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.

A rapid assessment of district health systems in six countries of the WHO African Region.

OBJECTIVES: This paper reviews the adequacy of inputs and processes at district level to support outputs and outcomes of service delivery at district level using a rapid assessment. The outputs included in this study are those considered essential for the attainment of the Health related Millennium Development Goals (MDGs). DATA SOURCES: A questionnaire based rapid District Health Systems assessment was conducted among six African countries during the year 2007. STUDY SELECTIONS: The study took place in a random sample of six out of 19 English speaking countries of the WHO African region. These countries are Ghana, Liberia, Namibia, Nigeria, Sierra Leone and Uganda. DATA EXTRACTION: The data was extracted from the questionnaires, entered and analysed in Excel spreadsheet. DATA SYNTHESIS: In spite of the variability in quality and completeness of reporting on the selected parameters, this paper does indicate that according to country norms and standards, the inputs and processes are insufficient to lead to acceptable outputs and outcomes, especially those related to the MDGs. An important point to note is that comparability across countries is made on the basis of individual country norms and standards. Implicit in this assessment is that country norms and standards are reasonable and are appropriate for the attainment of the MDGs. However reasonable the country norms and standard are, it is unlikely that the low resource base as well as weak organisational and managerial capacities in most countries will support effectively the attainment of the MDGs. CONCLUSION: Most countries manage to offer the essential health services at all levels of care despite the relatively low level of inputs. However, their level of quality and equity is debatable. The general trend is that provision of the essential health services is more at the higher levels of care prompting concerns for the populations served at lower levels of care. There is also a tendency to have wide variations in the performance of service delivery geographically as well as at the different levels of the health systems. This paper recommends further exploration of the impact of focusing on improving quality of existing health services while increasing quantity of service delivery points to achieve higher coverage of essential health services.

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

A Rapid Assessment of District Health Systems in Six Countries of the WHO African Regions

Objectives: This paper reviews the adequacy of inputs and processes at district level to support outputs and outcomes of service delivery at district level using a rapid assessment. The outputs included in this study are those considered essential for the attainment of the Health related Millennium Development Goals(MDGs). Data sources: A questionnaire based rapid District Health Systems assessment was conducted among six African countries during the year 2007. Study selections: The study took place in a random sample of six out of 19 eng speaking countries of the WHO African region. These countries are Ghana; Liberia; Namibia; Nigeria; Sierra Leone and Uganda. Data extraction: The data was extracted from the questionnaires; entered and analysed in Excel spreadsheet. Data synthesis: In spite of the variability in quality and completeness of reporting on the selected parameters; this paper does indicate that according to country norms and standards; the inputs and processes are insufficient to lead to acceptable outputs and outcomes; especially those related to the MDGs. An important point to note is that comparability across countries is made on the basis of individual country norms and standards. Implicit in this assessment is that country norms and standards are reasonable and are appropriate for the attainment of the MDGs. However reasonable the country norms and standard are; it is unlikely that the low resource base as well as weak organisational and managerial capacities in most countries will support effectively the attainment of the MDGs. Conclusion: Most countries manage to offer the essential health services at all levels of care despite the relatively low level of inputs. However; their level of quality and equity is debatable. The general trend is that provision of the essential health services is more at the higher levels of care prompting concerns for the populations served at lower levels of care. There is also a tendency to have wide variations in the performance of service delivery geographically as well as at the different levels of the health systems. This paper recommends further exploration of the impact of focusing on improving quality of existing health services while increasing quantity of service delivery points to achieve higher coverage of essential health services

Health Economics: Potential Applications in HIV/AIDS Control in Africa

There is growing evidence that HIV/AIDS has enormous negative impact on health status and economic development of individuals; households; communities and nations in the African region [33]. Thus; there is urgent need for various disciplines to demonstrate how they can contribute in curbing the spread of this deadly disease in the African region. This paper; using an extended version of Professor Alan Williams [32] schema as the conceptual framework; attempts to demonstrate how health economics can be used to inform policy and managerial choices related to HIV/AIDS advocacy; prevention; treatment and management. It argues that the discipline of health economics (and economics generally) is extremely valuable in: measuring health impacts of the disease and interventions; evaluating the relationships between health care-seeking behaviour of individuals and health system specific attributes; the estimation of determinants of compliance of HIV/AIDS patients with treatment regimen; establishing of health institutions efficiency in combating AIDS; guiding choices of HIV/AIDS interventions; assessing the relationships between HIV/AIDS; development; poverty; and trade; programme planning; monitoring and evaluation; and assessing health system's overall performance. The paper is a modest attempt to show how the discipline of health economics can elucidate; and help in resolving practical and conceptual issues in HIV/AIDS control in Africa

Health sector reform in sub-Saharan Africa: a synthesis of country experiences.

