A review of national health policies in seven countries in the WHO African Region.

OBJECTIVES: This paper proposes an analytical framework for assessing compliance of national health policies with WHO/AFRO guidelines. DATA SOURCES: Data for this study was obtained from the national health policies of Botswana, Eritrea, Liberia, Namibia, Swaziland, Gambia, and Uganda. STUDY SELECTIONS: National health policies of seven of the 19 Anglophone countries of the WHO African region were selected for review using simple random sampling method. These include: Botswana, Eritrea, Liberia, Namibia, Swaziland, Gambia, and Uganda. DATA EXTRACTION: An analytical framework derived from WHO/AFRO guidelines for developing national health policies and plans was used in the review. It identifies components which are pertinent for appropriate national health policy formulation. DATA SYNTHESIS: It appears that aspects related to policy content are well addressed. In relation to the process, there is need for improving the mapping of stakeholders and specifying their roles and aspects of collaboration; and the implications for meeting broad service and impact targets. CONCLUSION: Development of health policies needs to focus on all aspects of the analytical framework with emphasis on improving the articulation for mapping out stakeholders and specifying their roles and aspects of collaboration; and the implications for meeting broad service and impact targets.

Status of health sector strategic plans in five countries of the WHO African Region.

OBJECTIVES: To assess the adequacy of the existing strategic plans and compare the format and content of health sector strategic plans with the guidelines in selected countries of the African region. DATA SOURCE: The health strategic plans for Gambia, Liberia, Malawi, Tanzania and Uganda, which are kept at the WHO/AFRO, were reviewed. DATA EXTRACTION: All health strategic plans among the Anglophone countries (Gambia, Ghana, Kenya, Liberia, Malawi, Mauritius, Tanzania, Uganda, Zambia and Zimbabwe) that were developed after the year 2000 were eligible for inclusion. Fifty percent of these countries that fitted this criterion were randomly selected. They included Gambia, Liberia, Malawi, Tanzania and Uganda. The analysis framework used in the review included situation analysis; an assessment of appropriateness of strategies that are selected; well developed indicators for each strategy; the match between the service and outcomes targets with available resources; and existence of a clear framework for partnership engagement for implementation. DATA SYNTHESIS: Most of the strategic plans identify key ill health conditions and their contributing factors. Health service and resource gaps are described but not quantified in the Botswana, Gambia, Malawi, Tanzania strategic documents. Most of the plans selected strategies that related to the situational analysis. Generally, countries' plans had clear indicators. Matching service and outcome targets to available resources was the least addressed area in majority of the plans. Most of the strategic plans identified stakeholders and acknowledged their participation in the implementation, providing different levels of comprehensiveness. CONCLUSION: Some of the areas that are well addressed according to the analysis framework included: addressing the strategic concerns of the health policies; identifying key partners for implementation; and selection of appropriate strategies. The following areas needed more emphasis: quantification of health system gaps; setting targets that are cognisant of the local resource base; and being more explicit in what stakeholders' roles are during the implementation period.

Monitoring and evaluation of health sector reforms in the WHO African Region.

OBJECTIVES: To describe a comprehensive analytical framework for assessing health sector reforms and demonstrates use of the analysis framework using cost-recovery mechanisms as a case study in the WHO African Region. DATA SOURCES: Health sector reforms published literature review. STUDY SELECTION: No selection involved. DATA EXTRACTION: This paper draws from previous published literature to describe a comprehensive framework to assess the performance of health sector reforms in the African region. Using this framework, it goes on to illustrate how it may be used to analyze cost recovery reforms as a case study. The major elements for the analysis include a description of the context, design, process and intended results. DATA SYNTHESIS: In terms of context and design of the cost recovery reform, there were gaps in the stewardship role of governments as evidenced by the lack of appropriate policies and information to monitor and/or influence the process. Regarding the cost recovery implementation, it is not clear from the literature reviewed in this paper that there was a comprehensive stakeholder coordination mechanism that catered for all who were involved. Concerning results of the expected results of implementing cost recovery reforms such as improved quality of health services; equitable service utilisation; social sustainability through active community participation; and gains in efficiency were not always realised. CONCLUSIONS: Given that the aspects of the analysis framework described in this paper are interrelated, reviewing one without another provides an answer to a specific question but is insufficient for a comprehensive assessment.

