A cost-of-illness method was employed to calculate future non-health (NH) gross domestic product (GDP) (NHGDP) losses associated with EVD deaths. The future non-health GDP loss (NHGDPLoss) was discounted at 3 %. Separate analyses were done for three different age groups (< =14 years, 15-44 years and = >45 years) for the five countries (Guinea, Liberia, Mali, Nigeria, and Sierra Leone) affected by EVD. We also conducted a one-way sensitivity analysis at 5 and 10 % discount rates to gauge their impacts on expected NHGDPLoss.

RESULTS

The discounted value of future NHGDPLoss due to the 11,234 deaths associated with EVD was estimated to be Int$ (international dollars) 155,663,244. About 27.86 % of the loss would be borne by Guinea, 34.84 % by Liberia, 0.10 % by Mali, 0.24 % by Nigeria and 36.96 % by Sierra Leone. About 27.27 % of the loss is attributed to those aged under 14 years, 66.27 % to those aged 15-44 years and 6.46 % to those aged over 45 years. The average NHGDPLoss per EVD death was estimated to be Int$ 17,473 for Guinea, Int$ 11,283 for Liberia, Int$ 25,126 for Mali, Int$ 47,364 for Nigeria and Int$ 14,633 for Sierra Leone.

CONCLUSION

In spite of alluded limitations, the estimates of human and economic losses reported in this paper, in addition to those projected by the World Bank, show that EVD imposes a significant economic burden on the affected West African countries. That heavy burden, coupled with human rights and global security concerns, underscores the urgent need for increased domestic and external investments to enable Guinea, Liberia and Sierra Leone (and other vulnerable African countries) to develop resilient health systems, including core capacities to detect, assess, notify, verify and report events, and to respond to public health risks and emergencies.

Promoting public health legal preparedness for emergencies: review of current trends and their relevance in light of the Ebola crisis

BACKGROUND

Public health legal preparedness (PHLP) for emergencies is a core component of the health system response. However, the implementation of health legal preparedness differs between low- and middle-income countries (LMIC) and developed countries.

OBJECTIVE

This paper examines recent trends regarding public health legal preparedness for emergencies and discusses its role in the recent Ebola outbreak.

DESIGN

A rigorous literature review was conducted using eight electronic databases as well as Google Scholar. The results encompassed peer-reviewed English articles, reports, theses, and position papers dating from 2011 to 2014. Earlier articles concerning regulatory actions were also examined.

RESULTS

The importance of PHLP has grown during the past decade and focuses mainly on infection-disease scenarios. Amid LMICs, it mostly refers to application of international regulations, whereas in developed states, it focuses on independent legislation and creation of conditions optimal to promoting an effective emergency management. Among developed countries, the United States' utilisation of health legal preparedness is the most advanced, including the creation of a model comprising four elements: law, competencies, information, and coordination. Only limited research has been conducted in this field to date. Nevertheless, in both developed and developing states, studies that focused on regulations and laws activated in health systems during emergencies, identified inconsistency and incoherence. The Ebola outbreak plaguing West Africa since 2014 has global implications, challenges and paralleling results, that were identified in this review.

CONCLUSIONS

The review has shown the need to broaden international regulations, to deepen reciprocity between countries, and to consider LMICs health capacities, in order to strengthen the national health security. Adopting elements of the health legal preparedness model is recommended.

National health research system in Malawi: dead, moribund, tepid or flourishing?

BACKGROUND

Several instruments at both the global and regional levels to which countries in the WHO African Region are party call for action by governments to strengthen national health research systems (NHRS). This paper debates the extent to which Malawi has fulfilled this commitment.

DISCUSSION

Some research literature has characterized African research - and by implication NHRS - as moribund. In our view, the Malawi government, with partner support, has made effort to strengthen the capacities of individuals and institutions that generate scientific knowledge. This is reflected in the Malawi national NHRS index (MNSR4HI) of 51%, which is within the 50%-69% range, and thus, it should be characterized as tepid with significant potential to flourish. Governance of research for health (R4H) has improved with the promulgation of the Malawi Science and Technology Act in 2003. However, lack of an explicit R4H policy, a strategic plan and a national R4H management forum undermines the government's effectiveness in overseeing the operation of the NHRS. The mean index of 'governance of R4H' sub-functions was 67%, implying that research governance is tepid. Malawi has a national health research focal point, an R4H program, and four public and 11 private universities. The average index of 'creating and sustaining resources' sub-functions was 48.6%, meaning that R4H human and infrastructural resources can be considered to be in a moribund state. The average index of 'producing and using research' sub-functions of 50.4% implies that production and utilization of research findings in policy development and public health practice can best be described as tepid. Efforts need to be intensified to boost national research productivity. Over the five financial years 2011-2016 the government plans to spend 0.26% of its total health budget on R4H. The mean index of 'financing' sub-functions of 23.6% is within the range of 1-49%, which is considered moribund. A functional NHRS is a prerequisite for the achievement of the health system goal of universal health coverage. Malawi, like majority of African countries, needs to invest more in strengthening R4H governance, developing and sustaining R4H resources, and producing and using research findings.