Health sector reform is 'a sustained process of fundamental changes in national health policy, institutional arrangements, etc. guided by government and designed to improve the functioning and performance of the health sector and, ultimately, the health status of the population'. All the forty six countries in the African Region of the World Health Organisation have embarked on one form of health sector reform or the other. The contexts and contents of their health reform programmes have varied from one country to another. Health reforms in the region have been influenced largely by the poor performance of the health systems, particularly with regard to the quality of health services. Most countries have taken due congnizance of the deficiencies on their health systems in the design of their health reform programmes and they have made some progress in the implementation of such programmes. Indeed, some countries have adopted sector-wide approaches (SWAps) in developing and implementing their health reform programmes. Since countries are at various stages of implementing their health reform programmes, there is a lot of potential for countries to learn from one another. This paper is a synthesis of the experiences of the countries of the Region in the development and implementation of their health sector reform programmes. It also highlights the future perspectives in this important area.

Technical efficiency of public clinics in Kwazulu-Natal Province of South Africa.

BACKGROUND: In sub-Saharan Africa (SSA) much of the attention of policy makers, health care managers, health systems researchers and donors is focussed almost solely on mobilising additional resources and not on efficiency in their use. OBJECTIVE(S): To investigate the technical inefficiencies among 155 primary health care clinics in Kwazulu-Natal Province of South Africa; and to draw policy implications. DESIGN: Cross-sectional provincial health clinic survey. SELLING: Kwazulu-Natal Provincial Department of Health Clinics survey, 1996. SUBJECTS: The analysis is based on 155 public clinics. INTERVENTIONS: Non-intervention Data Envelopment Analysis (DEA) study. MAIN OUTCOME MEASURES: Technical and scale efficiency scores. RESULTS: Forty seven (30%) were found to be technically efficient. Among the 108 (70%) technically inefficient facilities, 16% had an efficiency score of 50% or less. The presence of inefficiencies indicates that a clinic has excess inputs or insufficient outputs compared to those clinics on the efficiency frontier. To achieve technical efficiency, Kwazulu-Natal clinics would, in total have to decrease inputs by 417 nurses and 457 general staff. Alternatively, outputs would have to be increased by 115,534 antenatal visits, 1,010 births (deliveries), 179,075 child care visits, 5,702 dental visits, 121,658 family planning visits, 36,032 psychiatric visits, 56,068 sexually transmitted disease visits and 34,270 tuberculosis visits. CONCLUSION: There is need for more detailed studies in a number of the relativdy efficient clinics to determine why they are efficient with a view of documenting attributes of 'best practise' that other clinics can emulate. The potential benefit of replicating this kind of study in other provinces, and indeed, other SSA countries cannot be overemphasised.

How to develop an operational plan for health.

BACKGROUND: About 88%, 8%, 36% and 28% of the ministries of health in African countries do not have long-term health plans (LTHPs), health policies (HPs), strategic plans (SPs), and operational plans (OPs), respectively. Eight per cent, 38% and 54% of the countries with OPs rated their formulation as 'excellent', 'satisfactory' and 'needs improvement', respectively. OBJECTIVE(S): To provide a rationale for an OP; to describe its contents; and to explain the process of developing it. DESIGN: Descriptive study. SETTING: Operational plans in the WHO African Region. INTERVENTIONS: Non-intervention descriptive study. MAIN OUTCOME MEASURES: Operational plan (OP) for health. RESULTS: An OP framework and process that could be adapted by countries is proposed. CONCLUSION: An adequately formulated OP will contain objectives, targets, expected results, activities, required resources, and a monitoring and evaluation plan (consisting of responsibilities, monitoring indicators, evaluation indicators, data sources - for verifying indicators, and periodicity). In the next two decades, we envision that all the UN agencies and other health partners working in Africa will cooperate with individual countries to develop (or strengthen) LTHPs, HPs, SPs, and OPs of the Ministries of Health (national, provincial and district level).

Evaluation of health-related programmes in Africa: a vision for 2020.

BACKGROUND: Whereas systematic evaluation practice is over five decades old in economically developed continents (DCs), that culture has not yet taken root in Africa. OBJECTIVE(S): To provide an overview of the current situation of health-related evaluation in the African Region; to envision an appropriate evaluation framework for the next two decades; and to provide overviews of what formative (FE) and summative (SE) evaluations are and how they could be conducted. DESIGN: Descriptive study. SETTING: Health policies and plans evaluation in the WHO African Region. SUBJECTS OR PARTICIPANTS: WHO Country Representatives for 25 African Countries. INTERVENTIONS: Non-intervention descriptive study. MAIN OUTCOME MEASURES: Availability and quality of long-term health plan (LTHP), health policy (HP), strategic plan (SP), operational plan (OP), and an evaluation culture. RESULTS: The study found that: 88%, 8%, 36%, 28% and 48% of the countries in the Region do not have LTHP, HP, SP, OP and evaluation culture. A conceptual evaluation framework, tools for formative and summative evaluations are proposed. CONCLUSION: It is envisioned that all partners for health development in Africa will cooperate with individual countries to develop (or strengthen) LTHPs, HPs, SPs, and Ministries of Health OPs (national, provincial and district level); and to make complementary investments in building technical and administrative capacity for evaluating implementation of District Operational Plans (DOPs).

