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HEALTH SYSTEMS, PUBLIC HEALTH AND RESEARCH CAPACITY STRENGTHENING IN SOUTH AFRICA:
ONGOING LITERATURE SEARCH and REVIEW
Simukai Shamu, School of Public Health, UWC
March 2010 DRAFT
This paper includes results of literature searches related to public health capacity, health systems strengthening, and health research capacity in Africa, emphasizing South Africa and links to HIV/AIDS interventions. This draft presents the search strategy and results (Part 1), a brief discussion of health systems strengthening frameworks, and an annotated review of some of the literature according to the framework (Part 2), p 27 in this version. The introductory/framing paragraph is copied below to help orient the user of this document. We welcome additions and comments to this living document. This literature search was supported by the “Human capacity development to address HIV and AIDS in South Africa” project, funded by PEPFAR through CDC, CDC‐RFA‐PS07‐719.
Framework:
“Health systems” refers to all the activities whose primary purpose is to promote, restore and
maintain health. One framework emphasizes four functions of stewardship, resource mobilisation,
service provision and financing (WHO ). Marchal et al’s (2009) article helps us to question health
systems strengthening definition and strategies in the context of the Global Health initiatives which
claim to be strengthening health systems yet some of their activities weaken health systems to some
extent. This literature review presents original research studies, commentaries and conceptual
frameworks from both published and gray literature on strengthening health systems in South
African in the context of HIV and AIDS. It uses Yu et al’s (2008) framework of analysis of HSS in the
developing countries published in an article, “Investment in HIV/AIDS programs: does it help
strengthen health systems in developing countries” and another Hanson et al (2003)’s framework on
the analysis of the relationship between injecting funding to HIV programmes and the effect it has
on health systems in general. In an analysis of whether HIV programs strengthen or weaken health
systems, Yu et al (2008) ask six questions whose answers help to monitor and evaluate the
performance of HIV and AIDS programmes’ in relation to health systems strengthening. The
following questions will be asked as well in this paper:
1. Has health service delivery been expanded?
2. Have health sector human resources been expanded?
3. Has the health information system been strengthened?
4. Have procurement and supply management been strengthened?
5. Has health financing been improved?
6. Have leadership and governance for health been improved?
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PART 1: THE SEARCH STRATEGY AND RESULTS
A Search of the Ebscohost electronic database was the major method used to get journal articles for
this review. The following databases were searched through the ebschost search engine: Academic
Search Premier, Information Science & Technology, Rehabilitation & Sports Medicine Source, Africa‐
Wide Information, Business Source Complete, CINAHL, CINAHL with Full Text, ERIC, Family & Society
Studies Worldwide, Health Source ‐ Consumer Edition, Health Source: Nursing/Academic Edition,
International Pharmaceutical Abstracts, MasterFILE Premier, MEDLINE, PsycARTICLES, SocINDEX,
Women's Studies International. To be as inclusive as possible, the search was set to include a cross
section of the journals in the social sciences, development together with health journals. Both full
text and abstract only were sought. We searched original research papers, commentaries, responses
to already published papers, books/monographs, published systematic reviews. Only peer reviewed
journals were searched by this search engine. A Google scholar search was also conducted using the
same search terms as used in the ebsco search. The articles were checked for duplications in the
different databases searched.
The following search terms were used to guide the search: “strengthening health human resources
capacity in Africa”, “health capacity development”, “health and organizational development” and
“health research capacity strengthening”. Articles containing these terms in their subjects and or
text were included. The search was commanded to cover articles reporting on Africa only. No dates
were set to limit the year the papers were published. Only articles published in English were
included.
The search found more than 1340 articles. After reading the titles of the papers to check the
relevance and reference to Africa a number of papers were dropped. This left a total of 304 journal
articles and 30 books and reports. We used the African Journals on line (AJOL) list of registered
journals in Africa to mark the journal articles published in Africa. We found that 23 out of 334
(12.3%) articles were published in journals in Africa while the rest were published in international
journals and journals outside Africa.
A further web search from government and nongovernmental organizations’ websites and
databases was conducted using the same search terms mentioned above. The search resulted in 90
papers, reports, books and monographs both published and unpublished. These are mainly reporting
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on South Africa and most of them published in South Africa and are managed by websites or
organizations based in South Africa.
List of searches based on EBSCOHOST search
1. The nursing implications of routine provider‐initiated HIV testing and counselling in sub‐Saharan Africa: a critical review of new policy guidance from WHO/UNAIDS.Citation Only Available By: Evans, Catrin; Ndirangu, Eunice. International Journal of Nursing Studies, 46(5): pp. 723‐31 ; 20 May 2009 ; 87 refs.. (AN: 19159879)
2. From research to control: Translating research findings into health policies, operational guidelines and health products.Citation Only Available (eng; includes abstract) By Kilama W, Acta Tropica [Acta Trop], ISSN: 1873‐6254, 2009 Nov; Vol. 112 Suppl 1, pp. S91‐S101; PMID: 19686696
3. Strengthening capacity, collaboration and quality of clinical research in Africa: EDCTP Networks of Excellence.Citation Only Available By: Kitua, A Y; Corrah, T; Herbst, K; Nyirenda, T; Agwale, S; Makanga, M; Mgone, C S. Tanzania journal of health research, 11(1): pp. 51‐4 ; Jan 2009. (AN: 19445106)
4. Human resource development and antiretroviral treatment in Free State province, South Africa.Citation Only Available (eng; includes abstract) By van Rensburg DH, Steyn F, Schneider H, Loffstadt L, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2008; Vol. 6, pp. 15; PMID: 18662390
5. Achieving effective cervical screening coverage in South Africa through human resources and health systems development.Citation Only Available By: Kawonga, Mary; Fonn, Sharon. Reproductive Health Matters, 16(32): pp. 32‐40; Nov 2008. (AN: 19027620)
6. Developing a District Health Information System in South Africa: a social process or technical solution?Citation Only Available (eng; includes abstract) By Williamson L, Stoops N, Heywood A, Studies In Health Technology And Informatics [Stud Health Technol Inform], ISSN: 0926‐9630, 2001; Vol. 84 (Pt 1), pp. 773‐7; PMID: 11604842
7. Affordability, availability and acceptability barriers to health care for the chronically ill: longitudinal case studies from South Africa.Full Text Available By: Goudge, Jane; Gilson, Lucy; Russell, Steven; Gumede, Tebogo; Mills, Anne. BMC Health Services Research, 9: p. 75 ; 09 05 2009. (AN: 19426533)
8. Developing health systems research capacities through north‐south partnership: an evaluation of collaboration with South Africa and Thailand.Citation Only Available (eng; includes abstract) By Mayhew SH, Doherty J, Pitayarangsarit S, Health Research Policy And Systems / Biomed Central [Health Res Policy Syst], ISSN: 1478‐4505, 2008; Vol. 6, pp. 8; PMID: 18673541
9. The Dar Es Salaam Urban Health Project, Tanzania: a multi‐dimensional evaluation.Citation Only Available By: Harpham, Trudy; Few, Roger. Journal of Public Health Medicine, 24(2): pp. 112‐9 ; Jun 2002. (AN: 12141579)
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11. Book. Evaluating capacity development: experiences from research and development organizations around the world.Citation Only Available By: HORTON, Douglas. The Hague: International Service for National Agricultural Research (ISNAR), 2003 ; 170 p. (AN: HEALTHLINK‐030477)
12. Managing health professional migration from sub‐Saharan Africa to Canada: a stakeholder inquiry into policy options.Citation Only Available (eng; includes abstract) By Labonté R, Packer C, Klassen N, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2006; Vol. 4, pp. 22; PMID: 16907969
13. Towards building equitable health systems in Sub‐Saharan Africa: lessons from case studies on operational research.Citation Only Available (eng; includes abstract) By Theobald S, Taegtmeyer M, Squire SB, Crichton J, Simwaka BN, Thomson R, Makwiza I, Tolhurst R, Martineau T, Bates I, Health Research Policy And Systems / Biomed Central [Health Res Policy Syst], ISSN: 1478‐4505, 2009; Vol. 7, pp. 26; PMID: 19939279
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14. The MESH approach: strengthening public health systems for the MDGs.Citation Only Available By: Thomas, Stephen; Mooney, Gavin; Mbatsha, Sandi. Health Policy, 83(2‐3): pp. 180‐5 ; 07 Oct 2007. (AN: 17289210)