Investing in health systems for universal health coverage in Africa

BACKGROUND

This study focused on the 47 Member States of the World Health Organization (WHO) African Region. The specific objectives were to prepare a synthesis on the situation of health systems' components, to analyse the correlation between the interventions related to the health Millennium Development Goals (MDGs) and some health systems' components and to provide overview of four major thrusts for progress towards universal health coverage (UHC).

METHODS

The WHO health systems framework and the health-related MDGs were the frame of reference. The data for selected indicators were obtained from the WHO World Health Statistics 2014 and the Global Health Observatory.

RESULTS

African Region's average densities of physicians, nursing and midwifery personnel, dentistry personnel, pharmaceutical personnel, and psychiatrists of 2.6, 12, 0.5, 0.9 and 0.05 per 10 000 population were about five-fold, two-fold, five-fold, five-fold and six-fold lower than global averages. Fifty-six percent of the reporting countries had fewer than 11 health posts per 100 000 population, 88% had fewer than 11 health centres per 100 000 population, 82% had fewer than one district hospital per 100 000 population, 74% had fewer than 0.2 provincial hospitals per 100 000 population, and 79% had fewer than 0.2 tertiary hospitals per 100 000 population. Some 83% of the countries had less than one MRI per one million people and 95% had fewer than one radiotherapy unit per million population. Forty-six percent of the countries had not adopted the recommendation of the International Taskforce on Innovative Financing to spend at least US$ 44 per person per year on health. Some of these gaps in health system components were found to be correlated to coverage gaps in interventions for maternal health (MDG 5), child health (MDG 4) and HIV/AIDS, TB and malaria (MDG 6).

CONCLUSIONS

Substantial gaps exist in health systems and access to MDG-related health interventions. It is imperative that countries adopt the 2014 Luanda Commitment on UHC in Africa as their long-term vision and back it with sound policies and plans with clearly engrained road maps for strengthening national health systems and addressing the social determinants of health.

Governance matters: an ecological association between governance and child mortality

BACKGROUND

Governance of a country may have widespread effects on the health of its population, yet little is known about the effect of governance on child mortality in a country that is undergoing urbanization, economic development, and disease control.

METHODS

We obtained indicators of six dimensions of governance (perceptions of voice and accountability, political stability and absence of violence, government effectiveness, regulatory quality, rule of law, and control of corruption) and national under-5 mortality rates for 149 countries between 1996 and 2010. We applied a semi-parametric generalized additive mixed model to examine associations after controlling for the effects of development factors (urbanization level and economy), disease control factors (hygienic conditions and vaccination rates), health expenditures, air quality, and time.

RESULTS

Governance, development, and disease control showed clear inverse relations with the under-5 mortality rate (p<0.001). Per unit increases in governance, development, and disease control factors, the child mortality rate had a 0.901-, 0.823-, and 0.922-fold decrease, respectively, at fixed levels of the other two factors.

CONCLUSIONS

In the effort to reduce the global under-5 mortality rate, addressing a country's need for better governance is as important as improvements in development and disease control.

Health systems performance assessment in low-income countries: learning from international experiences

BACKGROUND

The study aimed at developing a set of attributes for a 'good' health system performance assessment (HSPA) framework from literature and experiences in different contexts and using the attributes for a structured approach to lesson learning for low-income countries (LICs).

METHODS

Literature review to identify relevant attributes for a HSPA framework; attribute validation for LICs in general, and for Uganda in particular, via a high-level Ugandan expert group; and, finally, review of a selection of existing HSPA frameworks using these attributes.

RESULTS

Literature review yielded six key attributes for a HSPA framework: an inclusive development process; its embedding in the health system's conceptual model; its relation to the prevailing policy and organizational set-up and societal context; the presence of a concrete purpose, constitutive dimensions and indicators; an adequate institutional set-up; and, its capacity to provide mechanisms for eliciting change in the health system. The expert group contextualized these attributes and added one on the adaptability of the framework.Lessons learnt from the review of a selection of HSPA frameworks using the attributes include: it is possible and beneficial to involve a range of stakeholders during the process of development of a framework; it is important to make HSPA frameworks explicit; policy context can be effectively reflected in the framework; there are marked differences between the structure and content of frameworks in high-income countries, and low- and middle-income countries; champions can contribute to put HSPA high on the agenda; and mechanisms for eliciting change in the health system should be developed alongside the framework.