A cost-benefit analysis of preventive schistosomiasis interventions in Kenya.

The objectives of this paper are fourfold: first, to develop a model for a cost benefit analysis (CBA) to appraise various preventive schistosomiasis interventions; second, to identify the relevant types of data needed for such a model; third, to use the model to inform choices about optimal prevention strategies; and fourthly, to discuss the utility of this form of decision analysis to policy-makers. The following data were used: expected costs of each option over the 15 year project life; willingness-to-pay value for health states (outcomes); probabilities of health states with and without various interventions; 15 year population forecasts; discount factors for each year; and a standard conversion factor. All the interventions examined had a positive net present value, with the drip mollusciciding option dominating the other options. The study also highlighted the fact that there is as need for collaboration between tropical disease epidemiologists and health economists in the design and execution of randomized controlled trails to obtain the probabilistic effectiveness data needed in such decision analyzes.

Are public hospitals in Kwazulu-Natal Province of South Africa technically efficient?

Generally, policy-makers and researchers in South Africa acknowledge that hospitals absorb a disproportionate share of health sector resources. The latter, to a certain extent, have failed to provide evidence needed to guide the former's decisions. Albeit in an ad hoc manner, the post-apartheid policy-makers have been reducing hospital budgets to avail the resources needed to strengthen the hitherto neglected primary health care system. Since political will exists to reduce (if not eliminate) wastage of resources within the hospitals, micro-efficiency analyses (like the one reported here) are needed to guide the policy-makers. This study employs Data Envelopment Analysis (DEA) methodology to identify and measure individual hospital's inefficiencies. The key results are as follows. Forty percent of the hospitals had some degree of technical inefficiency. Fifty eight percent were scale-inefficient. In total, the following inputs are currently wasted and not utilized in the production of hospital outputs in Kwazulu-Natal public hospitals: 117.4 doctors (8.0%); 2709 nurses (11.9%); 61 paramedics (11.5% ); 58 Technician (13.1%); 295 Administrative staff (11.1%); 835 General staff (11.3%); 1,193 Labour provisioning staff (14.3%); 38 Other staff (10.7 %); and 1,752 Beds (7.1%). Those are the specific input reductions required to make inefficient hospitals become technically efficient. In conclusion, the DEA results constitute a strong guide to health care decision making, especially with regard to practical always of increasing efficiency and rational use of health care resources.

Willingness-to-pay for schistosomiasis-related health outcomes in Kenya.

Cost-benefit analysis (CBA) provides a framework for identifying, quantifying, and valuing in monetary terms all the important costs and consequences to society of competing disease interventions. Thus, CBA requires that impacts of schistosomiasis interventions on beneficiaries'health be valued in monetary terms Economic theory requires the use of the willingness to pay (WTP) approach in valuation of changes in health as a result of intervention. It is the only approach which is consistent with the potential Pareto improvement principle, and hence, consistent with CBA. The present study developed a health outcome measure and tested its operational feasibility. Contingent valuation for certain return to normal health from various health states, and for remaining in one's current health state were elicited through direct interview of randomly selected rice farmers, teachers, and health personnel in Kenya. The WTP to avoid risk of advancing to the next more severe state, seemed to be higher than WTP for a return to normal health. Generally, there was a significant difference between the average WTP values of farmers, teachers and health personnel populations. The gender and occupation variable coefficients were positive and highly significant in all regressions. The coefficients of the other explanatory variables were generally not statistically significant, indicating that medical expenses, anxiety cost, loss of earnings, and loss of work time, implied in various health states descriptions did not have significant effect on respondents expressed WTP values. The latter finding shows that there is need for more research to identify the other (besides gender and occupation) determinants of expressed WTP values in Africa. This study has demonstrated that it is possible to elicit coherent WTP values from economically under-developed countries. Further empirical work is clearly needed to at least address the validity and reliability of the contingent valuation approach and its measurements in Africa.

Demand for antenatal care in South Africa.

On May,24 1994, the then South African president, Mr. Nelson Mandela, declared that all health care for children under the age of 6 years, and pregnant women would be free. Unfortunately, there has been no significant decrease in maternal, perinatal and infant mortality. Thus, there is a need of research into the factors that influence the demand for antenatal services. The objectives of this paper are to (a) establish the determinants of individual pregnant women's choice to seek antenatal care; and (b) deal with potential endogeneity bias in the relationship between the decision to seek pre-natal care and perceived health status. The joint determination of consumption of antenatal care and pregnant woman's health status requires estimation of a simultaneous system. To help mitigate the simultaneity bias and avoid the inconsistency inherent in the application of Ordinary least Squares (OLS) method to simultaneous equations systems, we used Two-Stage Probit Maximum Likelihood Estimator Method. In the antenatal structural-form equation, the coefficients for TOILET, AGE, OCCUPATION, EMPLOYMENT, SMOKER, METHODS and QUALITY were statistically significant at P