A Review of National Health Policies in Seven Countries in the WHO African Region

Objectives: This paper proposes an analytical framework for assessing compliance of national health policies with WHO/AFRO guidelines. Data sources: Data for this study was obtained from the national health policies of Botswana; Eritrea; Liberia; Namibia; Swaziland; Gambia; and Uganda. Study selections: National health policies of seven of the 19 Anglophone countries of the WHO African region were selected for review using simple random sampling method. These include: Botswana; Eritrea; Liberia; Namibia; Swaziland; Gambia; and Uganda. Data extraction: An analytical framework derived from WHO/AFRO guidelines for developing national health policies and plans was used in the review. It identifies components which are pertinent for appropriate national health policy formulation. Data synthesis: It appears that aspects related to policy content are well addressed. In relation to the process; there is need for improving the mapping of stakeholders and specifying their roles and aspects of collaboration; and the implications for meeting broad service and impact targets. Conclusion: Development of health policies needs to focus on all aspects of the analytical framework with emphasis on improving the articulation for mapping out stakeholders and specifying their roles and aspects of collaboration; and the implications for meeting broad service and impact targets

Status of Health Sector Strategic Plans in Five Countries of the WHO African Region

Objectives: To assess the adequacy of the existing strategic plans and compare the format and content of health sector strategic plans with the guidelines in selected countries of the African region. Data source: The health strategic plans for Gambia; Liberia; Malawi; Tanzania and Uganda; which are kept at the WHO/AFRO; were reviewed. Data extraction: All health strategic plans among the Anglophone countries (Gambia; Ghana; Kenya; Liberia; Malawi; Mauritius; Tanzania; Uganda; Zambia and Zimbabwe) that were developed after the year 2000 were eligible for inclusion. Fifty percent of these countries that fitted this criterion were randomly selected. They included Gambia; Liberia; Malawi; Tanzania and Uganda. The analysis framework used in the review included situation analysis; an assessment of appropriateness of strategies that are selected; well developed indicators for each strategy; the match between the service and outcomes targets with available resources; and existence of a clear framework for partnership engagement for implementation. Data synthesis: Most of the strategic plans identify key ill health conditions and their contributing factors. Health service and resource gaps are described but not quantified in the Botswana; Gambia; Malawi; Tanzania strategic documents. Most of the plans selected strategies that related to the situational analysis. Generally; countries' plans had clear indicators. Matching service and outcome targets to available resources was the least addressed area in majority of the plans. Most of the strategic plans identified stakeholders and acknowledged their participation in the implementation; providing different levels of comprehensiveness. Conclusion: Some of the areas that are well addressed according to the analysis framework included: addressing the strategic concerns of the health policies; identifying key partners for implementation; and selection of appropriate strategies. The following areas needed more emphasis: quantification of health system gaps; setting targets that are cognisant of the local resource base; and being more explicit in what stakeholders' roles are during the implementation period

Monitoring and Evaluation of Health Sector Reforms in the WHO African Region

Objectives: To describe a comprehensive analytical framework for assessing health sector reforms and demonstrates use of the analysis framework using cost-recovery mechanisms as a case study in the WHO African Region. Data sources: Health sector reforms published literature review. Study selection: No selection involved. Data extraction: This paper draws from previous published literature to describe a comprehensive framework to assess the performance of health sector reforms in the African region. Using this framework; it goes on to illustrate how it may be used to analyze cost recovery reforms as a case study. The major elements for the analysis include a description of the context; design; process and intended results. Data synthesis: In terms of context and design of the cost recovery reform; there were gaps in the stewardship role of governments as evidenced by the lack of appropriate policies and information to monitor and/or influence the process. Regarding the cost recovery implementation; it is not clear from the literature reviewed in this paper that there was a comprehensive stakeholder coordination mechanism that catered for all who were involved. Concerning results of the expected results of implementing cost recovery reforms such as improved quality of health services; equitable service utilisation; social sustainability through active community participation; and gains in efficiency were not always realised. Conclusions: Given that the aspects of the analysis framework described in this paper are interrelated; reviewing one without another provides an answer to a specific question but is insufficient for a comprehensive assessment

An overview of health financing patterns and the way forward in the WHO African Region.

