Comparative health systems research in a context of HIV/AIDS: lessons from a multi-country study in South Africa, Tanzania and Zambia

Comparative, multi-country research has been underutilised as a means to inform health system development. South-south collaboration has been particularly poor, even though there have been clearly identified benefits of such endeavours. This commentary argues that in a context of HIV/AIDS, the need for regional learning has become even greater. This is because of the regional nature of the problem and the unique challenges that it creates for health systems. We draw on the experience of doing comparative research in South Africa, Tanzania and Zambia, to demonstrate that it can be useful for determining preconditions for the success of health care reforms, for affirming common issues faced by countries in the region, and for developing research capacity. Furthermore, these benefits can be derived by all countries participating in such research, irrespective of differences in capacity or socio-economic development

Interactions between Global Health Initiatives and Country Health Systems: The Case of a Neglected Tropical Diseases Control Program in Mali

Prevention of neglected tropical diseases was recently significantly scaled up in sub-Saharan Africa, protecting entire populations with mass distribution of drugs: five different diseases are now addressed simultaneously with a package of four drugs. Some argue however that, similarly to other major control programs dealing with specific diseases, this NTD campaign fails to strengthen health systems and might even negatively affect regular care provision. In 2007, we conducted an exploratory field study in Mali, observing how the program was implemented in two rural areas and how it affected the health system. At the local level, we found that the campaign effects of care delivery differed across health services. In robust and well staffed health centres, the personnel successfully facilitated mass drug distribution while running routine consultations, and overall service functioning benefitted from programme resources. In more fragile health centres however, additional program workload severely disturbed access to regular care, and we observed operational problems affecting the quality of mass drug distribution. Strong health services appeared to be profitable to the NTD control program as well as to general care

The Joint Action and Learning Initiative on National and Global Responsibilities for Health

A population’s health and wellbeing is primarily a national responsibility. Every state owes all of its inhabitants a comprehensive package of essential health goods and services under its obligations to respect, protect, and fulfill the human right to health. Yet health is also a global responsibility. Every state has a duty to ensure a safe and healthy world, with particular attention to the needs of the world’s poorest people. Improving health and reducing unconscionable health inequalities is both an international obligation under the human right to health and a matter of global social justice. The mutual obligations of states to safeguard the health of their own inhabitants and the health of people everywhere are poorly defined, with serious adverse consequences for world health. These obligations must be better understood. Central questions of vital importance to the health of the world’s population include: What are the duties of all states to ensure the right to the highest attainable standard of health for all their inhabitants? What are the components of a comprehensive package of essential goods and services under the right to health to which people everywhere are entitled? How specifically can states’ duties to govern well be incorporated into and realized through the health system? One of the most inadequately understood obligations is the responsibility of the international community to augment the capacity of low- and middle-income states to ensure their population’s health, with the specific contours of this obligation ill-defined. Indeed, international financial assistance is framed as “aid,” rather than an expression of mutual responsibility, leaving the flawed impression that international health assistance is a matter of charitable discretion rather than an international human rights obligation. The approach to health assistance as charity rather than as an obligation also means that this assistance is unreliable over the longer-term, leading to the reluctance of low- and middle-income countries to use it for recurrent public health expenditures. Continued and accelerated improvements in global health will require significant and reliable funding at a time of extended economic uncertainty and budget belt-tightening in many countries. Progress on global health therefore risks stagnating unless states have clarity on, accept, and adhere to national and international obligations to respect, protect, and fulfill the human right to health. Translating state obligations into improved health will also require building a more robust and effective global health governance structure. Current global health initiatives are too often undermined by a host of now well-recognized weaknesses: Global health actors do not sufficiently coordinate their activities with each other or the host countries, leading to fragmentation, nor do they make and keep longer-term funding commitments, leading to unpredictability. Development partners do not set the priorities required to meet all human health needs, and lack accountability for their own global health commitments. Host countries are not empowered to take “ownership” of health planning and programs. And the international community does not adequately monitor and evaluate programmatic effectiveness. Our aim is to propose a coherent global health governance framework for the post-MDG period that will clarify national and global responsibilities for health, enable countries to effectively carry out these responsibilities, and create accountability around them. In order to achieve this, we are establishing the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI). The primary purpose of the JALI is to catalyze and facilitate research, broad consultations, and campaigns that will lead to a global compact. Towards this end, the JALI will rigorously and systematically address the following issues: • Clarify the essential package of health goods and services to which all human beings are entitled as part of their right to health; • Clarify the responsibility of all states, even the poorest, to provide this essential package of health goods and services to all of their inhabitants; • Assess the gap between the conditions (financial and others) for the provision of an essential package of health goods and services, and the domestic capacity of and use of that capacity by poorer countries—the gap for which the international community should take responsibility; • Clarify the international responsibility to build the capacity of low- and middle-income states to provide an essential package of health goods and services to their inhabitants; • Clarify the principles of good governance, both nationally and globally, including transparency, honesty, and accountability. • Propose a coherent global health governance architecture to ensure robust national and global responsibilities for health. In particular, the JALI will answer the following four key questions: 1. What are the essential services and goods guaranteed to every human being under the human right to health? 2. What is the responsibility that all states have for the health of their own populations? 3. What is the responsibility of all countries to ensure the health of the world\u27s population? 4. What kind of global health governance is needed to ensure that all states live up to their mutual responsibilities

Professional skills development in a resource-poor setting: the case of pharmacy in Malawi

The dominance of the human capital approach in vocational skills development has been increasingly questioned for being de-humanised and de-contextualised. Contrary to this trend, the discourse in health professional skills development has shown increasing enthusiasm for consolidating this existing paradigm. To debate whether professional skills development should indeed be insulated from such scepticism, this paper examines one strategy adopted by the health professions. Called ‘task shifting’, this strategy involves re-delegating professional tasks to nonprofessional cadres according to a skills-based toolkit. Challenging the context-free approach to using this toolkit, this paper presents ethnographic evidence derived from a case study of pharmacy workforce issues in Malawi. It was found that task shifting was inhibited by a perception barrier about the moral and intellectual superiority of the pharmacists. Pharmacy technicians were judged to be unfit for a professional task because of a perceived lack of professional status, power and ethics. On tracing the origin of the inherent professional prowess assigned to the pharmacists, it was found that professionalism was an ideology borrowed from external sources, inter alia, colonial legacies and global health governance. This study exposes our hidden assumption about an axiomatic transferability of Anglo American skills development models to a postcolonial, aid-dependent context. This paper therefore suggests redefining this toolkit by bridging health research into dialogue with non-health disciplinary concerns such as postcolonialism and aiddependence. In conclusion, it argues that professional skills development is context-laden; and in need of a human-centred approach that involves true indigenousparticipation–challenges not unlike those faced by the vocational skills discourse