Geneva Health Forum Archive

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A New Approach for Assessing Health System Governance

Author(s): I. Mikkelsen-Lopez1, C. Baez-Camargo*2, E. Jacobs2, K. Wyss3, A. Lugon-Moulin2, D. de Savigny1
Affiliation(s): 1Public Health and Epidemiology, Swiss Tropical Institute, 2Governance, Basel Institute on Governance, 3Swiss Centre for International Health, Swiss Tropical Institute, Basel, Switzerland
Keywords: Governance, Health Systems

The 2007 WHO framework of health system building blocks identifies governance, financing, human resources, information, medicines and technologies and service delivery as the core sub-systems. Much work has focused on these building blocks, however concepts and methods for assessing governance of health systems are particularly lacking. This is especially problematic given that within the literature governance is recognized as a critical issue affecting health systems performance. Various institutions have measured selected aspects of governance in the past (World Bank Institute, Freedom House, Transparency International, WHO), yet only a couple have attempted to develop indicators specific for health systems. Based on the 2007 WHO framework, our research develops a general framework with a more comprehensive understanding of the dimensions of governance and how they are interrelated. We contribute to the notion that not all governance dimensions are qualitatively equal. We distinguish between governance attributes, governance outcomes and governance levers to show how within the health system these dimensions affect each other.

Results/Conclusions: In this framework accountability is the key governance attribute impacting on governance outcomes such as corruption, responsiveness, equity and efficiency. We develop a diagnostic tool that includes indicators to assess whether the appropriate accountability provisions exist across the health system and whether they are enforced. We also develop proxy indicators for key governance outcomes specific to the health sector which are grouped by WHO building blocks. Finally, we propose a set of governance levers which are possible intervention routes to address specific problems in governance. Based on the results of applying the diagnostic tool, these levers can be used to develop appropriate interventions that have stronger conceptual and empirical grounding. Therefore, the overall aim of our research is to build on the literature by developing a general conceptual framework to assess the impact of governance in health systems and ultimately health. We hope to highlight various outcomes of poor-governance so that interventions can be developed and targeted appropriately. This presentation will describe the Framework and we invite discussion on appropriate indicators and suggestions on how it can be applied.

Back to the Future for Migrants: Growing Challenges of Access

Author(s): Manuel Carballo1, A. Sundaram
Affiliation(s): 1International Centre for Migration and Health, Vernier, Switzerland
Key issues: At a time when progress toward the UN Millennium Development Goals is faltering, access to healthcare in general and reproductive healthcare in particular is becoming more of a challenge than ever. Despite the impressive progress being made in medical sciences, accessing quality healthcare is becoming more difficult for millions of people around the world. The problem is not unique to poor countries. In many of the richer countries, the number of people with limited access to healthcare services is growing. One of the contributing factors is migration.
Meeting challenges:

Migration is a complex health process. People move with health profiles that reflect socio-economic backgrounds, the diseases and health problems they may have confronted before they moved, and the experience they may have had with healthcare services and personnel in their home countries. The health of migrants is also a function of the way in which they move, what they had to do in order to move and what the modality of their movement was. Finally their health is affected by the social, political and economic context into which they are expected to insert themselves. Their access to healthcare if and when they need it is determined by all these factors and experiences. It is also influenced by their feeling of security, the extent to which they feel they are allowed to participate in the host health system, and the way in which they are received by and can communicate with healthcare personnel. The process is replete with pitfalls. Cultural perceptions and attitudes on the part of patients and healthcare providers intervene. National and local regulations concerning who is eligible for what and under which circumstances also play a critical role. So does the status of the migrant, the extent to which he or she is eligible for medical insurance, be it individually paid for or a shared responsibility between employers and employees. In many situations the underlying question is whether host societies have a positive attitude to migration and migrants, and whether migrants are seen as necessary. In the area of reproductive health we are on the verge of looking back to the future with patterns of maternal and newborn health that are reminiscent of situations that were obtained fifty or more years ago. Poor use of family planning and elevated requests for abortion are symptoms of the emerging scenario. So are the poor pregnancy outcomes and poor neonatal health, as well as late stage presentation for diagnosis of gynecological problems. In some countries of Europe, there are also signs that the incidence and prevalence of sexually transmitted infections may be becoming higher among migrant populations than others, and that women migrants may be especially vulnerable.