BACKGROUND: The way a health system is financed affects the performance of its other functions of stewardship, input (or resource) creation and services provision, and ultimately, the achievement of health system goals of health improvement (or maintenance), responsiveness to people's non-medical expectations and fair financial contributions. OBJECTIVES: To analyse the changes between 1998 and 2002,in health financing from various sources; and to propose ways of improving the performance of health financing function in the WHO African Region. DESIGN: A retrospective analysis of data obtained from the World Health Report, 2005. METHODS: The analysis reported in this paper is based on the National Health Accounts (NHA) data for the 46 WHO Member States in the African Region. The data were obtained from the World Health Report 2005. It consisted of information on: levels of per capita expenditure on health; total expenditure on health as a percentage of gross domestic product (GDP); general government expenditure on health as a percentage of total expenditure on health; private expenditure on health as a percentage of total expenditure on health; general government expenditure on health as a percentage of total government expenditure; external expenditure as a percentage of total expenditure on health; social security expenditure on health as a percentage of general government expenditure on health; out-of-pocket expenditure as a percentage of private expenditure on health; and private prepaid plans as a percentage of private expenditure on health. The analysis was done using Lotus SmartSuite software. RESULTS: The analysis revealed that: fifteen countries spent less than 4.5% of their GDP on health; forty four countries spent less than 15% of their national annual budget on health; sixty three percent of the governments in the Region spent less than US$10 per person per year; fifty per cent of the total expenditure on health in 24 countries came from government sources; prepaid health financing mechanisms cover only a small proportion of populations in the Region; private spending constituted over 40% of the total expenditure on health in 31; direct out-of-pocket expenditures constituted over 50% of the private health expenditure in 38 countries. CONCLUSION: Every country needs to develop clear pro-poor health financing policy and a comprehensive health financing strategic plan with a clear roadmap of how it plans to transit from the current health financing state dominated by inequitable, catastrophic and impoverishing direct out-of-pocket payments to a visionary scenario of universal coverage. The strategic plan should strengthening of health sector advocacy and health financing capacities, health economics evidence generation and utilisation in decision-making, making better use of available and expected resources, monitoring of equity in financing, strengthening of the exemption mechanisms, managed removal of direct out-of-pocket payments (for countries that choose to), and improving country-led sectoral coordination mechanisms (e.g. Sector Wide Approaches).

An Overview of Health Financing Patterns and the Way Forward in the WHO African Region

The way a health system is financed affects the performance of its other functions of stewardship; input (or resource) creation and services provision; and ultimately; the achievement of health system goals of health improvement (or maintenance); responsiveness to people's non-medical expectations and fair financial contributions. To analyse the changes between 1998 and 2002;in health financing from various sources; and to propose ways of improving the performance of health financing function in the WHO African Region. A retrospective analysis of data obtained from the World Health Report; 2005. The analysis reported in this paper is based on the National Health Accounts (NHA) data for the 46 WHO Member States in the African Region. The data were obtained from the World Health Report 2005. It consisted of information on: levels of per capita expenditure on health; total expenditure on health as a percentage of gross domestic product (GDP); general government expenditure on health as a percentage of total expenditure on health; private expenditure on health as a percentage of total expenditure on health; general government expenditure on health as a percentage of total government expenditure; external expenditure as a percentage of total expenditure on health; social security expenditure on health as a percentage of general government expenditure on health; out-of-pocket expenditure as a percentage of private expenditure on health; and private prepaid plans as a percentage of private expenditure on health. The analysis was done using Lotus SmartSuite software. Results: The analysis revealed that: fifteen countries spent less than 4.5of their GDP on health; forty four countries spent less than 15 of their national annual budget on health; sixty three percent of the governments in the Region spent less than US$10 per person per year; fifty per cent of the total expenditure on health in 24 countries came from government sources; prepaid health financing mechanisms cover only a small proportion of populations in the Region; private spending constituted over 40 of the total expenditure on health in 31; direct out-of-pocket expenditures constituted over 50of the private health expenditure in 38 countries. Every country needs to develop clear pro-poor health financing policy and a comprehensive health financing strategic plan with a clear roadmap of how it plans to transit from the current health financing state dominated by inequitable; catastrophic and impoverishing direct out-of-pocket payments to a visionary scenario of universal coverage. The strategic plan should strengthening of health sector advocacy and health financing capacities; health economics evidence generation and utilisation in decision-making; making better use of available and expected resources; monitoring of equity in financing; strengthening of the exemption mechanisms; managed removal of direct out-of-pocket payments (for countries that choose to); and improving country-led sectoral coordination mechanisms (e.g. Sector Wide Approaches)