CONCLUSION

It is possible for LICs to learn from literature and the experience of HSPA in other contexts, including HICs. In this study a structured approach to lesson learning included the development of a list of attributes for a 'good' HSPA framework. The attributes thus derived can be utilized by LICs like Uganda seeking to develop/adjust their HSPA frameworks as guidelines or a check list, while taking due consideration of the specific context. The review of frameworks from varied contexts, highlighted varied experiences which provide lessons for LICs.

Healthcare context and nursing workforce in a main city of Angola

BACKGROUND

Angola is one of the largest African countries with continuing levels of insecurity, considerable weakness in terms of respect for human rights, destroyed infrastructure and low transparency and social accountability levels. The health system displays gaps and nursing represents the main contingent among human resources in health.

AIM

This research aims to understand the healthcare context in Angola from the perspective of Brazilian nurses who were involved in helping their Angolan colleagues. This general view of health services is followed by a description of nursing workforce particularities at a tertiary health service in the province of Luanda.

METHODS

Data were extracted from the database of the Global Network of World Health Organization Collaborating Centres for Nursing and Midwifery Development, constructed based on technical visits to Angola in 2009. Information related to health service characteristics was used, focusing on nursing human resource activities at two tertiary, one secondary and one primary health institutions located in the province of Luanda. The study data were analysed through descriptive statistics.

FINDINGS

Among the problems the nursing workforce faces, the lack of human, material and financial resources stands out, as well as insufficient professional qualification, excessive work journeys, low remunerations, non-valuation of professionals, leading to unsatisfactory work environments and discouraged human resources.

CONCLUSIONS

Nursing in Angola is conquering its professional space. Therefore, regulatory policies are fundamental, defining the rights and obligations of all categories involved, with a view to determining nurses' function in the health team, including respect for and acknowledgement of their role in the community.

National health financing policy in Eritrea: a survey of preliminary considerations

Background

The 58th World Health Assembly and 56th WHO Regional Committee for Africa adopted resolutions urging Member States to ensure that health financing systems included a method for prepayment to foster financial risk sharing among the population and avoid catastrophic health-care expenditure. The Regional Committee asked countries to strengthen or develop comprehensive health financing policies. This paper presents the findings of a survey conducted among senior staff of selected Eritrean ministries and agencies to elicit views on some of the elements likely to be part of a national health financing policy.

Methods

This is a descriptive study. A questionnaire was prepared and sent to 19 senior staff (Directors) in the Ministry of Health, Labour Department, Civil Service Administration, Eritrean Confederation of Workers, National Insurance Corporation of Eritrea and Ministry of Local Government. The respondents were selected by the Ministry of Health as key informants.

Results

The key findings were as follows: the response rate was 84.2% (16/19); 37.5% (6/16) and 18.8% said that the vision of Eritrean National Health Financing Policy (NHFP) should include the phrases ‘equitable and accessible quality health services’ and ‘improve efficiency or reduce waste’ respectively; over 68% indicated that NHFP should include securing adequate funding, ensuring efficiency, ensuring equitable financial access, protection from financial catastrophe, and ensuring provider payment mechanisms create positive incentives to service providers; over 80% mentioned community participation, efficiency, transparency, country ownership, equity in access, and evidence-based decision making as core values of NHFP; over 62.5% confirmed that NHFP components should consist of stewardship (oversight), revenue collection, revenue pooling and risk management, resource allocation and purchasing of health services, health economics research, and development of human resources for health; over 68.8% indicated cost-sharing, taxation and social health insurance as preferred revenue collection mechanisms; and 68.75% indicated their preferred provider payment mechanism to be a global (lump sum) budget.

Conclusion

This study succeeded in gathering the preliminary views of senior staff of selected Eritrean ministries and agencies regarding the likely elements of the NHFP, i.e. the vision, objectives, components, provider payment mechanisms, and health financing agency and its governance. In addition to stakeholder surveys, it would be helpful to inform the development of the NHFP with other pieces of evidence, including cost-effectiveness analysis of health services and interventions, financial feasibility analysis of financing options, a survey of the political and professional acceptability of financing options, national health accounts, and equity analyses.