15. Book 20. No development without research: a challenge for research capacity strengthening. Citation Only Available By: NUYENS, Yvo. Geneva: Global Forum for Health Research, 2005 ; 44 p. (AN: HEALTHLINK‐033703)
16. Clinical ethicists' perspectives on organisational ethics in healthcare organisations.Citation Only Available (eng; includes abstract) By Silva DS, Gibson JL, Sibbald R, Connolly E, Singer PA, Journal Of Medical Ethics [J Med Ethics], ISSN: 1473‐4257, 2008 May; Vol. 34 (5), pp. 320‐3; PMID: 18448706
17. How to manage organisational change and create practice teams: experiences of a South African primary care health centre.Citation Only Available (eng; includes abstract) By Mash BJ, Mayers P, Conradie H, Orayn A, Kuiper M, Marais J, Education For Health (Abingdon, England) [Educ Health (Abingdon)], ISSN: 1469‐5804, 2008 Jul; Vol. 21 (2), pp. 132; PMID: 19039745
18. Mapping Africa's advanced public health education capacity: the AfriHealth project.Full Text Available (eng; includes abstract) By Ijsselmuiden CB, Nchinda TC, Duale S, Tumwesigye NM, Serwadda D, Bulletin Of The World Health Organization [Bull World Health Organ], ISSN: 0042‐9686, 2007 Dec; Vol. 85 (12), pp. 914‐22; PMID: 18278250
19. Strengthening nurses' capacity in HIV policy development in Sub‐Saharan Africa and the Caribbean: an international program of research and capacity building.Citation Only Available By: Edwards, Nancy C; Roelofs, Susan. The Canadian Journal of Nursing Research, 39(3): pp. 187‐9 ; Sep 2007. (AN: 17970467)
20. Implementation of a quality systems approach for laboratory practice in resource‐constrained countries.Citation Only Available (eng; includes abstract) By Martin R, Hearn TL, Ridderhof JC, Demby A, AIDS (London, England) [AIDS], ISSN: 0269‐9370, 2005 May; Vol. 19 Suppl 2, pp. S59‐65; PMID: 15930842
21. Laboratory challenges in the scaling up of HIV, TB, and malaria programs: The interaction of health and laboratory systems, clinical research, and service delivery.Citation Only Available By: Birx, Deborah; de Souza, Mark; Nkengasong, John N. American Journal of Clinical Pathology, 131(6): pp. 849‐51 ; Jun 2009 ; 11 refs.. (AN: 19461092)
22. Community‐directed treatment with ivermectin in two Nigerian communities: an analysis of first year start‐up processes, costs and consequences.Citation Only Available By: Onwujekwe, Obinna; Chima, Reginald; Shu, Elvis; Okonkwo, Paul. Health Policy, 62(1): pp. 31‐51 ; Oct 2002. (AN: 12151133)
23. Community health insurance in sub‐Saharan Africa: what operational difficulties hamper its successful development?Citation Only Available (eng; includes abstract) By De Allegri M, Sauerborn R, Kouyaté B, Flessa S, Tropical Medicine & International Health: TM & IH [Trop Med Int Health], ISSN: 1365‐3156, 2009 May; Vol. 14 (5), pp. 586‐96; PMID: 19389037
24. African countries propose a regional oral health strategy: The Dakar Report from 1998.Full Text Available (eng; includes abstract) By Myburgh NG, Hobdell MH, Lalloo R, Oral Diseases [Oral Dis], ISSN: 1354‐523X, 2004 May; Vol. 10 (3), pp. 129‐37; PMID: 15089921
25. How far should they walk? Increasing antiretroviral therapy access in a rural community in northern KwaZulu‐Natal, South Africa.Citation Only Available (eng; includes abstract) By Fredlund VG, Nash J, The Journal Of Infectious Diseases [J Infect Dis], ISSN: 0022‐1899, 2007 Dec 1; Vol. 196 Suppl 3, pp. S469‐73; PMID: 18181696
26. Status of national health research systems in ten countries of the WHO African Region.Full Text Available (eng; includes abstract) By Kirigia JM, Wambebe C, BMC Health Services Research [BMC Health Serv Res], ISSN: 1472‐6963, 2006; Vol. 6, pp. 135; PMID: 17052326
27. Composition, training needs and independence of ethics review committees across Africa: are the gate‐keepers rising to the emerging challenges?Citation Only Available (eng; includes abstract) By Nyika A, Kilama W, Chilengi R, Tangwa G, Tindana P, Ndebele P, Ikingura J, Journal Of Medical Ethics [J Med Ethics], ISSN: 1473‐4257, 2009 Mar; Vol. 35 (3), pp. 189‐93; PMID: 19251972
28. Use of Google Earth to strengthen public health capacity and facilitate management of vector‐borne diseases in resource‐poor environments.Full Text Available (eng; includes abstract) By Lozano‐Fuentes S, Elizondo‐Quiroga D, Farfan‐Ale JA, Loroño‐Pino MA, Garcia‐Rejon J, Gomez‐Carro S, Lira‐Zumbardo V, Najera‐Vazquez R, Fernandez‐Salas I, Calderon‐Martinez J, Dominguez‐Galera M, Mis‐Avila P, Morris N, Coleman M, Moore CG, Beaty BJ, Eisen L, Bulletin Of The World Health Organization [Bull World Health Organ], ISSN: 1564‐0604, 2008 Sep; Vol. 86 (9), pp. 718‐25; PMID: 18797648
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29. Something old or something new? Social health insurance in Ghana.Citation Only Available (eng; includes abstract) By Witter S, Garshong B, BMC International Health And Human Rights [BMC Int Health Hum Rights], ISSN: 1472‐698X, 2009; Vol. 9, pp. 20; PMID: 19715583
30. Research themes and advances in malaria research capacity made by the Multilateral Initiative on Malaria.Citation Only Available (eng; includes abstract) By Nantulya FN, Kengeya‐Kayondo JF, Ogundahunsi OA, The American Journal Of Tropical Medicine And Hygiene [Am J Trop Med Hyg], ISSN: 0002‐9637, 2007 Dec; Vol. 77 (6 Suppl), pp. 303‐13; PMID: 18165507
31. Empowering primary care workers to improve health services: results from Mozambique's leadership and management development program.Citation Only Available (eng; includes abstract) By Perry C, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2008; Vol. 6, pp. 14; PMID: 18651973
32. Estimating the resource needs of scaling‐up HIV/AIDS and tuberculosis interventions in sub‐Saharan Africa: a systematic review for national policy makers and planners.Citation Only Available (eng; includes abstract) By Vassall A, Compernolle P, Health Policy (Amsterdam, Netherlands) [Health Policy], ISSN: 0168‐8510, 2006 Nov; Vol. 79 (1), pp. 1‐15; PMID: 16388874
33. Health metrics and evaluation: strengthening the science.Citation Only Available (eng; includes abstract) By Murray CJ, Frenk J, Lancet [Lancet], ISSN: 1474‐547X, 2008 Apr 5; Vol. 371 (9619), pp. 1191‐9; PMID: 18395581
34. Strategies to optimize HIV treatment outcomes in resource‐limited settings.Citation Only Available (eng; includes abstract) By Nakanjako D, Colebunders R, Coutinho AG, Kamya MR, AIDS Reviews [AIDS Rev], ISSN: 1698‐6997, 2009 Oct‐Dec; Vol. 11 (4), pp. 179‐89; PMID: 19940945
35. 'Issues of equity are also issues of rights': lessons from experiences in Southern Africa.Full Text Available (eng; includes abstract) By London L, BMC Public Health [BMC Public Health], ISSN: 1471‐2458, 2007; Vol. 7, pp. 14; PMID: 17257421
36. Capacity‐building for health research in developing countries: a manager's approach.Citation Only Available (eng; includes abstract) By White F, Revista Panamericana De Salud Pública = Pan American Journal Of Public Health [Rev Panam Salud Publica], ISSN: 1020‐4989, 2002 Sep; Vol. 12 (3), pp. 165‐72; PMID: 12396634
37. Policy management in the Health and Welfare Department of North West Province.Citation Only Available By: Vivian, WT. (AN: NX081364) Strengthening capacity for health research in Africa.Citation Only Available By: Whitworth, James A G; Kokwaro, Gilbert; Kinyanjui, Samson; Snewin, Valerie A; Tanner, Marcel; Walport, Mark; Sewankambo, Nelson. Lancet, 372(9649): pp. 1590‐3 ; 1 Nov 2008. (AN: 18984193)
38. Building capacity without disrupting health services: public health education for Africa through distance learning.Citation Only Available (eng; includes abstract) By Alexander L, Igumbor EU, Sanders D, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2009; Vol. 7, pp. 28; PMID: 19338669
39. The 10/90 gap in sub‐Saharan Africa: resolving inequities in health research.Citation Only Available (eng; includes abstract) By Kilama WL, Acta Tropica [Acta Trop], ISSN: 1873‐6254, 2009 Nov; Vol. 112 Suppl 1, pp. S8‐S15; PMID: 19695211
40. Human rights, cultural pluralism, and international health research.Citation Only Available (eng; includes abstract) By Marshall PA, Theoretical Medicine And Bioethics [Theor Med Bioeth], ISSN: 1386‐7415, 2005; Vol. 26 (6), pp. 529‐57; PMID: 16292607
41. Caring for the caregivers: models of HIV/AIDS care and treatment provision for health care workers in Southern Africa.Citation Only Available (eng; includes abstract) By Uebel KE, Nash J, Avalos A, The Journal Of Infectious Diseases [J Infect Dis], ISSN: 0022‐1899, 2007 Dec 1; Vol. 196 Suppl 3, pp. S500‐4; PMID: 18181701
42. Public health in Primary Care Trusts: a resource needs assessment.Citation Only Available (eng; includes abstract) By Heller RF, Edwards R, Patterson L, Elhassan M, Public Health [Public Health], ISSN: 0033‐3506, 2003 May; Vol. 117 (3), pp. 157‐64; PMID: 12825465
43. Existing capacity to manage pharmaceuticals and related commodities in East Africa: an assessment with specific reference to antiretroviral therapy.Citation Only Available (eng; includes abstract) By Waako PJ, Odoi‐Adome R, Obua C, Owino E, Tumwikirize W, Ogwal‐Okeng J, Anokbonggo WW, Matowe L, Aupont O, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2009; Vol. 7, pp. 21; PMID: 19272134
44. Ensuring a broad and inclusive approach: a provincial perspective on pandemic preparedness.Citation Only Available (eng; includes abstract) By Kort R, Stuart AJ, Bontovics E, Canadian Journal Of Public Health. Revue Canadienne De Santé Publique [Can J Public Health], ISSN: 0008‐4263, 2005 Nov‐Dec; Vol. 96 (6), pp. 409‐11; PMID: 16350862
