The essence of governance in health development

<p>Abstract</p> <p>Background</p> <p>Governance and leadership in health development are critically important for the achievement of the health Millennium Development Goals (MDGs) and other national health goals. Those two factors might explain why many countries in Africa are not on track to attain the health MDGs by 2015. This paper debates the meaning of 'governance in health development', reviews briefly existing governance frameworks, proposes a modified framework on health development governance (HDG), and develops a HDG index.</p> <p>Discussion</p> <p>We argue that unlike 'leadership in health development', 'governance in health development' is the sole prerogative of the Government through the Ministry of Health, which can choose to delegate (but not abrogate) some of the governance tasks. The general governance domains of the UNDP and the World Bank are very pertinent but not sufficient for assessment of health development governance. The WHO six domains of governance do not include effective external partnerships for health, equity in health development, efficiency in resource allocation and use, ethical practises in health research and service provision, and macroeconomic and political stability. The framework for assessing health systems governance developed by Siddiqi <it>et al </it>also does not include macroeconomic and political stability as a separate principle. The Siddiqi <it>et al </it>framework does not propose a way of scoring the various governance domains to facilitate aggregation, inter-country comparisons and health development governance tracking over time.</p> <p>This paper argues for a broader health development governance framework because other sectors that assure human rights to education, employment, food, housing, political participation, and security combined have greater impact on health development than the health systems. It also suggests some amendments to Siddigi <it>et al</it>'s framework to make it more relevant to the broader concept of 'governance in health development' and to the WHO African Region context.</p> <p>Summary</p> <p>A strong case for broader health development governance framework has been made. A health development governance index with 10 functions and 42 sub-functions has been proposed to facilitate inter-country comparisons. Potential sources of data for estimating HDGI have been suggested. The Governance indices for individual sub-functions can aid policy-makers to establish the sources of weak health governance and subsequently develop appropriate interventions for ameliorating the situation.</p

Inequalities in selected health-related Millennium Development Goals indicators in all WHO Member States

The objective of this study was to quantify inequalities in selected Millennium Development Goal (MDG) indicators in all the 192 WHO Member States using descriptive statistics, the Gini coefficient and the Theil coefficient. The data on all the indicators were obtained from The World Health Report 2004. The main findings were as follows: (i) generally, all the MDG indicators are significantly worse in low-income countries than in the other three income groupings; (ii) for all the MDG indicators, there are inequalities within individual countries, within the four income groups, and across income groups of countries; (iii) the inequalities in the MDG indicators are higher among the low-income countries than in high-income countries; and (iv) the ranking of income groups, by various indicators, is fairly stable whether one employs the Gini coefficient or Theil coefficient. As Member States strive to expand the effective coverage of strategies and interventions (including health promotion, primary and secondary prevention, treatment, and care) geared at reducing child mortality; improving maternal health; combating HIV/AIDS, malaria and TB; and ensuring environmental sustainability (through reduction in the use of solid fuels and expansion in access to improved water and sanitation), it is vitally important to ensure that they are implemented in a manner that redresses the inequalities in various MDG indicators. Thus, it is vital for countries to systematically monitor not only the changes in various MDG indicators but also the inequalities across the various income quintiles. In addition, at the regional and global levels, it is necessary to set up mechanisms for rigorous monitoring of the inequalities in the MDG indicators across the income groups of countries. The lessons learnt from the monitoring processes should inform the design and targeting of the various MDG-related policies, strategies and interventions with a view to eradicating the inequalities

Beyond needs-based health funding: resource allocation and equity at the state and area health service levels in New South Wales - Australia

Addressing inequities in health both within and between countries has attracted considerable global attention in recent years. In theory, equity remains one of the key policy objectives of health systems and underpins the allocation of health sector resources in many countries. In practice, however, current evidence demonstrates that only limited progress has been made in terms of bridging the health inequity gap and improving the health of the least advantaged. The persistence of inequities in health and health outcomes raises concerns about how governments and health authorities distribute limited health resources to improve the health of the poor and most vulnerable and thereby promote equity. This thesis is about equity and allocation of financial resources in the health system of New South Wales, one of the eight states of Australia. It investigated the extent to which there has been a movement towards equity in resource allocation to Area Health Services under the NSW Health Resource Distribution Formula and whether this has been reflected in equitable resource allocation within Area Health Services. It considered only resources allocated through the NSW Department of Health. The study employed a combination of qualitative and quantitative methods to gather and analyse data. The qualitative component analysed data gathered through semi-structured interviews with policy makers, health executives, managers, and other stakeholders to establish the resource allocation processes and the factors upon which the allocation decisions were based. The quantitative component analysed health expenditure and health needs data to assess the extent to which allocation of resources from the State to Area Health Service levels has been equitable in terms of reflecting the level of health needs. Two indices were constructed and used as proxies for health needs. Principal component analysis was used in the construction of one of the indices, using demographic, socio-economic and health-related data. The other index was developed using a combination of premature mortality and morbidity data. The quantitative study spans the two decades 1989/90 to 2006/07, with a more detailed analysis of material for the years 2003/04 to 2006/07. The findings of the study show a considerable degree of inequity in resource allocation with several Area Health Services (AHSs) receiving less than a fair share of funding for the years analysed, although some movements towards equity were evident. This contradicts the general impression that the introduction of the resource distribution formula in NSW has significantly improved equity in resource allocation. In general, funding allocation at the State level correlated significantly with population size but not with health needs of the eight AHSs in NSW. Similarly, within the AHSs, allocation of funds was based on programs and services and not on health needs. Key issues that emerged from the qualitative data as affecting the equity with which health funds are allocated in the NSW health system include limited use of the resource distribution formula at the state level, lack of an effective resource allocation tool to guide the distribution of funds within AHSs, and insufficient emphasis on equity at the AHS level. It is crucial that these and several other issues identifies in the study are addressed if current inequities in funding and in health outcomes generally are to be effectively reduced