Conclusion (max 400 words): As we move into the 21st century and an era of growing mobility within and between countries, the question of access to healthcare in general and reproductive health in particular by migrants will weigh heavily on national policy makers, healthcare providers and the public at large. Everyone stands to gain from equitable access to quality care and ultimately everyone, be they migrants or non-migrants, stands to lose if inequities are allowed to emerge and persist. As migration continues to grow and become an even more indispensable part of social and economic development, it will become increasingly incumbent on all stakeholders to take up this issue and redress these inequities. Medical insurance coverage for all, more training of health personnel on multi-cultural health, greater focus on health promotion and disease prevention among migrants and their social insertion will go far in redressing the problem.

Global Public-Private Partnerships and Global Health Governance

Author(s): Eduardo Missoni1
Affiliation(s): 1Faculty of Sociology, Università degli Studi di Milano Bicocca, Milano, Italy
Key issues: Partnership, a good feelings evocative concept, is one of the trendiest key words in the international development jet set today. Repeatedly, declarations and commitments summarising international events conclude launching new global partnerships to solve the problems they have been addressing. The need for a wide commitment and shared responsibilities in the pursuit of development goals is often being mystified with the establishment of structured narrowly focused public-private partnerships whose promotion often responds more to ideological criteria than to sound comprehensive evaluation of costs and benefits. The notion of partnership for development is not new, however in the language of international meetings sponsored by, or with the participation of, UN agencies and other international and bilateral public actors, the rhetoric of partnership has now become dominant assuming the need for public-private joint-ventures, notwithstanding the lack of any evidence for that declared need.
Meeting challenges: Indicated as the eighth Millennium Development Goal and otherwise understood mainly in terms of shared values, goals, commitment and responsibilities, in the text of the Millennium Declaration the idea of partnership is translated into a pledge for strong partnerships with the private sector and civil society organizations in pursuit of development and poverty eradication. At the eave of the 21st century, Global Public-Private Partnerships have become one of the most notable features of the global arena. Pretending lack of public resources where the reality is one of reduced public commitment and of progressive privatization of international aid the GPPP model is repeatedly proposed at every Summit as the answer to the most varied and dramatic issues that the world is facing today. Including the GAVI which served as a prototype and the GFATM mostly imposed by a preconceived political agenda, at present there are more than 90 different health-related GPPP, duplicating efforts and further fragmenting global action for health, with heavy consequences also in terms of governance of national health systems and provision of health-care of beneficiary countries.
Conclusion (max 400 words): GPPPs offer easy quick-fix solutions to avoid more complex and disturbing global political rethinking and decisions. They involve issues of growing concern that need to be understood in the wider socioeconomical context of dominating neo-liberal ideologies that have influenced public policy since the early 1980s, with a growing commercialization of health care and the incapacity of WHO to keep up to its mandate and leadership. Important strategic decisions about health policies, appear to be taken in the new public-private setting, while WHO’s own legitimate authority is undermined, and its role reduced to pure technical assistance, in times when global health governance is widely felt as a critical issue.

Alternatives in Healthcare Financing: Examples from Low and Middle Income Countries