45. Wellness programme and health policy development at a large faith‐based organisation in Khayelitsha, South Africa.Citation Only Available By: Arend, E.D.. African Journal of AIDS Research, Vol. 7, Iss 3, 259‐270, 2008. (AN: 599343)
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46. Review of North‐South and South‐South cooperation and conditions necessary to sustain research capability in developing countries.Citation Only Available (eng; includes abstract) By Chandiwana S, Ornbjerg N, Journal Of Health, Population, And Nutrition [J Health Popul Nutr], ISSN: 1606‐0997, 2003 Sep; Vol. 21 (3), pp. 288‐97; PMID: 14717574
47. Prevention of HIV transmission through breast‐feeding: strengthening the research agenda.Citation Only Available (eng; includes abstract) By Dabis F, Newell ML, Fowler MG, Read JS, Ghent IAS Working Group on HIV in Women and Children, Journal Of Acquired Immune Deficiency Syndromes (1999) [J Acquir Immune Defic Syndr], ISSN: 1525‐4135, 2004 Feb 1; Vol. 35 (2), pp. 167‐8; PMID: 14722450
48. Standardized patients for HIV/AIDS training in resource‐poor settings: the expert patient‐trainer.Citation Only Available (eng; includes abstract) By Seung KJ, Bitalabeho A, Buzaalirwa LE, Diggle E, Downing M, Bhatt Shah M, Tumwebaze B, Gove S, Academic Medicine: Journal Of The Association Of American Medical Colleges [Acad Med], ISSN: 1938‐808X, 2008 Dec; Vol. 83 (12), pp. 1204‐9; PMID: 19202501
49. HIV prevention in Africa: programs and populations served by non‐governmental organizations.Citation Only Available (eng; includes abstract) By Benotsch EG, Stevenson LY, Sitzler CA, Kelly JA, Makhaye G, Mathey ED, Somlai AM, Brown KD, Amirkhanian Y, Fernandez MI, Opgenorth KM, Journal Of Community Health [J Community Health], ISSN: 0094‐5145, 2004 Aug; Vol. 29 (4), pp. 319‐36; PMID: 15186017
50. The organisational and human resource challenges facing primary care trusts: protocol of a multiple case study.Full Text Available (eng; includes abstract) By Newbronner EV, Pedler MJ, Tim Scott J, Sheldon TA, BMC Health Services Research [BMC Health Serv Res], ISSN: 1472‐6963, 2001; Vol. 1 (1), pp. 12; PMID: 11737883
51. WHO analysis of causes of maternal death: a systematic review.Full Text Available (eng; includes abstract) By Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF, Lancet [Lancet], ISSN: 1474‐547X, 2006 Apr 1; Vol. 367 (9516), pp. 1066‐74; PMID: 16581405
52. Building health impact assessment capacity as a lever for healthy public policy in urban planning.Citation Only Available (eng; includes abstract) By Hughes JL, Kemp LA, New South Wales Public Health Bulletin [N S W Public Health Bull], ISSN: 1034‐7674, 2007 Sep‐Oct; Vol. 18 (9‐10), pp. 192‐4; PMID: 17949594
53. Communication strategy for implementing community IMCI.Full Text Available By: Ford, Neil; Williams, Abimbola; Renshaw, Melanie; Nkum, John. Journal of Health Communication, 10(5): pp. 379‐401 ; 2005 Jul‐Aug. (AN: 16199384)
54. Ethics and the ethnography of medical research in Africa.Citation Only Available (eng; includes abstract) By Molyneux S, Geissler PW, Social Science & Medicine (1982) [Soc Sci Med], ISSN: 0277‐9536, 2008 Sep; Vol. 67 (5), pp. 685‐95; PMID: 18455856
55. Effectiveness of community health financing in meeting the cost of illness.Full Text Available By: Preker, Alexander S.; Carrin, Guy; Dror, David; Jakab, Melitta; Hsiao, William; Arhin‐Tenkorang, Dyna. Bulletin of the World Health Organization, 2002, Vol. 80 Issue 2, p143, 8p, 2 charts, 3 graphs; (AN 6183742)
56. The impact of ART (anti‐retroviral treatment) scale‐up on health systems de‐strengthening in sub‐Saharan Africa: justice and justification.Citation Only Available (eng; includes abstract) By Nixon S, Veenstra N, Medicine And Law [Med Law], ISSN: 0723‐1393, 2008 Sep; Vol. 27 (3), pp. 685‐703; PMID: 19004389
57. Use of Google Earth TM to strengthen public health capacity and facilitate management of vector‐borne diseases in resource‐poor environments.Full Text Available By: Eisen, L; Lozano‐Fuentes, S.; Elizondo‐Quiroga, D; Farfan‐Ale, J A; Lorono‐Pino, M A; Garcia‐Rejon, J.; Gomez‐Carro, S; Lira‐Zumbardo, V; Najera‐Vazquez, R; Fernandez‐Salas, I.; Calderon‐Martinez, J; Dominguez‐Galera, M; Mis‐Avila, P; Morris, N; Coleman, M; Moore, C G; Beaty, B J. World Health Organization. Bulletin, 86(9): pp. 718‐725 ; 2008. (AN: 1083709)
58. Book. Community based organisations: the emerging force within the third sector ‐ Strengthening the human rights capacity of community based organisations [CBOS]: a survey of 9 southern African countries.Citation Only Available Corporate Author: Centre for Adult Education, University of KwaZulu‐Natal. South Africa, Durban: Fahamu SA, 2004 (Jan) ; 136 p. ; fig. (AN: NIZA‐700005982)
59. Estimation of potential effects of improved community‐based drug provision, to augment health‐facility strengthening, on maternal mortality due to post‐partum haemorrhage and sepsis in sub‐Saharan Africa: an equity‐effectiveness model.Citation Only Available (eng; includes abstract) By Pagel C, Lewycka S, Colbourn T, Mwansambo C, Meguid T, Chiudzu G, Utley M, Costello AM, Lancet [Lancet], ISSN: 1474‐547X, 2009 Oct 24; Vol. 374 (9699), pp. 1441‐8; PMID: 19783291
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60. Public‐private partnerships to build human capacity in low income countries: findings from the Pfizer program.Citation Only Available (eng; includes abstract) By Vian T, Richards SC, McCoy K, Connelly P, Feeley F, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2007; Vol. 5, pp. 8; PMID: 17335578
61. Experience establishing tuberculosis laboratory capacity in a developing country setting.Citation Only Available (eng; includes abstract) By Paramasivan CN, Lee E, Kao K, Mareka M, Kubendiran G, Kumar TA, Keshavjee S, Satti H, Alabi G, Raviglione M, Roscigno G, The International Journal Of Tuberculosis And Lung Disease: The Official Journal Of The International Union Against Tuberculosis And Lung Disease [Int J Tuberc Lung Dis], ISSN: 1815‐7920, 2010 Jan; Vol. 14 (1), pp. 59‐64; PMID: 20003696
62. Research capacity strengthening in the South.Citation Only Available By: Nchinda, Thomas C. Social Science & Medicine, 54(11): pp. 1699‐711 ; Jun 2002. (AN: 12113452)
63. Substandard anti‐malarial drugs in Burkina Faso.Full Text Available (eng; includes abstract) By Tipke M, Diallo S, Coulibaly B, Störzinger D, Hoppe‐Tichy T, Sie A, Müller O, Malaria Journal [Malar J], ISSN: 1475‐2875, 2008; Vol. 7, pp. 95; PMID: 18505584
64. Implementation of a quality systems approach for laboratory practice in resource‐constrained countries.Citation Only Available By: Martin, Robert; Hearn, Thomas L; Ridderhof, John C; Demby, Austin. AIDS, 19 Suppl 2: pp. S59‐65 ; May 2005 ; 7 refs.. (AN: 15930842)
65. Addressing the challenges of underdevelopment in environmental and occupational health in southern Africa.Citation Only Available (eng; includes abstract) By Naidoo RN, Jeebhay MF, Robins TG, Myers JE, Nogueira C, Zeleznik WS, International Journal Of Occupational And Environmental Health [Int J Occup Environ Health], ISSN: 1077‐3525, 2006 Oct‐Dec; Vol. 12 (4), pp. 392‐9; PMID: 17168228
66. Health Research Ethics Committees in South Africa 12 years into democracy.Citation Only Available (eng; includes abstract) By Moodley K, Myer L, BMC Medical Ethics [BMC Med Ethics], ISSN: 1472‐6939, 2007; Vol. 8, pp. 1; PMID: 17254335
67. Transdisciplinary approaches to building the capacity of the public health workforce.Citation Only Available (eng; includes abstract) By Taub A, Ethnicity & Disease [Ethn Dis], ISSN: 1049‐510X, 2003 Summer; Vol. 13 (2 Suppl 2), pp. S45‐7; PMID: 13677413
68. Human resource management in project‐based organisations: a case study of the characteristics of an organisation able to develop human resource capacity and the implications for the public works department.Citation Only Available By: Klein, KJ. (AN: NX0137550)
69. Wellness programme and health policy development at a large faith‐based organisation in Khayelitsha, South Africa.Citation Only Available By: Arend, Elizabeth. African Journal of AIDS Research, Vol. 7(3): pp. 259‐270 ; 2008. (AN: AJOL0903‐001818)
70. Monitoring and evaluation of integrated disease surveillance and response in selected districts in Tanzania.Citation Only Available (eng; includes abstract) By Rumisha SF, Mboera LE, Senkoro KP, Gueye D, Mmbuji PK, Tanzania Health Research Bulletin [Tanzan Health Res Bull], ISSN: 0856‐6496, 2007 Jan; Vol. 9 (1), pp. 1‐11; PMID: 17547094
71. Transformation of ministries of health in the era of health reform: the case of Colombia.Citation Only Available By: BOSSERT, Thomas et al; Hsiao, W; Barrera, M; Alarcon, L; Leo, M; Casares, C. Health Policy and Planning, Vol 13 No 1 ; p 59‐77, 1998 Mar. (AN: HEALTHLINK‐024844)
72. Strategies to reduce early morbidity and mortality in adults receiving antiretroviral therapy in resource‐limited settings.Citation Only Available (eng; includes abstract) By Lawn SD, Harries AD, Wood R, Current Opinion In HIV And AIDS [Curr Opin HIV AIDS], ISSN: 1746‐6318, 2010 Jan; Vol. 5 (1), pp. 18‐26; PMID: 20046144
73. Seizing the big missed opportunity: linking HIV and maternity care services in sub‐Saharan Africa.Citation Only Available (eng; includes abstract) By Druce N, Nolan A, Reproductive Health Matters [Reprod Health Matters], ISSN: 0968‐8080, 2007 Nov; Vol. 15 (30), pp. 190‐201; PMID: 17938084