Technical efficiency of human resources for health in Africa

There is growing peer and donor pressure on African countries to utilize available resources more efficiently in a bid to support the ongoing efforts to expand coverage of health interventions with a view to achieving the health-related Millennium Development Goals. The purpose of this study was to estimate the technical and scale efficiency of national health systems (NHS) in utilizing human resources for health in African continent. The study applied the Data Envelopment Analysis (DEA) approach to estimate the technical efficiency and scale efficiency among the 53 countries of the African Continent. Out of the 38 low-income African countries, 12 countries national health systems manifested a constant returns to scale technical efficiency (CRSTE) score of 100%; 15 countries had a variable returns to scale technical efficiency (VRSTE) score of 100%; and 12 countries had a SE score of one. The average VRSTE score was 95% and the mean scale efficiency (SE) score was 59%; meaning that while on average the degree of inefficiency was only 5% and the magnitude of scale inefficiency was 41%. Of the 15 middle-income countries, 5 countries, 9 countries and 5 countries had CRSTE, VRSTE and SE scores of 100%. Ten countries, six countries and 10 countries had CRSTE, VRSTE and SE scores of less than 100%; and thus, they were deemed inefficient. The average VRSTE (i.e. pure efficiency) score was 97.6%. The average SE score was 49.9%. There is large unmet need for health and health-related services among countries of the African Continent. Thus, it would not be advisable for health policy-makers address NHS inefficiencies through reduction in excess human resources for health. Instead, it would be more prudent for them to leverage health promotion approaches and universal access prepaid (tax-based, insurance-based or mixtures) health financing systems to create demand for underutilized health services/interventions with a view to increasing ultimate health outcomes to efficient target levels

Does expanding fiscal space lead to improved funding of the health sector in developing countries?: lessons from Kenya, Lagos State (Nigeria) and South Africa

This article examines whether increased tax revenue in the three territories of Kenya, Lagos State (Nigeria) and South Africa was accompanied by improved resource allocation to their public health sectors, and explores the reasons underlying the observed trends.CW201

Economic burden of cholera in the WHO African region

<p>Abstract</p> <p>Background</p> <p>In 2007, various countries around the world notified 178677 cases of cholera and 4033 cholera deaths to the World Health Organization (WHO). About 62% of those cases and 56.7% of deaths were reported from the WHO African Region alone. To date, no study has been undertaken in the Region to estimate the economic burden of cholera for use in advocacy for its prevention and control. The objective of this study was to estimate the direct and indirect cost of cholera in the WHO African Region.</p> <p>Methods</p> <p>Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health-care system and the family in directly addressing cholera; and (b) the indirect costs, i.e. loss of productivity caused by cholera, which is borne by the individual, the family or the employer. The study was based on the number of cholera cases and deaths notified to the World Health Organization by countries of the WHO African Region.</p> <p>Results</p> <p>The 125018 cases of cholera notified to WHO by countries of the African Region in 2005 resulted in a real total economic loss of US$39 million, US$ 53.2 million and US$64.2 million, assuming a regional life expectancies of 40, 53 and 73 years respectively. The 203,564 cases of cholera notified in 2006 led to a total economic loss US$91.9 million, US$128.1 million and US$156 million, assuming life expectancies of 40, 53 and 73 years respectively. The 110,837 cases of cholera notified in 2007 resulted in an economic loss of US$43.3 million, US$60 million and US$72.7 million, assuming life expectancies of 40, 53 and 73 years respectively.</p> <p>Conclusion</p> <p>There is an urgent need for further research to determine the national-level economic burden of cholera, disaggregated by different productive and social sectors and occupations of patients and relatives, and national-level costs and effectiveness of alternative ways of scaling up population coverage of potable water and clean sanitation facilities.</p

Effects of Maternal Mortality on Gross Domestic Product (GDP) in the WHO African Region*

