The Institute for Global Health and Development
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Item Leaving no one behind: Lessons on rebuilding health systems in conflict- and crisis-affected states(BMJ, 2017-07-28) Martineau, Tim; McPake, Barbara; Theobald, Sally; Raven, Joanna; Ensor, Tim; Fustukian, Suzanne; Ssengooba, Freddie; Chirwa, Yotamu; Vong, Sreytouch; Wurie, Haja; Hooton, Nick; Witter, SophieConflict and fragility are increasing in many areas of the world. This context has been referred to as the 'new normal' and affects a billion people. Fragile and conflict-affected states have the worst health indicators and the weakest health systems. This presents a major challenge to achieving universal health coverage. The evidence base for strengthening health systems in these contexts is very weak and hampered by limited research capacity, challenges relating to insecurity and apparent low prioritisation of this area of research by funders. This article reports on findings from a multicountry consortium examining health systems rebuilding post conflict/crisis in Sierra Leone, Zimbabwe, northern Uganda and Cambodia. Across the ReBUILD consortium's interdisciplinary research programme, three cross-cutting themes have emerged through our analytic process: communities, human resources for health and institutions. Understanding the impact of conflict/crisis on the intersecting inequalities faced by households and communities is essential for developing responsive health policies. Health workers demonstrate resilience in conflict/crisis, yet need to be supported post conflict/crisis with appropriate policies related to deployment and incentives that ensure a fair balance across sectors and geographical distribution. Postconflict/crisis contexts are characterised by an influx of multiple players and efforts to support coordination and build strong responsive national and local institutions are critical. The ReBUILD evidence base is starting to fill important knowledge gaps, but further research is needed to support policy makers and practitioners to develop sustainable health systems, without which disadvantaged communities in postconflict and postcrisis contexts will be left behind in efforts to promote universal health coverage.Item Health economics in low income countries: adapting to the reality of the unofficial economy.(Elsevier, 2001) Ensor, Tim; Witter, SophieThere is some evidence in established market economies that health economics is having a positive impact on policy. Although many of the underlying assumptions can be questioned, the predictions made are broadly applicable to a range of relatively wealthy industrialised economies. In low and middle income countries these assumptions are often less applicable. In particular, assumptions about the regulation and functioning of public and private sector activities often fail to account for the operation of the unofficial health care sector. This paper illustrates how unofficial markets might operate in the context of the health care sector in a developing economy. In particular it examines how the motives of practitioners may be influenced by a lack of regulation and under-funding which in turn contribute to the presence of unofficial activities. Unofficial market activities could influence and distort the impact of policies commonly being pursued in many countries. Further research is required into the functioning of these markets in order to align the assumptions of policy with the reality of the developing health care sector.Item Financing maternal health care services.(CABI, 2012-07) Witter, Sophie; Ensor, Tim; Hussein, Julia; McCaw-Binns, Affette M.; Webber, RogerItem Health Economics for Developing Countries. A Practical Guide.(MacMillan Education, 2000) Witter, Sophie; Ensor, Tim; Thompson, Robin; Jowett, MatthewItem The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe(BioMed Central, 2013-05-28) Chirwa, Yotamu; Witter, Sophie; Munjoma, M.; Mashange, W.; Ensor, Tim; McPake, Barbara; Munyati, S.Abstract (provisional) Background A paradigm shift in global health policy on user fees has been evident in the last decade with a growing consensus that user fees undermine equitable access to essential health care in many low and middle income countries. Changes to fees have major implications for human resources for health (HRH), though the linkages are rarely explicitly examined. This study aimed to examine the inter-linkages in Zimbabwe in order to generate lessons for HRH and fee policies, with particular respect to reproductive, maternal and newborn health (RMNH). Methods The study used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011. Results The past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Human resources are constrained in managing current demand and any growth in demand by high external and internal migration, and low remuneration, amongst other factors. We find that nurses and midwives are evenly distributed across the country (at least in the public sector), though doctors are not. This means that for four provinces, there are not enough doctors to provide more complex care, and only three provinces could provide cover in the event of all deliveries