74. Health research ethics review and needs of institutional ethics committees in Tanzania.Citation Only Available By: Ikingura, J K B; Kruger, M; Zeleke, W. Tanzania Health Research Bulletin, 9(3): pp. 154‐8 ; Sep 2007. (AN: 18087891)
75. Responding to HIV and AIDS in the fishery sector in Africa: Proceedings of the International Workshop, February 20‐21 2006, Lusaka, Zambia.Citation Only Available Corporate Author: WorldFish Center [*]. oneFish Newsletter, 2008(February): p. 98 pp ; 2008. (AN: 407354)
76. Strengthening research capacity in Africa.Citation Only Available (eng), Lancet [Lancet], ISSN: 1474‐547X, 2009 Jul 4; Vol. 374 (9683), pp. 1; PMID: 19577676
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77. Capacity building: a strategy for development.Citation Only Available By: Turton, Y. (AN: NX061899)
78. Book. The role of the International Labour Organisation in regional reconstruction, development and equality: Gharieballa Hamid.Citation Only Available By: Hamid, Gharieballa. 1995, p 25‐28 (AN: 00065735)
79. The malaria burden and the need for research and capacity strengthening in Africa.Citation Only Available (eng) By Kilama WL, The American Journal Of Tropical Medicine And Hygiene [Am J Trop Med Hyg], ISSN: 0002‐9637, 2001 Jan‐Feb; Vol. 64 (1‐2 Suppl), pp. iii; PMID: 11425184
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81. Building capacity for anaesthesia in low resource settings.Citation Only Available (eng; includes abstract) By Grady K, BJOG: An International Journal Of Obstetrics And Gynaecology [BJOG], ISSN: 1471‐0528, 2009 Oct; Vol. 116 Suppl 1, pp. 15‐7; PMID: 19740164
82. Strategies for more effective monitoring and evaluation systems in HIV programmatic scale‐up in resource‐limited settings: Implications for health systems strengthening.Citation Only Available (eng; includes abstract) By Nash D, Elul B, Rabkin M, Tun M, Saito S, Becker M, Nuwagaba‐Biribonwoha H, Journal Of Acquired Immune Deficiency Syndromes (1999) [J Acquir Immune Defic Syndr], ISSN: 1944‐7884, 2009 Nov; Vol. 52 Suppl 1, pp. S58‐62; PMID: 19858942
83. Report. Strengthening DFID's support for civil society: report of responses to the consultation paper.Citation Only Available By: SCOTLAND, Patricia; PHILLIPS, Sue. London: DFID, 1999 ; 43 p (AN: HEALTHLINK‐026215)
84. Short communication: Strengthening sub‐national communicable disease surveillance in a remote Pacific Island country by adapting a successful African outbreak surveillance model.Full Text Available (eng; includes abstract) By Nelesone T, Durrheim DN, Speare R, Kiedrzynski T, Melrose WD, Tropical Medicine & International Health: TM & IH [Trop Med Int Health], ISSN: 1360‐2276, 2006 Jan; Vol. 11 (1), pp. 17‐21; PMID: 16398751
85. Research capacity development for CVD prevention: the role of partnerships.Citation Only Available By: Nchinda, Thomas C. Ethnicity & Disease, 13(2 Suppl 2): pp. S40‐4 ; 2003. (AN: 13677412)
86. The implications of shortages of health professionals for maternal health in sub‐saharan Africa.Citation Only Available (eng; includes abstract) By Gerein N, Green A, Pearson S, Reproductive Health Matters [Reprod Health Matters], ISSN: 0968‐8080, 2006 May; Vol. 14 (27), pp. 40‐50; PMID: 16713878
87. Book. HR in NGO relationships.Citation Only Available By: SWARBRICK, AleX. London: People in Aid, 2004 ; 47 p. (AN: HEALTHLINK‐035180)
88. Global health and primary care research.Citation Only Available (eng; includes abstract) By Beasley JW, Starfield B, van Weel C, Rosser WW, Haq CL, Journal Of The American Board Of Family Medicine: JABFM [J Am Board Fam Med], ISSN: 1557‐2625, 2007 Nov‐Dec; Vol. 20 (6), pp. 518‐26; PMID: 17954858
89. Capacity strengthening in malaria research: the Gates Malaria Partnership.Citation Only Available By: Greenwood, Brian M; Bhasin, Amit; Bowler, Cathy H; Naylor, Heather; Targett, Geoffrey A. Trends in Parasitology, 22(7): pp. 278‐84 ; 24 Jul 2006 ; 16 refs.. (AN: 16725373)
90. Joint reviews and inspections: strategic forms of collaboration for strengthening the regulatory oversight of vaccine clinical trials in Africa.Citation Only Available (eng; includes abstract) By Maïga D, Akanmori BD, Chocarro L, Vaccine [Vaccine], ISSN: 1873‐2518, 2009 Dec 11; Vol. 28 (2), pp. 571‐5; PMID: 19833249
91. Report. The 10/90 report on health research 2001‐2002.Citation Only Available Corporate Author: GLOBAL FORUM FOR HEALTH RESEARCH. Geneva: Global Forum for Health Research, 2002 ; 224 p. (AN: HEALTHLINK‐030157)
92. Developing laboratory systems and infrastructure for HIV scale‐up: A tool for health systems strengthening in resource‐limited settings.Citation Only Available (eng; includes abstract) By Justman JE, Koblavi‐Deme S, Tanuri A, Goldberg A, Gonzalez LF, Gwynn CR, Journal Of Acquired Immune Deficiency Syndromes (1999) [J Acquir Immune Defic Syndr], ISSN: 1944‐7884, 2009 Nov; Vol. 52 Suppl 1, pp. S30‐3; PMID: 19858935
93. Learning From Our Apartheid Past: human rights challenges for health professionals in contemporary South Africa.Full Text Available By: Baldwin‐Ragaven, Laurel; London, Leslie; De Gruchy, Jeanelle. Ethnicity & Health, Aug/Nov2000, Vol. 5 Issue 3/4, p227‐241, 15p, 1 chart; DOI: 10.1080/135578500200009347; (AN 3976952)
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94. Participatory training in a sustainable community managed sanitation project.Citation Only Available By: Tedile, JMH. (AN: NX0115577)
95. Tackling Malawi's human resources crisis.Citation Only Available (eng; includes abstract) By Palmer D, Reproductive Health Matters [Reprod Health Matters], ISSN: 0968‐8080, 2006 May; Vol. 14 (27), pp. 27‐39; PMID: 16713877
96. Expanding the reach of health sciences education and empowering others: the OpenCourseWare initiative at Tufts University.Full Text Available (eng; includes abstract) By Lee MY, Albright S, O'Leary L, Terkla DG, Wilson N, Medical Teacher [Med Teach], ISSN: 1466‐187X, 2008; Vol. 30 (2), pp. 159‐63; PMID: 18464140
97. Strengthening capacity in developing countries for evidence‐based public health: the data for decision‐making project.Citation Only Available By: Pappaioanou, Marguerite; Malison, Michael; Wilkins, Karen; Otto, Bradley; Goodman, Richard A; Churchill, R Elliott; White, Mark; Thacker, Stephen B. Social Science & Medicine, Vol 57 No 10 ; p 1925‐1937, Nov 2003. (AN: 14499516)
98. Building and strengthening research capacity in health: the challenge to Africa.Citation Only Available By: HABTE, D. Journal of Diarrhoeal Diseases Research, Vol 10 No 2 ; p 73‐78, Jun 92. (AN: HEALTHLINK‐010005)
99. Training of disaster managers at a masters degree level: from emergency care to managerial control.Full Text Available (eng; includes abstract) By Macfarlane C, Joffe AL, Naidoo S, Emergency Medicine Australasia: EMA [Emerg Med Australas], ISSN: 1742‐6731, 2006 Oct‐Dec; Vol. 18 (5‐6), pp. 451‐6; PMID: 17083633
100. "Women enjoy punishment": attitudes and experiences of gender‐based violence among PHC nurses in rural South Africa.Citation Only Available (eng; includes abstract) By Kim J, Motsei M, Social Science & Medicine (1982) [Soc Sci Med], ISSN: 0277‐9536, 2002 Apr; Vol. 54 (8), pp. 1243‐54; PMID: 11989960
101. Using immunization delivery strategies to accelerate progress in Africa towards achieving the Millennium Development Goals.Citation Only Available (eng; includes abstract) By Clements CJ, Nshimirimanda D, Gasasira A, Vaccine [Vaccine], ISSN: 0264‐410X, 2008 Apr 7; Vol. 26 (16), pp. 1926‐33; PMID: 18343540
102. Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub‐Saharan Africa.Citation Only Available (eng; includes abstract) By Zachariah R, Ford N, Philips M, Lynch S, Massaquoi M, Janssens V, Harries AD, Transactions Of The Royal Society Of Tropical Medicine And Hygiene [Trans R Soc Trop Med Hyg], ISSN: 1878‐3503, 2009 Jun; Vol. 103 (6), pp. 549‐58; PMID: 18992905
103. Integration of antiretroviral treatment within antenatal care in Gauteng Province, South Africa.Citation Only Available (eng; includes abstract) By van der Merwe K, Chersich MF, Technau K, Umurungi Y, Conradie F, Coovadia A, Journal Of Acquired Immune Deficiency Syndromes (1999) [J Acquir Immune Defic Syndr], ISSN: 1525‐4135, 2006 Dec 15; Vol. 43 (5), pp. 577‐81; PMID: 17031321
104. Cost, affordability and cost‐effectiveness of strategies to control tuberculosis in countries with high HIV prevalence.Full Text Available (eng; includes abstract) By Currie CS, Floyd K, Williams BG, Dye C, BMC Public Health [BMC Public Health], ISSN: 1471‐2458, 2005; Vol. 5, pp. 130; PMID: 16343345
105. Report. Strengthening local capacities to create and adapt healthcare information.Citation Only Available By: PAKENHAM‐WALSH, Neil. The Hague: IICD, Oct 2002 ; 20 p. (AN: HEALTHLINK‐030239)
106. An overview of health financing patterns and the way forward in the WHO African Region.Citation Only Available (eng; includes abstract) By Kirigia JM, Preker A, Carrin G, Mwikisa C, Diarra‐Nama AJ, East African Medical Journal [East Afr Med J], ISSN: 0012‐835X, 2006 Sep; Vol. 83 (9 Suppl), pp. S1‐28; PMID: 17476860
107. The 10/90 report on health research 2003‐2004.Citation Only Available Corporate Author: GLOBAL FORUM FOR HEALTH RESEARCH. Geneva: Global Forum for Health Research, 2004 ; 224 p. (AN: HEALTHLINK‐030905)
108. Capacity building for the clinical investigation of AIDS malignancy in East Africa.Citation Only Available (eng; includes abstract) By Orem J, Otieno MW, Banura C, Katongole‐Mbidde E, Johnson JL, Ayers L, Ghannoum M, Fu P, Feigal EG, Black J, Whalen C, Lederman M, Remick SC, Cancer Detection And Prevention [Cancer Detect Prev], ISSN: 0361‐090X, 2005; Vol. 29 (2), pp. 133‐45; PMID: 15829373
