Managing Health in Africa: The Health Systems Perspective

By Prosper Tumusiime and Jennifer Nyoni

An authoritative analysis of the challenges of public health management in Africa, with concrete suggestions on how to overcome them. The three authors have a combined experience of more than 83 years in national and international health work. The topics they cover include the status of public health in Africa today; integrated health

• Language: English
• Publisher: Service Resource Africa
• Release date: Jul 31, 2018
• ISBN: 9780998085715

Prosper Tumusiime

Dr Tumusiime was born in Uganda in 1958. His areas of expertise are Epidemiology, Health Policy Development, Health Reform, Programme Management and Public Health Planning. He is currently Team Leader and oversees Health Service Delivery for the governments of the 47 Member Countries of the World Health Organization Regional Office for Africa in Brazzaville, Congo. He has been with WHO since 2000 and has held several senior positions in his areas of expertise within that Organization. Before Dr Tumusiime joined WHO, he served the Government of Uganda as Senior Programme Officer, Assistant Commissioner for Health Services, Deputy Director of Rural and Urban Health Services, and Medical Officer. He graduated from Case Western Reserve University in the USA with an M Sc and a PhD in Epidemiology and Biostatistics. He holds the Doctor of Medicine and a postgraduate diploma in Public Health from Makerere University in Uganda and a certificate in Planning and Management of District Health Services from the Royal Tropical Institute in Amsterdam, The Netherlands. Dr Tumusiime has served on scores of taskforces, has consulted for dozens of international bodies active in health development and management, and is a member of many professional societies. He has published 27 papers in his areas of expertise. He is married, has 4 children, and lives and works in Brazzaville, Republic of Congo.

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Published by Service Resource Africa

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Copyright © 2018 Prosper Tumusiime, Jennifer Nyoni, Martins Ovberedjo

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WHO/AFRO Library Cataloguing-in-Publication Data

Managing health in Africa: the health system perspective

1. Health services – organization and administration – economics

2. Delivery of health care – organization and administration

3. Health status

4. Health planning – organization and administration

5. National health programmes – organization and administration – economics

6. Health personnel

7. Pharmaceutical preparations

(NLM Classification: WA 540 HA1)

Printed in the U.S.A.

Editing and Publishing Assistance: Service Resource Africa ([phone]; www.winsra.org; [e-mail])

Contents

Foreword

Preface

Chapter 1: Status of health in Africa

Introduction

Epidemics in Africa

Double burden of disease

Social determinants of health

Opportunities for improving the current situation

Experiences, good practices, lessons learnt and proposed approaches

Summary

Exercises and assignments

For further reading

References

Endnotes

Chapter 2: Developing and implementing comprehensive national health policies and plans

Introduction

Status of national health policies and strategic plans in Africa

Development of national health policies and national health sector strategic plans

Important observations in the development process

Implementation of national health policies and national health strategic plans

Monitoring and evaluating implementation of strategic plans

Summary

Exercises and assignments

For further reading

References

Endnote

Chapter 3: Towards client-centred and integrated service delivery

Introduction

Definitions

Service delivery models

The nature of integrated health services delivery

The situation in Africa

Review of experiences

Summary

Exercises and assignments

For further reading

References

Chapter 4: Community involvement in health services organization and delivery

Introduction

Definitions

Rationale

Evidence-based community approach

Some strategies

Some tools and resources to consider

Summary

Exercises and assignments

References, and for further reading

Chapter 5: How to improve the performance of district health systems

Introduction

What performance of a health system entails

A district health system and its functions

Situation in Africa

Experiences, challenges, and lessons learnt

Summary

Exercises and assignments

For further reading

References

Endnotes

Chapter 6: Prerequisites for improving resources for the health agenda

Introduction

The problem with resources in sub-Saharan Africa

Prerequisite 1: Effective leadership and governance at all levels

Prerequisite 2: Coordinated partnerships

Prerequisite 3: Access to health care and health services

Estimating resource requirements

Making the case for a health agenda

Summary

Exercises and assignments

For further reading

Endnotes

Chapter 7: Production, recruitment and retention of an efficient workforce

Introduction

Availability of the health workforce in sub-Saharan Africa

The reality on the ground in general

Health workforce training

A ready and performing health workforce

Good practices in workforce motivation and retention

Health workers who stay and those who won’t

Options at the district or local level

Summary

Exercises and assignments

For further reading

Endnotes

Chapter 8: Increasing the availability of essential medicines and medical supplies