taking place in facilities. Conclusions This analysis suggests that there is a strong case for reducing the financial burden on clients of RMNH services and also a pressing need to improve the terms and conditions of key health staff. Numbers need to grow, and distribution is also a challenge, suggesting the need for differentiated policies in relation to rural areas, especially for doctors and specialists. The management of user fees should also be reviewed, particularly for non-Ministry facilities, which do not retain their revenues, and receive limited investment in return from the municipalities and district councils. Overall public investment in health needs to grow.Item Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources for health(BioMed Central, 2013-09-22) McPake, Barbara; Witter, Sophie; Ensor, Tim; Fustukian, Suzanne; Newlands, D.; Martineau, Tim; Chirwa, YotamuThe last decade has seen widespread retreat from user fees with the intention to reduce financial constraints to users in accessing health care and in particular improving access to reproductive, maternal and newborn health services. This has had important benefits in reducing financial barriers to access in a number of settings. If the policies work as intended service utilization rates increase. However this increases workloads for health staff and at the same time, the loss of user fee revenues can imply that health workers lose bonuses or allowances, or that it becomes more difficult to ensure uninterrupted supplies of health care inputs. This research aimed to assess how policies reducing demand-side barriers to access to health care have affected service delivery with a particular focus on human resources for health. Methods We undertook case studies in five countries (Ghana, Nepal, Sierra Leone, Zambia and Zimbabwe). In each we reviewed financing and HRH policies, considered the impact financing policy change had made on health service utilization rates, analysed the distribution of health staff and their actual and potential workloads, and compared remuneration terms in the public sectors. Results We question a number of common assumptions about the financing and human resource inter-relationships. The impact of fee removal on utilization levels is mostly not sustained or supported by all the evidence. Shortages of human resources for health at the national level are not universal; maldistribution within countries is the greater problem. Low salaries are not universal; most of the countries pay health workers well by national benchmarks. Conclusions The interconnectedness between user fee policy and HRH situations proves difficult to assess. Many policies have been changing over the relevant period, some clearly and others possibly in response to problems identified associated with financing policy change. Other relevant variables have also changed. However, as is now well-recognised in the user fee literature, co-ordination of health financing and human resource policies is essential. This appears less well recognised in the human resources literature. This coordination involves considering user charges, resource availability at health facility level, health worker pay, terms and conditions, and recruitment in tandem. All these policies need to be effectively monitored in their processes as well as outcomes, but sufficient data are not collected for this purpose.Item Health Worker Incentives Survey (HWIS)(Immpact, University of Aberdeen, 2007) Ensor, Tim; Witter, SophieOne of the most important components of maternal health services is adequate, skilled human resources (Campbell and Graham, 2006; WHO, 2006). Paying and motivating this key resource is just as important as ensuring that enough workers are in place to provide the service. At the same time, health financing policy implementation especially in low-income countries requires hard decisions about priorities for channelling limited resources, and the use of staff incentives may come into competition with other claims for resource prioritization (Ensor and Ronoh, 2005). It is important, therefore, to be able to produce evidence for the desirability and expected efficacy of offering financial incentives to staff. A methodology to assess the incentives to deliver maternal health services was developed out of three Immpact evaluations of maternal health care interventions in Ghana, Indonesia and Burkina Faso. Although in each of the initial Immpact evaluations (see Module 2 and Module 3 for more information) the effect on human resources was considered important, the initial development of this tool was undertaken during a project in Cambodia which examined the restructuring of the medical workforce in a context of very low public spending on wages. A key question in that study was to determine how great a financial incentive is required to ensure that public sector health workers remain in their posts rather than spending part of their working hours in private practice, leaving the public sector entirely, or engaging other activities to boost their income - alternative opportunities that often motivate public health workers in many, if not most, low- and middle-income countries. Immpact's experience