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110. Capacity building in Africa: the role of multilateral financial institutions [MFIs].Citation Only Available By: KIFLE, HENOCK; Edited by: Lennart Wohlgemuth. Institution building and leadership in Africa, 1998, p 79‐90 ; UPPSALA: NAI, 1998. (AN: 00077144)
111. How AIDS funding strengthens health systems: progress in pharmaceutical management.Citation Only Available (eng; includes abstract) By Embrey M, Hoos D, Quick J, Journal Of Acquired Immune Deficiency Syndromes (1999) [J Acquir Immune Defic Syndr], ISSN: 1944‐7884, 2009 Nov; Vol. 52 Suppl 1, pp. S34‐7; PMID: 19858936
112. Cost‐effectiveness analysis of establishing a distance‐education programme for health personnel in Swaziland.Citation Only Available (eng; includes abstract) By Kirigia JM, Sambo LG, Phiri M, Matsembula G, Awases M, African Journal Of Health Sciences [Afr J Health Sci], ISSN: 1022‐9272, 2002 Jan‐Jun; Vol. 9 (1‐2), pp. 3‐15; PMID: 17298141
113. [Toward strengthening the health politics in Africa: the military health system and its contribution to health policy in Senegal]Citation Only Available Pour le renforcement des politiques de santé en Afrique: le cas de la contribution de l'armée à l'effort en matière de santé au Sénégal. (fre; includes abstract) By Dotou CR, Dieng MM, Zamble BI, Lafarge H, Bulletin De La Société De Pathologie Exotique (1990) [Bull Soc Pathol Exot], ISSN: 0037‐9085, 2004; Vol. 97 (5), pp. 329‐33; PMID: 15787265
114. The Pediatric AIDS Corps: responding to the African HIV/AIDS health professional resource crisis.Citation Only Available (eng; includes abstract) By Kline MW, Ferris MG, Jones DC, Calles NR, Mizwa MB, Schwarzwald HL, Wanless RS, Schutze GE, Pediatrics [Pediatrics], ISSN: 1098‐4275, 2009 Jan; Vol. 123 (1), pp. 134‐6; PMID: 19117871
115. Workforce development to embed mental health promotion research and evaluation into organisational practice.Citation Only Available By: Joss, Nerida; Keleher, Helen. Health Promotion Journal of Australia, 18(3): pp. 255‐9 ; Dec 2007. (AN: 18201170)
116. A systematic review of the effect of primary care‐based service innovations on quality and patterns of referral to specialist secondary care.Citation Only Available By: Faulkner, Alex; Mills, Nicola; Bainton, David; Baxter, Kate; Kinnersley, Paul; Peters, Tim J; Sharp, Deborah. British Journal of General Practice, 53(496): pp. 878‐84 ; Nov 2003 ; 60 refs.. (AN: 14702909)
117. Community stakeholders' perspectives on the impact of the minority AIDS initiative in strengthening HIV prevention capacity in four communities.Full Text Available (eng; includes abstract) By Eshel A, Moore A, Mishra M, Wooster J, Toledo C, Uhl G, Agüero LW, Ethnicity & Health [Ethn Health], ISSN: 1355‐7858, 2008 Jan; Vol. 13 (1), pp. 39‐54; PMID: 18066737
118. Strengthening district management training and capacity.Citation Only Available Corporate Author: CENTRE FOR EDUCATIONAL DEVELOPMENT IN HEALTH ARUSHA [CEDHA]. Arusha: CEDHA, 1997 ; 65 p ; Unedited version (AN: HEALTHLINK‐021147)
119. A rapid assessment of district health systems in six countries of the WHO African Region.Citation Only Available (eng; includes abstract) By Barry SP, Bakeera S, Kirigia JM, Sambo LG, East African Medical Journal [East Afr Med J], ISSN: 0012‐835X, 2009 Jan; Vol. 86 (1 Suppl), pp. S13‐24; PMID: 19563137
120. Assessing missed opportunities for the prevention of mother‐to‐child HIV transmission in an Eastern Cape local service area.Citation Only Available (eng; includes abstract) By Rispel LC, Peltzer K, Phaswana‐Mafuya N, Metcalf CA, Treger L, South African Medical Journal = Suid‐Afrikaanse Tydskrif Vir Geneeskunde [S Afr Med J], ISSN: 0256‐9574, 2009 Mar; Vol. 99 (3), pp. 174‐9; PMID: 19563095
121. Evidence‐based public health: what does it offer developing countries?Citation Only Available (eng; includes abstract) By McMichael C, Waters E, Volmink J, Journal Of Public Health (Oxford, England) [J Public Health (Oxf)], ISSN: 1741‐3842, 2005 Jun; Vol. 27 (2), pp. 215‐21; PMID: 15820994
122. Geographic patterns of deprivation in South Africa: informing health equity analyses and public resource allocation strategies.Citation Only Available (eng; includes abstract) By McIntyre D, Muirhead D, Gilson L, Health Policy And Planning [Health Policy Plan], ISSN: 0268‐1080, 2002 Dec; Vol. 17 Suppl, pp. 30‐9; PMID: 12477739
123. Challenges and issues in health professions education in Africa.Full Text Available (eng; includes abstract) By Burdick W, Medical Teacher [Med Teach], ISSN: 1466‐187X, 2007 Nov; Vol. 29 (9), pp. 882‐6; PMID: 18158658
124. Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa.Citation Only Available (eng; includes abstract) By Bradshaw D, Chopra M, Kerber K, Lawn JE, Bamford L, Moodley J, Pattinson R, Patrick M, Stephen C, Velaphi S, South Africa Every Death Counts Writing Group, Lancet [Lancet], ISSN: 1474‐547X, 2008 Apr 12; Vol. 371 (9620), pp. 1294‐304; PMID: 18406864
125. Global policy change and women's access to safe abortion: the impact of the World Health Organization's guidance in Africa.Citation Only Available (eng; includes abstract) By Hessini L, Brookman‐Amissah E, Crane BB, African Journal Of Reproductive Health [Afr J Reprod Health], ISSN: 1118‐4841, 2006 Dec; Vol. 10 (3), pp. 14‐27; PMID: 17518128
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126. Community health workers for ART in sub‐Saharan Africa: learning from experience ‐ capitalizing on new opportunities.Citation Only Available (eng; includes abstract) By Hermann K, Van Damme W, Pariyo GW, Schouten E, Assefa Y, Cirera A, Massavon W, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2009; Vol. 7, pp. 31; PMID: 19358701
127. Technical efficiency of district hospitals: evidence from Namibia using data envelopment analysis.Citation Only Available (eng; includes abstract) By Zere E, Mbeeli T, Shangula K, Mandlhate C, Mutirua K, Tjivambi B, Kapenambili W, Cost Effectiveness And Resource Allocation: C/E [Cost Eff Resour Alloc], ISSN: 1478‐7547, 2006; Vol. 4, pp. 5; PMID: 16566818
128. Book. Learning from experience: strengthening organisations of women with disabilities. Solidez, Nicaragua.Citation Only Available By: DIXON, Helen. London: One World Action, September 2001 ; 24 p. (AN: HEALTHLINK‐035357)
129. Institutional linkages: strategic bridges for research capacity strengthening.Citation Only Available By: Lansang, M A; Olveda, R O. Acta Tropica, 57(2‐3): pp. 139‐45 ; Aug 1994. (AN: 7985548)
130. The private sector and HIV/AIDS in Africa: taking stock of 6 years of applied research.Citation Only Available (eng; includes abstract) By Rosen S, Feeley F, Connelly P, Simon J, AIDS (London, England) [AIDS], ISSN: 0269‐9370, 2007 Jul; Vol. 21 Suppl 3, pp. S41‐51; PMID: 17666961
131. Estimating the capacity for ART provision in Tanzania with the use of data on staff productivity and patient losses.Citation Only Available (eng; includes abstract) By Hanson S, Thorson A, Rosling H, Ortendahl C, Hanson C, Killewo J, Ekström AM, Plos One [PLoS One], ISSN: 1932‐6203, 2009; Vol. 4 (4), pp. e5294; PMID: 19381270
132. Health information system reform in South Africa: developing an essential data set.Full Text Available (eng; includes abstract) By Shaw V, Bulletin Of The World Health Organization [Bull World Health Organ], ISSN: 0042‐9686, 2005 Aug; Vol. 83 (8), pp. 632‐6; PMID: 16184283
133. Oil for health in sub‐Saharan Africa: health systems in a 'resource curse' environment.Citation Only Available (eng; includes abstract) By Calain P, Globalization And Health [Global Health], ISSN: 1744‐8603, 2008; Vol. 4, pp. 10; PMID: 18939986
134. Mapping Africa's advanced public health education capacity: the AfriHealth project.Full Text Available By: Ijsselmuiden, C B; Nchinda, T C; Duale, S; Tumwesigye, N M; Serwadda, D. World Health Organization. Bulletin, 85(12): pp. 914‐22 ; Dec 2007. (AN: 18278250)
135. Large‐scale affordable PanLeucogated CD4+ testing with proactive internal and external quality assessment: in support of the South African national comprehensive care, treatment and management programme for HIV and AIDS.Citation Only Available (eng; includes abstract) By Glencross DK, Janossy G, Coetzee LM, Lawrie D, Aggett HM, Scott LE, Sanne I, McIntyre JA, Stevens W, Cytometry. Part B, Clinical Cytometry [Cytometry B Clin Cytom], ISSN: 1552‐4957, 2008; Vol. 74 Suppl 1, pp. S40‐51; PMID: 18228554
136. Health worker motivation in Africa: the role of non‐financial incentives and human resource management tools.Citation Only Available (eng; includes abstract) By Mathauer I, Imhoff I, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2006; Vol. 4, pp. 24; PMID: 16939644
137. What interventions do South African qualified doctors think will retain them in rural hospitals of the Limpopo province of South Africa?Citation Only Available (eng; includes abstract) By Kotzee TJ, Couper ID, Rural And Remote Health [Rural Remote Health], ISSN: 1445‐6354, 2006 Jul‐Sep; Vol. 6 (3), pp. 581; PMID: 16965219
138. The role of leadership in HRH development in challenging public health settings.Citation Only Available (eng; includes abstract) By Schiffbauer J, O'Brien JB, Timmons BK, Kiarie WN, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2008; Vol. 6, pp. 23; PMID: 18983671
139. Staffing remote rural areas in middle‐ and low‐income countries: a literature review of attraction and retention.Full Text Available (eng; includes abstract) By Lehmann U, Dieleman M, Martineau T, BMC Health Services Research [BMC Health Serv Res], ISSN: 1472‐6963, 2008; Vol. 8, pp. 19; PMID: 18215313