Introduction

Definitions

Situation of essential medicines and supplies in sub-Saharan Africa

Experiences, good practices, and lessons learnt

Proposed approaches

Summary

Exercises and assignments

For further reading

References

Endnotes

Chapter 9: The role of health technologies in improving care and service delivery

Introduction

Blood transfusion safety

Diagnostic and laboratory technology

Organ transplants

Emergency and essential surgical care

Injection safety

Diagnostic imaging

Medical devices and equipment

E-health for health care delivery

Overview of health technologies in sub-Saharan Africa

The way forward for health technologies

Summary

Exercises and assignments

For further reading

Endnotes

Chapter 10: Financing and resource mobilization for efficient and affordable health services

Introduction

Status of health financing in sub-Saharan Africa

Health financing reforms and strategies

Financing, allocation, and health outcomes

Health financing approaches

Accountability

Experiences, good practices, lessons learnt, and proposed approaches

The way to universal health coverage

Resource mobilization

Summary

Exercises and assignments

For further reading

References

Endnotes

Chapter 11: Managing health beyond the health sector

Introduction

Managing health in sub-Saharan Africa

Experiences, good practices, lessons learnt, and proposed approaches

Summary

Exercises and assignments

For further reading

References

Endnote

Chaprter 12: Monitoring and evaluating progress

Introduction

Importance of performance monitoring and evaluation

The issue being addressed in sub-Saharan Africa

Experiences, good practices, lessons learnt, and proposed approaches

Summary

Exercises and assignments

For further reading

References

Chapter 13: Conclusion

About the Authors

List of Tables

Table 1.1: Estimated life expectancy in selected countries with and without AIDS

Table 1.2: Annual number of deaths by cause for children under five years of age in WHO regions: estimates for 2013

Table 1.3: Cumulative EVD cases and deaths as of 18 October 2015

Table 1.4: Countries in the WHO African Region likely to attain their health MDGs

Table 2.1: Key contents of a national health policy and a national health strategic plan

Table 5.1: Autonomy-resource triangulation

Table 10.1: Trends in total health expenditure per capita in current US dollars

Table 12.1: Logical framework: the ‘if−then’ approach

List of Figures

Figure 1.1: The link between health and socio-economic development

Figure 1.2: Life expectancy at birth for the world and other UN regions

Figure 1.3: Reforms for Primary health care renewal

Figure 1.4: Health system building blocks and the role of leadership and governance

Figure 2.1: Transforming data into information and evidence

Figure 3.1: Service production and delivery

Figure 3.2: Relevance of integration by level of the organization

Figure 4.1: The health map

Figure 5.1: Relation between the functions and objectives of a health system

Figure 5.2: The performance chain of a health system

Figure 5.3: A district health system and its linkage with other structures in the district (Hypothetical model)

Figure 7.1: Countries with a critical shortage of doctors, nurses and midwives

Figure 7.2: Health worker density and health outcomes

Figure 8.1: Availability and update of essential medicines lists among countries over a five-year period ending in 2003

Figure 8.2: Effects of generic medicines competition*

Figure 10.1: Government health financing as a percentage of government expenditure in some African countries for 2000 and 2010

Figure 10.2: Reversing the trend in child mortality: interventions in two districts of Tanzania

Figure 10.3: Maternal mortality ratio and total health expenditure per capita, 2010

Figure 10.4: Three things a country considering universal coverage should do

Figure 11.1: Spheres of influence on health

Figure 11.2: Women with access to delivery assistance by richest and poorest wealth quintiles