Author(s): Sania Nishtar1
Affiliation(s): 1President, Heartfi le, Pakistan
Summary (max 100 words): Pakistan currently principally uses three modes of financing health taxation, out of pocket payments and donor contributions of which the latter is the least significant in terms of size. The government spends 0.6 of its GDP and 11.6% of its development budget on health. Less than 3.6% of the employees are covered under the social security scheme and there is a limited social protection mechanism, which collectively serves the health needs of 3.4% of the population. The main issues in health financing include low spending, lack of attention to alternate sources of financing and issues with fund mobilization and utilization. With respect to the first, recently proposed health reforms make a strong case for promoting the reallocation of taxbased revenues and developing sustainable alternatives to low levels of public spending on health. With respect to alternative sources of health financing, the proposed reforms as articulated in the Gateway Paper lay stress on exploring policy options for private health insurance, broadening the base of Employees Social Security, creating a Federal Employees Social Security Programme, developing social health insurance within the framework of a broad-based social protection strategy, which scopes beyond the formally employed sector, establishing a widely inclusive safety net for the poor; mainstreaming philanthropic grants as a major source of health financing; developing a conducive tax configuration; generating greater corporate support for social sector causes within the framework of the concept of Corporate Social Responsibility and developing cost-sharing programmes, albeit with safeguards. The Gateway Paper regards efficient fund utilization a priority and lays stress on striking a balance between minimizing costs, controlling costs and using resources more efficiently and equitably in other words, getting the best value for the money, on the one hand, and increasing the pool of available resources, on the other. Specific interventions such as the promotion of transparent financial administration, budgeting and cost controls and enhancing the capacity to overcome onerous financial management procedures and decentralizing decision-making are underscored as a priority as is the need for ensuring greater financial procedural clarity at the federal-provincial-district interface.

Do Global Funds Really Facilitate Access to Health?

Presenter(s): Lola Dare, Marcos Cueto, Wibulpolprasert Suwit
Chair(s): Elisabeth Fee, Bernardino Fantini
Author(s): Elisabeth Fee1, Bernardino Fantini2, Marcos Cueto3 Lola Dare4, Wibulpolprasert Suwit5
Affiliation(s): 1Chief, History of Medication Division, National Library of Medicine, USA, 2Director, History of Medicine and Health Institute, Faculty of Medicine, University of Geneva, Switzerland, 3Professor Principal, Universidad Peruana Cayetano Heredia, Peru, 4Executive Secretary, African Council for Sustainable Health Development, Nigeria, 5Ministry of Public Health Advisor, Ministry of Health, Thailand
Summary (max 100 words): Numerous international funds have been set up in recent times to address global health challenges such as HIV, TB and malaria, in an effort to provide sustainable funding for selected diseases affecting billions of people in the poorer regions of the world. Despite impressive investments in terms of money and stakeholders  involvement at national and international levels, enabling the scaling up of specific health initiatives, the collective impact of these initiatives has sometimes created or exacerbated problems such as the poor coordination or duplication of programmes, heavy burdens on local health practitioners, variable degrees of country ownership, and a lack of alignment with country systems. Relying on the establishment of inclusive partnerships, financial institutions like the Global Fund to Fight AIDS, Tuberculosis, and Malaria do not take full responsibility for implementing funded programmes which require the active participation of partners in proposal development and realization (through Country Coordinating Mechanisms). One of the major reasons for the apparent ineffectiveness of global interventions is the historical weakness of the health systems of underdeveloped countries, which contribute to bottlenecks in the distribution and utilisation of funds. What are the pros and cons of the global funds from different country perspectives? In theory, the global funds programmes are to be continued and sustained in the long term by the countries themselves. Is this a reasonable expectation? Is the money coming into the global funds programmes (from the donors and also the recipient countries) new money, or is it simply being shifted from one health programme to another? How can the funds best support equity, universal coverage, and sustained improvement in health systems? performance? What are the key steps needed to implement the Paris declaration, with its guiding principles of ownership, harmonisation, alignment, results, and mutual accountability? This round table session will debate the pros and cons of the ways the global funds work (or fail to work) in practice and try to answer the above questions.