140. Challenges and strategies in developing nursing research capacity: a review of the literature.Citation Only Available (eng; includes abstract) By Segrott J, McIvor M, Green B, International Journal Of Nursing Studies [Int J Nurs Stud], ISSN: 0020‐7489, 2006 Jul; Vol. 43 (5), pp. 637‐51; PMID: 16157338
141. Book. Research capacity strengthening for essential national health research [ENHR].Citation Only Available Corporate Author: COUNCIL ON HEALTH RESEARCH FOR DEVELOPMENT [COHRED]. Geneva: COHRED, 1994 ; 51 p (AN: HEALTHLINK‐013955)
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142. Can highly active antiretroviral therapy reduce the spread of HIV?: A study in a township of South Africa.Citation Only Available (eng; includes abstract) By Auvert B, Males S, Puren A, Taljaard D, Caraël M, Williams B, Journal Of Acquired Immune Deficiency Syndromes (1999) [J Acquir Immune Defic Syndr], ISSN: 1525‐4135, 2004 May 1; Vol. 36 (1), pp. 613‐21; PMID: 15097305
143. Progress toward strengthening blood transfusion services‐‐14 countries, 2003‐2007.Full Text Available (eng; includes abstract) By Centers for Disease Control and Prevention (CDC), MMWR. Morbidity And Mortality Weekly Report [MMWR Morb Mortal Wkly Rep], ISSN: 1545‐861X, 2008 Nov 28; Vol. 57 (47), pp. 1273‐7; PMID: 19037194
144. Data safety and monitoring boards for African clinical trials.Citation Only Available (eng; includes abstract) By Lang T, Chilengi R, Noor RA, Ogutu B, Todd JE, Kilama WL, Targett GA, Transactions Of The Royal Society Of Tropical Medicine And Hygiene [Trans R Soc Trop Med Hyg], ISSN: 1878‐3503, 2008 Dec; Vol. 102 (12), pp. 1189‐94; PMID: 18644610
145. Book. Research capacity strengthening for essential national health research [ENHR].Citation Only Available Corporate Author: COUNCIL ON HEALTH RESEARCH FOR DEVELOPMENT [COHRED]. Geneva: COHRED, 1994 ; 51 p (AN: HEALTHLINK‐013955)
146. Designing and implementing an electronic health record system in primary care practice in sub‐Saharan Africa: a case study from Cameroon.Full Text Available (eng; includes abstract) By Kamadjeu RM, Tapang EM, Moluh RN, Informatics In Primary Care [Inform Prim Care], ISSN: 1476‐0320, 2005; Vol. 13 (3), pp. 179‐86; PMID: 16259857
147. EQUINET: networking for equity in health in eastern and southern Africa.Citation Only Available (eng; includes abstract) By Loewenson R, Promotion & Education [Promot Educ], ISSN: 1025‐3823, 2007; Vol. 14 (2), pp. 105‐6; PMID: 17665715
148. Strengthening health information systems to address health equity challenges.Full Text Available (eng; includes abstract) By Nolen LB, Braveman P, Dachs JN, Delgado I, Gakidou E, Moser K, Rolfe L, Vega J, Zarowsky C, Bulletin Of The World Health Organization [Bull World Health Organ], ISSN: 0042‐9686, 2005 Aug; Vol. 83 (8), pp. 597‐603; PMID: 16184279
149. Building capacity for nurse‐led research.Citation Only Available By: Edwards, N; Webber, J; Mill, J; Kahwa, E; Roelofs, S. International Nursing Review, 56(1): pp. 88‐94 ; Mar 2009. (AN: 19239521)
150. Understanding job satisfaction amongst mid‐level cadres in Malawi: the contribution of organisational justice.Citation Only Available (eng; includes abstract) By McAuliffe E, Manafa O, Maseko F, Bowie C, White E, Reproductive Health Matters [Reprod Health Matters], ISSN: 1460‐9576, 2009 May; Vol. 17 (33), pp. 80‐90; PMID: 19523585
151. An investigation of nurse educator's perceptions and experiences of undertaking clinical practice.Citation Only Available (eng; includes abstract) By Williams A, Taylor C, Nurse Education Today [Nurse Educ Today], ISSN: 0260‐6917, 2008 Nov; Vol. 28 (8), pp. 899‐908; PMID: 18586358
152. Strengthening Health Systems in Poor Countries: A Code of Conduct for Nongovernmental Organizations.Full Text Available By: Pfeiffer, James; Johnson, Wendy; Fort, Meredith; Shakow, Aaron; Hagopian, Amy; Gloyd, Steve; Gimbel‐Sherr, Kenneth. American Journal of Public Health, Dec2008, Vol. 98 Issue 12, p2134‐2140, 7p, 1 chart; DOI: 10.2105/AJPH.2007.125989; (AN 35562812)
153. A capacity‐building conceptual framework for public health nutrition practice.Citation Only Available (eng; includes abstract) By Baillie E, Bjarnholt C, Gruber M, Hughes R, Public Health Nutrition [Public Health Nutr], ISSN: 1475‐2727, 2009 Aug; Vol. 12 (8), pp. 1031‐8; PMID: 18940028
154. Strengthening the performance and effectiveness of the public health system.Citation Only Available (eng; includes abstract), Issue Brief (Grantmakers In Health) [Issue brief (Grantmakers Health)], ISSN: 1559‐5609, 2008 Nov; (31), pp. iv, 1‐37; PMID: 19688915
155. Strengthening health services to control epidemics: empirical evidence from Guinea on its cost‐effectiveness.Full Text Available (eng; includes abstract) By Van Damme W, Van Lerberghe W, Tropical Medicine & International Health: TM & IH [Trop Med Int Health], ISSN: 1360‐2276, 2004 Feb; Vol. 9 (2), pp. 281‐91; PMID: 15040567
156. Strengthening public health in South Africa: building a stronger evidence base for improving the health of the nation.Citation Only Available (eng) By Bradshaw D, Norman R, Lewin S, Joubert J, Schneider M, Nannan N, Groenewald P, Laubscher R, Matzopoulos R, Nojilana B, Pieterse D, Steyn K, Vos T, South African Comparative Risk Assessment Collaborating Group, South African Medical Journal = Suid‐Afrikaanse Tydskrif Vir Geneeskunde [S Afr Med J], ISSN: 0256‐9574, 2007 Aug; Vol. 97 (8 Pt 2), pp. 643‐9; PMID: 17957837
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157. The impact of HIV scale‐up on the role of nurses in South Africa: Time for a new approach.Citation Only Available (eng; includes abstract) By Dohrn J, Nzama B, Murrman M, Journal Of Acquired Immune Deficiency Syndromes (1999) [J Acquir Immune Defic Syndr], ISSN: 1944‐7884, 2009 Nov; Vol. 52 Suppl 1, pp. S27‐9; PMID: 19858933
158. Immunization in patients with HIV infection: are practical recommendations possible?Full Text Available (eng; includes abstract) By Eley B, Drugs [Drugs], ISSN: 0012‐6667, 2008; Vol. 68 (11), pp. 1473‐81; PMID: 18627205
159. Programme development through research: strengthening national capacity in applied research.Citation Only Available Corporate Author: United Nations Development Programme: HIV and Development Programme. 1995 (AN: Legal‐199601360)
160. Health inequities, environmental insecurity and the attainment of the millennium development goals in sub‐Saharan Africa: the case study of Zambia.Citation Only Available (eng; includes abstract) By Anyangwe SC, Mtonga C, Chirwa B, International Journal Of Environmental Research And Public Health [Int J Environ Res Public Health], ISSN: 1661‐7827, 2006 Sep; Vol. 3 (3), pp. 217‐27; PMID: 16968967
161. Agreement between physicians and non‐physician clinicians in starting antiretroviral therapy in rural Uganda.Citation Only Available (eng; includes abstract) By Vasan A, Kenya‐Mugisha N, Seung KJ, Achieng M, Banura P, Lule F, Beems M, Todd J, Madraa E, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2009; Vol. 7, pp. 75; PMID: 19695083
162. Strengthening the public health workforce: three CDC programs that prepare managers and leaders for the challenges of the 21st century.Citation Only Available (eng; includes abstract) By Setliff R, Porter JE, Malison M, Frederick S, Balderson TR, Journal Of Public Health Management And Practice: JPHMP [J Public Health Manag Pract], ISSN: 1078‐4659, 2003 Mar‐Apr; Vol. 9 (2), pp. 91‐102; PMID: 12629911
163. The burden of natural and technological disaster‐related mortality on gross domestic product (GDP) in the WHO African region.Citation Only Available (eng; includes abstract) By Kirigia JM, Sambo LG, Aldis W, Mwabu GM, African Journal Of Health Sciences [Afr J Health Sci], ISSN: 1022‐9272, 2002 Jul‐Dec; Vol. 9 (3‐4), pp. 169‐80; PMID: 17298162
164. Botswana: strengthening capacity for sustained development: a country profile in capacity building.Citation Only Available By: GREY‐JOHNSON, CRISPIN. Corporate Author: ECA‐MRAG [Addis Ababa]. ADDIS ABABA: ECA‐MRAG, 1994, 20P: TABLES: 30CM (AN: 00070828)
165. Most of our social scientists are not institution based... they are there for hire‐‐research consultancies and social science capacity for health research in East Africa.Citation Only Available (eng; includes abstract) By Wight D, Social Science & Medicine (1982) [Soc Sci Med], ISSN: 0277‐9536, 2008 Jan; Vol. 66 (1), pp. 110‐6; PMID: 17826877
166. Strengthening capacity to limit intrusion: theorizing family health promotion in the aftermath of woman abuse.Citation Only Available (eng; includes abstract) By Ford‐Gilboe M, Wuest J, Merritt‐Gray M, Qualitative Health Research [Qual Health Res], ISSN: 1049‐7323, 2005 Apr; Vol. 15 (4), pp. 477‐501; PMID: 15761094
167. A case for further strengthening of the national health system in South Africa.Citation Only Available (eng) By Tshabalala‐Msimang M, South African Medical Journal = Suid‐Afrikaanse Tydskrif Vir Geneeskunde [S Afr Med J], ISSN: 0256‐9574, 2005 Mar; Vol. 95 (3), pp. 159‐60; PMID: 15832662
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170. Building nurses' capacity in community health services.Full Text Available (eng; includes abstract) By Edwards N, MacDonald JA, International Journal Of Nursing Education Scholarship [Int J Nurs Educ Scholarsh], ISSN: 1548‐923X, 2009; Vol. 6 (1), pp. Article25; PMID: 19725806