WHO African region has got the highest maternal mortality rate compared to the other five regions. Maternal mortality is hypothesized to have significantly negative effect on the gross domestic product (GDP). The objective of the current study was to estimate the loss in GDP attributable to maternal mortality in the WHO African Region. The burden of maternal mortality on GDP was estimated using a doublelog econometric model. The analysis is based on cross-sectional data for 45 of the 46 Member States in the WHO African Region. Data were obtained from UNDP and the World Bank publications. All the explanatory variables included in the doublelog model were found to have statistically significant effect on per capita gross domestic product (GDP) at 5% level in a t-distribution test. The coefficients for land (D), capital (K), educational enrolment (EN) and exports (X) had a positive sign; while labor (L), imports (M) and maternal mortality rate (MMR) were found to impact negatively on GDP. Maternal mortality of a single person was found to reduce per capita GDP by US$ 0.36 per year. The study has demonstrated that maternal mortality has a statistically significant negative effect on GDP. Thus, as policy-makers strive to increase GDP through land reform programs, capital investments, export promotion and increase in educational enrolment, they should always remember that investments in maternal mortalityreducing interventions promises significant economic returns

Technical efficiency of peripheral health units in Pujehun district of Sierra Leone: a DEA application

BACKGROUND: The Data Envelopment Analysis (DEA) method has been fruitfully used in many countries in Asia, Europe and North America to shed light on the efficiency of health facilities and programmes. There is, however, a dearth of such studies in countries in sub-Saharan Africa. Since hospitals and health centres are important instruments in the efforts to scale up pro-poor cost-effective interventions aimed at achieving the United Nations Millennium Development Goals, decision-makers need to ensure that these health facilities provide efficient services. The objective of this study was to measure the technical efficiency (TE) and scale efficiency (SE) of a sample of public peripheral health units (PHUs) in Sierra Leone. METHODS: This study applied the Data Envelopment Analysis approach to investigate the TE and SE among a sample of 37 PHUs in Sierra Leone. RESULTS: Twenty-two (59%) of the 37 health units analysed were found to be technically inefficient, with an average score of 63% (standard deviation = 18%). On the other hand, 24 (65%) health units were found to be scale inefficient, with an average scale efficiency score of 72% (standard deviation = 17%). CONCLUSION: It is concluded that with the existing high levels of pure technical and scale inefficiency, scaling up of interventions to achieve both global and regional targets such as the MDG and Abuja health targets becomes far-fetched. In a country with per capita expenditure on health of about US$7, and with only 30% of its population having access to health services, it is demonstrated that efficiency savings can significantly augment the government's initiatives to cater for the unmet health care needs of the population. Therefore, we strongly recommend that Sierra Leone and all other countries in the Region should institutionalise health facility efficiency monitoring at the Ministry of Health headquarter (MoH/HQ) and at each health district headquarter

E-health: Determinants, opportunities, challenges and the way forward for countries in the WHO African Region

BACKGROUND: The implementation of the 58(th )World Health Assembly resolution on e-health will pose a major challenge for the Member States of the World Health Organization (WHO) African Region due to lack of information and communications technology (ICT) and mass Internet connectivity, compounded by a paucity of ICT-related knowledge and skills. The key objectives of this article are to: (i) explore the key determinants of personal computers (PCs), telephone mainline and cellular and Internet penetration/connectivity in the African Region; and (ii) to propose actions needed to create an enabling environment for e-health services growth and utilization in the Region. METHODS: The effects of school enrolment, per capita income and governance variables on the number of PCs, telephone mainlines, cellular phone subscribers and Internet users were estimated using a double-log regression model and cross-sectional data on various Member States in the African Region. The analysis was based on 45 of the 46 countries that comprise the Region. The data were obtained from the United Nations Development Programme (UNDP), the World Bank and the International Telecommunications Union (ITU) sources. RESULTS: There were a number of main findings: (i) the adult literacy and total number of Internet users had a statistically significant (at 5% level in a t-distribution test) positive effect on the number of PCs in a country; (ii) the combined school enrolment rate and per capita income had a statistically significant direct effect on the number of telephone mainlines and cellular telephone subscribers; (iii) the regulatory quality had statistically significant negative effect on the number of telephone mainlines; (iv) similarly, the combined school enrolment ratio and the number of telephone mainlines had a statistically significant positive relationship with Internet usage; and (v) there were major inequalities in ICT connectivity between upper-middle, lower-middle and low income countries in the Region. By focusing on the adoption of specific technologies we attempted to interpret correlates in terms of relationships instead of absolute "causals". CONCLUSION: In order to improve access to health care, especially for the majority of Africans living in remote rural areas, there is need to boost the availability and utilization of e-health services. Thus, universal access to e-health ought to be a vision for all countries in the African Region. Each country ought to develop a road map in a strategic e-health plan that will, over time, enable its citizens to realize that vision