Partnerships to Promote Global Public Health Security

Author(s): David L. Heymann1
Affiliation(s): 1Representative of the Director-General for Polio Eradication, World Health Organization, Geneva 27, Switzerland
Key issues:

The emergence of new infectious diseases such as Severe Acute Respiratory Syndrome (SARS) and avian influenza A (H5N1); and the re-emergence of others such as cholera and yellow fever combined with the increased speed and volume of international travel and trade have alerted countries to the ease with which infectious diseases can cross national borders and defy traditional defences. The international spread of infectious diseases from any country is an external danger from which state citizens need to be shielded through stronger systems of public health defence. Infectious diseases also threaten national security when deteriorating health trends in any one country lead to instability and social upheaval. Endemic infectious diseases are a particular security challenge as they resurge, because they behave in ways that can overwhelm social and public health infrastructures and cause demographic disparity. The emergence of AIDS and its rapid progression to endemicity convinced the world that a previously unknown pathogen can cause social and economic upheaval on a scale that threatens to destabilize whole regions.

Meeting challenges:

In developing countries, the destabilizing effect of AIDS, and other endemic diseases such as tuberculosis and malaria, is amplified by emerging and epidemic-prone diseases. Outbreaks and epidemics disrupt routine control programmes and health services, often for extended time periods, due to the extraordinary resources and logistics required for their containment. The dramatic interruption of trade, travel, and tourism that can follow news of an outbreak or epidemic thus places a further burden on public health systems in already fragile economies.

Conclusion (max 400 words):

Foreign policy agendas that aim to build a more secure world are increasingly including the emergence and resurgence of infectious diseases as a security challenge that needs to be addressed. They have global causes and consequences that can only be addressed through international global partnership, supported by strong national public health capacity. In April 2000, WHO launched the Global Outbreak Alert and Response Network (GOARN) as a partnership to keep the volatile microbial world under close surveillance and ensure that outbreaks are quickly detected and contained. This network of networks interlinks, in real time, over 110 existing networks that, together, posses much of the data, expertise and skills required to keep the international community alert to outbreaks and ready to respond. It was GOARN that detected and responded to the SARS outbreak in 2003, and it is GOARN that continues to watch over the current avian influenza pandemic threat.

Research Ethics in Africa: Needs and Opportunities

Author(s): Peter M. Ndumbe1
Affiliation(s): 1Microbiology, Haematology and Infectious Diseases, Faculty of Medicine and Biomedical Sciences, Yaounde, Cameroon
Key issues:

It is a truism that health policy as well as the teaching and practice of the health sciences ought to be guided by evidence. The collection and validation of this evidence has to depend on methodologically and ethically acceptable standards. Whilst there is some agreement that issues related to methodology have been fairly well addressed in low-income countries such as Cameroon, the same is not true for ethical issues.

Meeting challenges:

Training institutions for the health sciences such as the Faculty of Medicine and Biomedical Sciences in Yaounde have to take the leadership in ensuring that research is conducted in an ethical manner. Appropriate training has to be provided both to the teachers and to the students in this area. Since its creation in 1969, the Faculty of Medicine and Biomedical Sciences has forged the research culture into its graduates. All graduates have to provide a thesis, dissertation, or research report as part of the requirements for qualifying. Within the last fifteen years, the faculty has grappled with the issue of conducting research in an ethically sound manner. This has resulted in the installation of an Ethical Committee at the Faculty. In order to ensure its recognition and use, training had to be provided first for the teachers, and later for the students. Continuing education sessions are required for the teachers whilst every new crop of students is immersed into the ethical culture of conducting research. The major concerns encountered are the total neglect of the research culture in daily decision making and the assumption that health provision services are inherently good and cannot be challenged. Issues related to the financing of research are commonly found to be poorly understood by researchers. Other challenges related to the functioning of the Committee (administrative, displeasure with results, use of other facilities, financial, follow-up of studies) are dealt with in innovative manners and the Ethical Committee is becoming well known.

Conclusion (max 400 words):

In conclusion, although wrought with difficulties in the beginning, training institutions should provide leadership in ensuring that research is conducted in an ethical manner in low-income settings. This not only safeguards the dignity and human rights of participants, but also ensures that medical practice becomes accountable to its users.