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178. Strengthening the HIV/AIDS service delivery system in Liberia: an international research capacity‐building strategy.Full Text Available By: Johnson, Knowlton; Kennedy, Stephen B; Harris, Albert O; Lincoln, Adams; Neace, William; Collins, David. Journal of Evaluation in Clinical Practice, 11(3): pp. 257‐73 ; Jun 2005. (AN: 15869556)
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181. Capacity of health‐care facilities to deliver HIV treatment and care services, Northern Tanzania, 2004.Citation Only Available By: Landman, Keren Z; Kinabo, Grace D; Schimana, Werner; Dolmans, Wil M; Swai, Mark E; Shao, John F; Crump, John A. International Journal of S T D & AIDS, 17(7): pp. 459‐62 ; Jul 2006. (AN: 16820075)
182. The political undertones of building national health research systems‐‐reflections from The Gambia.Citation Only Available (eng; includes abstract) By Palmer A, Anya SE, Bloch P, Health Research Policy And Systems / Biomed Central [Health Res Policy Syst], ISSN: 1478‐4505, 2009; Vol. 7, pp. 13; PMID: 19476660
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184. Strengthening healthcare capacity through a responsive, country‐specific, training standard: the KITSO AIDS training program's support of Botswana's national antiretroviral therapy rollout.Citation Only Available (eng; includes abstract) By Bussmann C, Rotz P, Ndwapi N, Baxter D, Bussmann H, Wester CW, Ncube P, Avalos A, Mine M, Mabe E, Burns P, Cardiello P, Makhema J, Marlink R, The Open AIDS Journal [Open AIDS J], ISSN: 1874‐6136, 2008; Vol. 2, pp. 10‐6; PMID: 18923699
185. Strengthening health information systems to address health equity challenges.Full Text Available By: Nolen, Lexi Bambas; Braveman, Paula; Dachs, J Norberto W; Delgado, Iris; Gakidou, Emmanuela; Moser, Kath; Rolfe, Liz; Vega, Jeanette; Zarowsky, Christina. World Health Organization. Bulletin, 83(8): pp. 597‐603 ; 22 Aug 2005. (AN: 16184279)
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189. Community support and disclosure of HIV serostatus to family members by public‐sector antiretroviral treatment patients in the Free State Province of South Africa.Full Text Available (eng; includes abstract) By Wouters E, van Loon F, van Rensburg D, Meulemans H, AIDS Patient Care And Stds [AIDS Patient Care STDS], ISSN: 1557‐7449, 2009 May; Vol. 23 (5), pp. 357‐64; PMID: 19327099
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190. Health Research Profile to assess the capacity of low and middle income countries for equity‐oriented research.Full Text Available (eng; includes abstract) By Tugwell P, Sitthi‐Amorn C, Hatcher‐Roberts J, Neufeld V, Makara P, Munoz F, Czerny P, Robinson V, Nuyens Y, Okello D, BMC Public Health [BMC Public Health], ISSN: 1471‐2458, 2006; Vol. 6, pp. 151; PMID: 16768792
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195. A strategy to improve skills in pharmaceutical supply management in East Africa: the regional technical resource collaboration for pharmaceutical management.Citation Only Available (eng; includes abstract) By Matowe L, Waako P, Adome RO, Kibwage I, Minzi O, Bienvenu E, Human Resources For Health [Hum Resour Health], ISSN: 1478‐4491, 2008; Vol. 6, pp. 30; PMID: 19105836
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199. A review of studies assessing the costs and consequences of interventions to reduce mother‐to‐child HIV transmission in sub‐Saharan Africa.Citation Only Available (eng; includes abstract) By Scotland GS, van Teijlingen ER, van der Pol M, Smith WC, AIDS (London, England) [AIDS], ISSN: 0269‐9370, 2003 May 2; Vol. 17 (7), pp. 1045‐52; PMID: 12700455
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203. Using health and demographic surveillance to understand the burden of disease in populations: the case of tuberculosis in rural South Africa.Citation Only Available (eng; includes abstract) By Pronyk PM, Kahn K, Tollman SM, Scandinavian Journal Of Public Health. Supplement [Scand J Public Health Suppl], ISSN: 1403‐4956, 2007 Aug; Vol. 69, pp. 45‐51; PMID: 17676502
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205. Public‐sector ART in the Free State Province, South Africa: community support as an important determinant of outcome.Citation Only Available (eng; includes abstract) By Wouters E, Van Damme W, Van Loon F, van Rensburg D, Meulemans H, Social Science & Medicine (1982) [Soc Sci Med], ISSN: 1873‐5347, 2009 Oct; Vol. 69 (8), pp. 1177‐85; PMID: 19692165
206. Design and implementation of a health management information system in Malawi: issues, innovations and results.Citation Only Available (eng; includes abstract) By Chaulagai CN, Moyo CM, Koot J, Moyo HB, Sambakunsi TC, Khunga FM, Naphini PD, Health Policy And Planning [Health Policy Plan], ISSN: 0268‐1080, 2005 Nov; Vol. 20 (6), pp. 375‐84; PMID: 16143590
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207. The impact of social environments on the effectiveness of youth HIV prevention: a South African case study.Full Text Available (eng; includes abstract) By Campbell C, Foulis CA, Maimane S, Sibiya Z, AIDS Care [AIDS Care], ISSN: 0954‐0121, 2005 May; Vol. 17 (4), pp. 471‐8; PMID: 16036233
208. Progress and Emerging Challenges in Preventing Mother‐to‐Child Transmission.Citation Only Available (eng; includes abstract) By Chersich MF, Gray GE, Current Infectious Disease Reports [Curr Infect Dis Rep], ISSN: 1523‐3847, 2005 Sep; Vol. 7 (5), pp. 393‐400; PMID: 16107237
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212. Barriers to the equitable funding of primary healthcare in South Africa.Citation Only Available (eng; includes abstract) By Thomas S, Okorafor OA, Mbatsha S, Applied Health Economics And Health Policy [Appl Health Econ Health Policy], ISSN: 1175‐5652, 2005; Vol. 4 (3), pp. 183‐90; PMID: 16309336
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214. The status of HIV‐1 resistance to antiretroviral drugs in sub‐Saharan Africa.Citation Only Available (eng; includes abstract) By Hamers RL, Derdelinckx I, van Vugt M, Stevens W, Rinke de Wit TF, Schuurman R, PharmAccess African Studies to Evaluate Resistance Programme, Antiviral Therapy [Antivir Ther], ISSN: 1359‐6535, 2008; Vol. 13 (5), pp. 625‐39; PMID: 18771046
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216. Strengthening the nation's public health infrastructure: historic challenge, unprecedented opportunity.Citation Only Available (eng; includes abstract) By Baker EL Jr, Koplan JP, Health Affairs (Project Hope) [Health Aff (Millwood)], ISSN: 0278‐2715, 2002 Nov‐Dec; Vol. 21 (6), pp. 15‐27; PMID: 12442836
217. The challenge of measuring quality of care at health centre level in Africa: the example of Tsholotsho health district in Matabeleland North, Zimbabwe.Citation Only Available (eng; includes abstract) By Van Eygen L, Van Lerberghe V, Blaise P, Woelk G, Criel B, The International Journal Of Health Planning And Management [Int J Health Plann Manage], ISSN: 0749‐6753, 2007 Jan‐Mar; Vol. 22 (1), pp. 63‐89; PMID: 17385333
218. Scaling up child and adolescent mental health services in South Africa: human resource requirements and costs.Citation Only Available (eng; includes abstract) By Lund C, Boyce G, Flisher AJ, Kafaar Z, Dawes A, Journal Of Child Psychology And Psychiatry, And Allied Disciplines [J Child Psychol Psychiatry], ISSN: 1469‐7610, 2009 Sep; Vol. 50 (9), pp. 1121‐30; PMID: 19243477
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220. A case study of research ethics capacity development in Africa.Citation Only Available (eng; includes abstract) By Hyder AA, Harrison RA, Kass N, Maman S, Academic Medicine: Journal Of The Association Of American Medical Colleges [Acad Med], ISSN: 1040‐2446, 2007 Jul; Vol. 82 (7), pp. 675‐83; PMID: 17595564
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223. Strengthening local public health practice: a view to the millennium.Citation Only Available (eng; includes abstract) By Milne TL, Journal Of Public Health Management And Practice: JPHMP [J Public Health Manag Pract], ISSN: 1078‐4659, 2000 Jan; Vol. 6 (1), pp. 61‐6; PMID: 10724694
224. Research capacity building and collaboration between South African and American partners: the adaptation of an intervention model for HIV/AIDS prevention in corrections research.Full Text Available (eng; includes abstract) By Reddy P, Taylor SE, Sifunda S, AIDS Education And Prevention: Official Publication Of The International Society For AIDS Education [AIDS Educ Prev], ISSN: 0899‐9546, 2002 Oct; Vol. 14 (5 Suppl B), pp. 92‐102; PMID: 12413197
225. Report on the two‐day seminar on "Research needs for population and development planning" organised jointly by the Government of Sierra Leone and the UNFPA/ILO held in Freetown 17th & 18th July, 1990.Citation Only Available Corporate Author: Ministry of National Development and Economic Planning, Central Planning Unit, Population and Human Resources Section, National Population Commission [Freetown]. Freetown: Ministry of National Development and Economic Planning. Central Planning Unit. Population and Human Resources Section. National Population Commission ; 70 p; 30 cm ; 1990 (AN: LEIDEN‐121713652)
226. Health promotion competency building in Africa: a call for action.Citation Only Available (eng; includes abstract) By Onya HE, Global Health Promotion [Glob Health Promot], ISSN: 1757‐9759, 2009 Jun; Vol. 16 (2), pp. 47‐50; PMID: 19477863