showed also that financial incentives are particularly useful when scaling up a public health policy intervention, when there is a need to attract skilled staff to less popular areas of work (for instance in remoter locations) in order to be able to implement the policy comprehensively and effectively.Item PROPOSED REVISIONS TO THE SDIP - STRENGTHENING A MAJOR NATIONAL INITIATIVE FOR SAFE MOTHERHOOD IN NEPAL(Options for DFID and MoHP, 2008) Ensor, Tim; Witter, SophieItem Exploring the influence of context and policy on health district productivity in Cambodia(BioMed Central, 2016-01) Ensor, Tim; So, Sovannarith; Witter, SophieBackground Cambodia has been reconstructing its economy and health sector since the end of conflict in the 1990s. There have been gains in life expectancy and increased health expenditure, but Cambodia still lags behind neighbours One factor which may contribute is the efficiency of public health services. This article aims to understand variations in efficiency and the extent to which changes in efficiency are associated with key health policies that have been introduced to strengthen access to health services over the past decade. Methods The analysis makes use of data envelopment analysis (DEA) to measure relative efficiency and changes in productivity and regression analysis to assess the association with the implementation of health policies. Data on 28 operational districts were obtained for 2008-11, focussing on the five provinces selected to represent a range of conditions in Cambodia. DEA was used to calculate efficiency scores assuming constant and variable returns to scale and Malmquist indices to measure productivity changes over time. This analysis was combined with qualitative findings from 17 key informant interviews and 19 in-depth interviews with managers and staff in the same provinces. Results The DEA results suggest great variation in the efficiency scores and trends of scores of public health services in the five provinces. Starting points were significantly different, but three of the five provinces have improved efficiency considerably over the period. Higher efficiency is associated with more densely populated areas. Areas with health equity funds in Special Operating Agency (SOA) and non-SOA areas are associated with higher efficiency. The same effect is not found in areas only operating voucher schemes. We find that the efficiency score increased by 0.12 the year any of the policies was introduced. Conclusions This is the first study published on health district productivity in Cambodia. It is one of the few studies in the region to consider the impact of health policy changes on health sector efficiency. The results suggest that the recent health financing reforms have been effective, singly and in combination. This analysis could be extended nationwide and used for targeting of new initiatives. The finding of an association between recent policy interventions and improved productivity of public health services is relevant for other countries planning similar health sector reforms.Item Evaluating a health financing policy change: framework and suggested approaches(Immpact, University of Aberdeen, 2007) Witter, Sophie; Ensor, TimImmpact is a global research initiative which seeks to strengthen the evidence base for policy decision-makers on cost-effective intervention strategies to reduce maternal mortality. Immpact has been working in partnership with local stakeholders to identify and evaluate strategies with the potential for significantly reducing maternal and perinatal mortality. In Ghana, one of the focus countries for the first phase , the government policy of providing free deliveries for all women was selected for evaluation through a consultative process. The aim of the overall Immpact evaluation was to assess how the free delivery policy had affected utilization, quality of services and health and non-health outcomes for households (NMIMR and Immpact, 2005). Tools were developed and fieldwork began in 2005, leading to an evaluation report in 2006 (Armar-Klemesu et al, 2006). Although the evaluation focused on a specific policy and evaluated the policy from the point of view of maternal health, the approach used was one which is of wider relevance to any situation where the health financing burden is being changed. It was decided therefore that this technical paper should be produced, describing the evaluation framework and the specific tools and approaches used, together with the experience of using them. These tools are intended to assist researchers looking at related questions in future. All the tools require adaptation to different contexts, but the examples may at least serve as a starting point for other evaluations. Within Immpact, the approach described in this document has already been adapted twice - once for an evaluation of a cost-sharing scheme for maternal health in Nepal (ICH, SSMP, & Immpact, 2006), and again for an evaluation of a free delivery and Caesarean policy in Senegal (MoH et al, 2006). Two of the approaches discussed in this paper were also used in relation to different evaluation questions in Indonesia and Burkina Faso, and these experiences will be reflected.