Figure 12.1: Monitoring and evaluating health systems strengthening

List of Boxes

Box 3.1: Community at work in the Democratic Republic of Congo

Box 3.2: Example of integrated support supervision from Uganda

Box 3.3: Example of HAST committees from South Africa

Box 3.4: Example of initiatives on integrated service delivery

Box 3.5: Integrating mental health into primary health care in Uganda

Box 3.6: The joint LLIN and immunization programme campaign in Rwanda

Box 3.7: Ghana’s integrated child health campaign

Box 3.8: Integrating HIV services in Zambia

Box 3.9: Strategic directions for global people-centred and integrated health services

Box 6.1: Public-private partnership in health service delivery in Botswana

Box 6.2: Good partnerships that address people’s priorities and make resources available

Box 8.1: WHO-recommended interventions for promotion of rational use of medicines

Box 9.1: Typical story of a mother’s everyday experience with health technology

Box 9.2: First blood transfusions

Box 9.3: The Millennium village project

Box 9.4: Experiences with e-health in Rwanda

Box 9.5: E-health workshop for the East African Community, November 2010

Box 10.1: Mixed-effects model analysis for health expenditures and health outcomes

Box 10.2: Performance-based financing in Burundi

Box 10.3: Example of an AIDS levy from Zimbabwe

Box 10.4: Case study: les Mutuelles de santé in the Thiès Region of Senegal

Box 10.5: Effect of user fee abolition in Burkina Faso

Box 11.1: Main recommendations of the Commission on social determinants of health

Box 11.2: Sustainable development goals

Foreword

Global concern over the deplorable state of weak health management systems in sub-Saharan Africa has deepened profoundly, and despite recorded improvements, the health of the vast majority of people in the region remains unacceptably poor. Millions of people in Africa are still suffering from diseases that are relatively simple to prevent or treat. As health managers in the region struggle to meet basic standards of care, many experts have come to the conclusion that system-wide barriers linked to existing weak health management systems remain a major obstacle to progress.

Yet, better management of health systems in Africa presents an unprecedented opportunity to deliver quality health services to all people in the continent. It is also clear that a comprehensive approach is required to overcome the health-system-wide barriers. Managing health in Africa: the health systems perspective is a most welcome and candid attempt to address these growing health system management weaknesses. This book will complement ongoing efforts by health managers, health service providers and training institutions to help countries strengthen their health systems. Make no mistake! All countries are eager to deliver on important global, regional and national goals and obligations, including Universal Health Coverage. The book proves that development of effective health management capacity is critical across the board in African health systems. The material presented painstakingly highlights the important challenges facing frontline health practitioners in health care settings in Africa.

The book focuses on sub-Saharan Africa where it has become clearer that despite the ongoing investments by governments and external donor agencies, much more is required in terms of concrete action to strengthen health management systems, given the existing fragile health systems in several countries. Based on more than 83 years of combined field experience, the authors have provided readers with a systematic exploration of key health system issues and challenges. In doing so, they have generously shared their understanding and appreciation of the practical challenges Africa faces, and the learning opportunities that are needed to contribute to desired improvements in existing health services and health system performance. The concepts of better health systems and management and promotion of learning and innovation are extremely useful in identifying practical health interventions and partnerships to produce, manage and sustain health services in a continent where there is growing concern about resource scarcity and sustainability.

Universal health coverage will not come about without robust health management systems. And just as universal health coverage will benefit everyone involved, every sector and every individual in every country in Africa will have to come on board: politicians and decision makers need to thoroughly review how they develop and implement national health policies and strategies; local communities must no longer be considered passive consumers of health services but as full partners with rights and privileges in health services delivery; new ways of building and retaining a reliable and efficient health workforce need to be devised − an open call to health practitioners, training institutions and employers alike; more particularly, Africa needs to latch on to the fast-moving train of new health technologies; in a sense, the future of universal health coverage depends on it; the book even indicates new approaches to fundraising and resource mobilization, with a focus on accountability and transparency. In short, no one − public or private − will ignore the urgent message of this book, or its importance to the continent of Africa. The practical and helpful solutions proposed in it are the path we must follow if we are to achieve resilient health systems for a very deserving but often neglected continent.