[Identification of malfunctioning in the treatment and quality of care of maternal morbidity in Abidjan, Côte d'Ivoire]. / Identification des dysfonctionnements dans la prise en charge de la morbidité maternelle grave à Abidjan (Côte d'Ivoire).

A study was carried out using a clinical audit aimed at identifying the dysfunctions in the care of female patients with serious morbidity. The study was done at the University Hospital of Cocody (CHU de Codody) and in the health training unit in the southern part of Abobo (Abidjan) from January to May 2000. The study allowed us to track and record the frequency of women who nearly died (40.4%) in both of the sites during the period of the study. Malfunctions were found at all stages of the female patients' care. The provision of medical care during the patients' hospitalisation and care provided in the emergency room were the cases and situations wherein the most frequency was noted, with 42.8% and 39.6% of dysfunctions found respectively. The delay for patients to wait to receive care was long, varying from 80 minutes to 5 days coupled with a lack of follow-up and surveillance of patients. This data demonstrates the inadequacy of the quality of obstetrical care.

Responsiveness to life-threatening obstetric emergencies in two hospitals in Abidjan, Côte d'Ivoire.

OBJECTIVES: To document the frequency of severe obstetric illness, and the intervals between admission or decision and life-saving surgery and the factors contributing to delays, which were reported during case reviews in two hospitals in Abidjan, Côte d'Ivoire. METHODS: The study was conducted in the teaching hospital in Cocody (CHUC) and the district hospital in Abobo (FSAS) in 2000-01. All severe obstetric cases were inventoried over a period of 1 year, and a subset of cases selected for in-depth review. For the 23 audited cases requiring emergency surgery, the interval between admission/decision and surgery was determined and reasons for the delays examined. FINDINGS: The yearly incidence of severe obstetric morbidity was 224.5 and 11.8 per 1000 live births in the CHUC and FSAS respectively. In CHUC, the decision-to-delivery time was extremely long (median 4.8 h) and this was largely determined by the time needed to obtain a complete surgical kit (median 2.8 h), either because the family had to pay for it in advance or because the kit lacked some essential components, which had to be bought separately. In FSAS, the decision-to-delivery time was much shorter (median 1.0 h). CONCLUSION: The interval between decision and emergency obstetric surgery substantially exceeded the 30 min generally advocated in industrialized countries. The reasons for the long delays were multiple and complex, but the main factors governing them were the huge case load of severe cases and the absence of any clear policy towards ensuring prompt and adequate treatment for life-threatening emergencies. In-depth reviews of cases of severe obstetric morbidity focusing in particular on the timing of emergency treatment could increase the responsiveness of the health system and providers to the needs of women requiring emergency obstetric care.

[Morbidity and mortality related to obstetrical transfers in the Bouafle health district of Ivory Coast]. / Morbidité et mortalité liées aux transferts obstétricaux dans le district sanitaire de Bouaflé en Côte d'Ivoire.

During one year of observation, the reference hospital of the sanitary district Bouaflé received 112 women evacuated by peripheral structures. 90.2% of the average women who were 25.8 +/- 7.4 years old had been evacuated before their delivery. Their evacuation was mainly due to dystocia (56.2% of cases) post partum haemorrhage (5.4%) and amniotic infection (4.5%). The reasons of the evacuation did not correspond to the admission diagnosis in 45.5% of the case (51/112). The differences that could be observed concerned dystocia and ruptures of the uterus of which 2 cases out of 9 had been diagnosed before their evacuation. During the study, it was noticed the deaths of 4 mothers and 55 babies. These deaths registered most among the evacuees having used public transportation, having received less than 3 prenatal consultations, multiparous (Chi 2 = 10.32; p = 0.04) and having run more than 30 kilometers.