An Overview of the TRREE for Africa Project

Author(s): Marie Hirtle1
Affiliation(s): 1Biotika Inc., Mont-Royal, Canada
Key issues: Ensuring the protection of persons who participate in research, especially in clinical drug trials, and promoting the highest ethical standards for research involving humans is the responsibility of many actors who participate in international collaborative research. And, while international and national regulations apply to some aspects of clinical trials, many others fall under ethical principles and processes that require interpretation and judgment to ensure subject protection and to promote highest ethical standards in concrete situations. Despite this difficult task, those involved in research involving humans receive little or no training and support to enhance their understanding and comfort level of the legal and ethical framework that applies to research involving humans.
Meeting challenges: TRREE-for Africa (Training and Resources in Research Ethics Evaluation) is a project that aims at developing a distance learning programme on research ethics for all those involved in ensuring research participant protection and in promoting highest ethical standards in international collaborative research. TRREE-for Africa will also provide a platform for a participatory website of resources that apply to research involving humans.
Conclusion (max 400 words): This presentation will describe the origins of this project, its goals, anticipated challenges and the proposed results.

A Short Overview of the KFPE and an Introduction to the Session

Author(s): Jon-Andri Lys1
Affiliation(s): 1Commission for Research Partnership with Developing Countries, KFPE, Bern, Switzerland
Key issues:

The KFPE (The Commission for Research Partnership with Developing Countries) is dedicated to promoting research partnerships with developing and transition countries. In this way, it wishes to contribute to sustainable development. The KFPE is engaged in Swiss scientific policies and is committed to promoting the interests of researchers and their affiliated institutions on both national and international levels. It furthers development-oriented research and elaborates research-strategic concepts. In this context, it ascertains that partnership principles are followed, that the quality of research is assured, and that the interests of all partners are respected. The KFPE is a commission of the four Swiss scientific Academies. This session, Research Networks in Partnership, gives an introduction and an overview of a new initiative of partnership and ethics in research called TRREE. Research partnerships and ethics are also two central topics of interest for the KFPE. TRREE (Training and Resources in Research Ethics Evaluation) for Africa will provide training in research ethics evaluation designed specifically to address the ethics of clinical trials conducted in Africa that must comply with international ethical standards. The session will highlight various aspects of such research networks in partnership, such as the challenges or pre-conditions of such networks or assessing the needs for the evaluation of ethics in research.

The Health System’s Challenge to Deliver Malaria Prevention and Treatment

Author(s): Don De Savigny1
Affiliation(s): 1Epidemiology and Public Health, Swiss Tropical Institute, Basel, Switzerland
Key issues:

Effective control of malaria in Africa faces many challenges and bottlenecks. The dramatic increase in financial resources for malaria control provided by recent Global Health Initiatives and new partnerships for financing at country level have improved the prospects of having sufficient commodities for malaria prevention (long-lasting insecticidal nets, insecticides for indoor residual spraying) and treatment (artemisinin combination therapy and other drugs). As this higher-level constraint resolves, another array of constraints are quickly becoming evident. These include large-scale procurement of commodities once financing is available, and the delivery of these commodities in programmes that actually reach the population in need. These constraints are all health system constraints. Failure of countries and donor partners to invest wisely in health systems development have resulted in the current frustration to meet Millennium Development and other international and national goals.

Objective(s): This presentation will examine the common health system weaknesses that currently impede effective national-scale malaria prevention and treatment. Under health systems dimensions of stewardship, resources, financing and programme delivery, key weaknesses revolve around: policies and guidelines; tendering and procurement; public-private partnerships; human resources, training and supervision; decentralization and ownership; national and local planning, priority setting and resource allocation; population access and targeting; provider compliance; consumer adherence; home care and household behaviours; monitoring and evaluation.
Meeting challenges: There are a number of strategies for both quickly scaling up equitable access and coverage of malaria interventions that can temporarily avoid these system constraints (e.g. campaign approaches for preventive interventions), yet help build systems for more sustainable continuous availability of quality interventions through routine systems (integration). This presentation will examine some recent successes in such approaches.
Conclusion (max 400 words): When it comes to achieving malaria control, health system strengthening is ignored at our peril. There are a number of system strengthening strategies that have been shown to work, but all require political commitment from all partners.