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Prof Evarist Kisito Njelesani

Deputy Vice Chancellor

Lusaka Apex Medical University

Lusaka, Zambia

Preface

Health is a complex phenomenon that is influenced by many factors, health-related and non-health-related. These same factors, often referred to as determinants of health, interplay such that the resultant effect on health depends on how the interplay of these factors is managed. Some of the factors depend on individuals whereas others are factors within the environment (geographical, social, economic, political, etc.) surrounding the individual. Thus, management of health entails management of both the factors within and around us that have an effect on our health, and the interaction among those factors. The health of the individual, therefore, depends on how well the individual and other people in the individual’s environment manage these factors. It is the practical aspects of the art of this management that this book desires to address.

The book provides an overview of health status in Africa, and then covers various thematic areas important to managing health. These include comprehensive policies and plans, re-orientation of service delivery, resource management, the interface with other sectors beyond the health sector, improvement of the performance of district health systems, empowerment and effective involvement of the community, and monitoring and evaluation of progress made in attempts to improve health. The book also discusses the important themes of human resources for health; health financing; essential medicines and other supplies; health technologies, including health infrastructure (physical structures, medical, laboratory, diagnostic and other equipment and supplies); and information and communications technology (ICT) in health management.

Moreover, the book will be suitable for public health students in in-service or basic training, as well as those already in the field practising public health. In particular, it is intended to be used for improving effectiveness and efficiency in the management of health at operational level (the district or its equivalent). The book is not meant to be an academic technical textbook; rather, it is intended to serve as a vade mecum or quick field reference that can assist those at operational level in their day-to-day work. That said, it can also be used as a training resource, especially for orienting health staff and for capacity building to improve service delivery and the health of the people. In this regard, particular effort has been made to ensure that the contents are devoid of ‘frills’, and are focused solely on the business at hand.

The content and style of the book are based on long experience in health and health management. We have attempted to bring out not only lessons learnt along the way but also those that one rarely finds in current curricula on basic and post-basic training. The book covers a wide range of common problems encountered in public health in most African countries and elsewhere, especially in limited-resource settings.

Finally, we have paid particular attention to the situation of isolation within which many health workers function. Very often, health workers or health managers do not find the time to leave their workplace to undergo training in health management. In many African countries, given perennial human resources constraints, these same health workers or health managers are the only ones at their health service institution. This textbook offers such health workers the opportunity to improve their skills and approaches to problem solving, the aim being to improve management in their efforts to improve health. In this regard, the book offers many isolated health workers a refreshing ‘one-stop’ shop and comprehensive companionship at no additional cost.

Throughout the book, we have used practical examples taken from real life that readers can easily relate to. Tackling issues and problems that relate to health vividly facilitates understanding of the theory behind management of health; in fact, the authors walk the readers through the problems and their possible solutions. In other words, the book takes on the perspective of the individual or group intent on solving health problems. The readers are then taken through the various practical steps that one would take to come to identify the most appropriate solutions. Several exercises and problem-solving questions that will offer the reader a chance to make sure that the concepts have been well understood are provided at the end of each chapter. The design of the exercises is such that readers can use the application introduced in each chapter to analyse, understand and solve the problem in their respective settings.

The assignments can also be adapted to group discussions, or used in workshops or seminars to find solutions to the many real problems the book alludes to. Furthermore, and given the fact that change is happening faster than the book may have been able to capture, it allows the reader to adapt the material in the book to happenings relating to particular themes developed in each chapter. With proper facilitation, and as a way of applying the knowledge gained from the book, the health worker can also update the information presented herein, along with the references and reading lists attached to each chapter.

Although chapters in the book may be interrelated, its structure allows the reader to go directly to his or her relevant chapter of interest. For this reason, each chapter has been developed in a comprehensive manner. Of course, the structure and outline of the book also encourages the reader to consult other chapters for more treatment of certain aspects that may be referred to in the course of their reading. In other words, the book has followed a modular approach, and serves as a tool box where one is free to choose the appropriate tool that one may need at any material time.

In summary, Chapter 1 describes the status of health in sub-Saharan Africa. Chapter 2 focuses on processes and content in developing and implementing comprehensive national health policies and plans, including their monitoring and evaluation. Chapter 3 deals with the all-important client-centred and integrated services delivery; it defines key terms and presents delivery models of care. Chapter 4 discusses how communities can be made to play an active role both in improving their own health, and in the organization and delivery of health services. It makes a case for why it is important, and clearly outlines possible approaches to follow. Chapter 5 offers practical ways of improving the performance of district health systems, focusing on the key factors that influence their functionality. Chapter 6 describes the pre-requisites for increasing resources for the health agenda, and shows how these pre-requisites influence the availability of resources for health. Chapter 7 treats of what it takes to build and retain an efficient health workforce. It singles out the workforce as an essential component for health services to occur, especially at the district level. Chapter 8 looks at the process of increasing availability of essential medicines and medical supplies. It indicates where and when these are required, and presents the situation in sub-Saharan Africa. Chapter 9 defines health technologies and what they constitute, and assesses their role in improving care and service delivery. Chapter 10 discusses efficiency and affordability in health services delivery. It sketches the landscape of health financing and resource mobilization. Chapter 11 explores aspects of the management of health beyond the traditional health sector. Chapter 12 examines how to track and measure progress and achievements in health. Chapter 13 is the concluding chapter; it summarizes the contents of the book, enunciating its philosophy and highlighting the main subjects covered.

Chapter

1

Status of health in Africa

Introduction

Before we discuss the status of health in Africa, we need to understand what health means. The World Health Organization (WHO) defines health as the state of well-being and not only the absence of disease and infirmity. In individuals, the status of health would be viewed in terms of whether they are sick or not, whether they have abnormal body system characteristics, or whether they have a disability or not. If people are overweight, for example, even if they are not sick, they are not healthy. Thus, the highest level of individual health can be said to exist when that individual’s body has full optimal functions. In the same way, the status of health of the population is normally measured in terms of the level of illness (morbidity), the level of abnormal body system characteristics, the degree of disability, the number of deaths, and average life expectancy at birth (on average how long an individual is expected to live). Each of these could be used to measure health status. We are aware of such measures as infant mortality rate, fertility rate, maternal mortality rate, level of obesity, among others.

However, in the last two decades, there has been an effort to put together all these aspects into a single measure. One of these is the Disability adjusted life years (DALYs). It is a measure of the burden of disease that takes into account healthy life years lost due to premature death, and those lost because of disability. It is basically the number of healthy years of life lost due to premature death and disability. Another similar but better summary measure of health status is the Disability-adjusted life expectancy (DALE). DALE is most easily understood as the expectation of life lived in equivalent full health, that is, the number of healthy years of life that can be expected on average in a given population. It is generally calculated at birth, but estimates can also be prepared at other ages. Healthy life expectancy has the advantage of capturing all causes of disability across a population and relating them to life expectancy defined by mortality¹.

Whereas health as a sector, has been regarded by many as a non-productive component, it is now well known that it is at the centre of socio-economic development. Provision of health care and services to a population makes and keeps the population healthy, and consequently, with increased potential for higher levels of productivity. The latter improves the economic situation of the community or country, which in turn, has a better capacity to deliver social services, including health. Health is, thus, a crucial element of human capital development, and hence, an essential input in a country’s development process. The figure below illustrates the above concept, and further illustrates how a strengthened health system that is able to deliver essential health services contributes to improvement in health status. This, in turn, improves the health status of individuals and the population.

Figure 1.1: The link between health and socio-economic development

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General health status in Africa

From the middle of the twentieth century, most countries in sub-Saharan Africa experienced improvement in their health indices, but towards the end of the twentieth century and thereafter, the gains that had been made started to be eroded by the advent of the HIV and AIDS epidemic, as shown in Table 1.1 below:

Table 1.1: Estimated life expectancy in selected countries with and without AIDS

table-1-1.jpg

Source: United Nations Population Division (2000)

It is also illustrated in Figure 1.2 that, although life expectancy at birth was similar for Asia and Africa, by the 1950s, fifty-five years later, the gap had widened to almost 20 years. This is suggestive of something having gone wrong in Africa.

Figure 1.2: Life expectancy at birth for the world and