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232. Community group participation: can it help young women to avoid HIV? An exploratory study of social capital and school education in rural Zimbabwe.Citation Only Available (eng; includes abstract) By Gregson S, Terceira N, Mushati P, Nyamukapa C, Campbell C, Social Science & Medicine (1982) [Soc Sci Med], ISSN: 0277‐9536, 2004 Jun; Vol. 58 (11), pp. 2119‐32; PMID: 15047071
233. Capacity development through reflective practice and collaborative research among clinic supervisors in rural South Africa‐‐a case study.Full Text Available (eng; includes abstract) By Lehmann U, Blom W, Dlanjwa M, Fikeni L, Hewana N, Madlavu N, Makaula V, Pennacchini M, Seal S, Sivuku T, Snyman K, Education For Health (Abingdon, England) [Educ Health (Abingdon)], ISSN: 1357‐6283, 2004 Mar; Vol. 17 (1), pp. 53‐61; PMID: 15203474
234. Evaluation of a learner‐designed course for teaching health research skills in Ghana.Citation Only Available By: Bates, Imelda; Ansong, Daniel; Bedu‐Addo, George; Agbenyega, Tsiri; Akoto, Alex Yaw Osei; Nsiah‐Asare, Anthony; Karikari, Patrick. BMC medical education, 7: p. 18 ; 27 06 2007. (AN: 17596260)
235. HIV/AIDS treatment and HIV vaccines for Africa.Full Text Available By: Weidle, Paul J; Mastro, Timothy D; Grant, Alison D; Nkengasong, John; Macharia, Doris. Lancet, 6/29/2002, Vol. 359 Issue 9325, p2261, 7p, 1 chart, 1 color; (AN 6881750)
236. Global health partnerships in practice: taking stock of the GAVI Alliance's new investment in health systems strengthening.Citation Only Available (eng; includes abstract) By Naimoli JF, The International Journal Of Health Planning And Management [Int J Health Plann Manage], ISSN: 0749‐6753, 2009 Jan‐Mar; Vol. 24 (1), pp. 3‐25; PMID: 19165763
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238. Report. International Institute for Capacity Building in Africa: Strengthening Africa's Educational InstitutionsCitation Only Available . By: United Nations Educational, Scientific, and Cultural Organization, Addis Ababa (Ethiopia). International Inst. for Capacity Building in Africa.. UNESCO International Institute for Capacity Building in Africa. 2006 4 pp. (ED496623) Full Text from ERIC
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246. Scaling up antiretroviral therapy in Malawi‐implications for managing other chronic diseases in resource‐limited countries.Citation Only Available (eng; includes abstract) By Harries AD, Zachariah R, Jahn A, Schouten EJ, Kamoto K, Journal Of Acquired Immune Deficiency Syndromes (1999) [J Acquir Immune Defic Syndr], ISSN: 1944‐7884, 2009 Nov; Vol. 52 Suppl 1, pp. S14‐6; PMID: 19858929
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248. The public health workforce in sub‐Saharan Africa: challenges and opportunities.Citation Only Available (eng; includes abstract) By Beaglehole R, Sanders D, Dal Poz M, Ethnicity & Disease [Ethn Dis], ISSN: 1049‐510X, 2003 Summer; Vol. 13 (2 Suppl 2), pp. S24‐30; PMID: 13677409
249. Building capacity in health research in the developing world.Full Text Available (eng; includes abstract) By Lansang MA, Dennis R, Bulletin Of The World Health Organization [Bull World Health Organ], ISSN: 0042‐9686, 2004 Oct; Vol. 82 (10), pp. 764‐70; PMID: 15643798
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251. Organisational climate as a cause of job dissatisfaction among nursing staff in selected hospitals within the Mpumalanga Province.Full Text Available (eng; includes abstract) By Lephoko CS, Bezuidenhout MC, Roos JH, Curationis [Curationis], ISSN: 0379‐8577, 2006 Nov; Vol. 29 (4), pp. 28‐36; PMID: 17310742
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253. Strengthening grant applications from Africa.Citation Only Available (eng) By Ogunbanwo JA, Tsoka J, Egan A, Trends In Parasitology [Trends Parasitol], ISSN: 1471‐4922, 2001 Apr; Vol. 17 (4), pp. 162‐3; PMID: 11360882
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255. The metrics and correlates of physician migration from Africa.Full Text Available (eng; includes abstract) By Arah OA, BMC Public Health [BMC Public Health], ISSN: 1471‐2458, 2007; Vol. 7, pp. 83; PMID: 17509147
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70. Buthelezi G, Barron P, Makhanya N, Edwards – Miller J. Towards Equity: From the Site of Service Delivery
71. Results from the Nine Provinces. Durban: Health Syatems Trust.
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74. A National Human Resources Plan for Health to provide skilled human resources for healthcare adequate to take care of all South Africans. Final Draft. http://www.doh.gov.za/docs/discuss‐f.html.
75. Department of Health South Africa. A Strategic Framework for the Human Resources for Health Plan - Draft for discussion. 2005. http://www.doh.gov.za/docs/discuss-f.html
76. Department of Health South Africa. Draft Charter of the Private and Public Health Sectors of the Republic of South Africa. 2005 South Africa. http://www.doh.gov.za/docs/discuss‐f.html
77. Department of Health. A National Human Resources for Health Planning Framework 2006. http://www.doh.gov.za/docs/discuss/2006/hrh_plan/chapt1.pdf
78. Department of Health. Training manual - Operational plan for comprehensive HIV and AIDS care, management and treatment for South Africa
79. Báez C and Barron, P Community voice and role in district health systems in east and southern Africa: A literature review. Regional Network for Equity in Health in
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east and southern Africa (EQUINET) June 2006 EQUINET DISCUSSION PAPER 39. http://www.doh.gov.za/docs/index.html
80. Revised Draft Health Charter - 28 October 2005
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82. Department of Health. Developing an Appropriate Health Sector Response to Gender-Based Violence - Workshop Report June 2001
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90. Department of Health. Research Findings and Policy Implications of the Review of Highly Specialised Services in the Public Hospital Sector. 26th June 2001. http://www.doh.gov.za/docs/index.html
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PART 2: ANNOTATED DISCUSSION OF THE LITERATURE
INTRODUCTION AND FRAMEWORK
“Health systems” refers to all the activities whose primary purpose is to promote, restore and
maintain health. One framework emphasizes four functions of stewardship, resource mobilisation,
service provision and financing (WHO). Marchal et al’s (2009) article helps us to question health
systems strengthening definition and strategies in the context of the Global Health initiatives which
claim to be strengthening health systems yet some of their activities weaken health systems to some
extent. This literature review presents original research studies, commentaries and conceptual
frameworks from both published and gray literature on strengthening health systems in South
African in the context of HIV and AIDS. It uses Yu et al’s (2008) framework of analysis of HSS in the
developing countries published in an article, “Investment in HIV/AIDS programs: does it help
strengthen health systems in developing countries” and another Hanson et al (2003)’s framework on
the analysis of the relationship between injecting funding to HIV programmes and the effect it has
on health systems in general. In an analysis of whether HIV programs strengthen or weaken health
systems, Yu et al (2008) ask six questions whose answers help to monitor and evaluate the
performance of HIV and AIDS programmes’ in relation to health systems strengthening. The
following questions will be asked as well in this paper:
1. Has health service delivery been expanded?
2. Have health sector human resources been expanded?
3. Has the health information system been strengthened?
4. Have procurement and supply management been strengthened?
5. Has health financing been improved?
6. Have leadership and governance for health been improved?
Operational plan for comprehensive HIV and AIDS care, management and treatment for South Africa, 2003. Department of Health, Republic of South Africa
This literature review also discusses the literature in the context of the operational plan for HIV and
AIDS in South Africa. The germination of the “operational plan for comprehensive HIV and AIDS care,
management and treatment for south Africa” also called the “Comprehensive Plan” dates back to
34
the Strategic Plan for HIV / AIDS in 2000 which identified and sought to encourage research and
programming on 4 main areas of intervention, that is, prevention; treatment, care and support;
research monitoring and surveillance; legal and human rights. The Comprehensive plan’s two main
areas are to establish a minimum of one HIV and AIDS service point in every health district by the
end of the first year of the plan’s implementation and to provide all South Africans and permanent
residents with comprehensive and equitable access to care and treatment within their locale within
5 years. The comprehensive plan paid significant amount of attention to health system
strengthening in a section on “Strengthening the National Health System” which provided the
following six items,
1. Providing significant investments to strengthen the overall national health delivery system
2. Adding professional health workers to strengthen the health system as a whole in which HIV
and AIDS patients will be treated
3. Upgrading the skills base and competencies of health care workers within the public health
system
4. Improving physical infrastructure
5. Improving access to laboratory services
6. Making investments to upgrade the national drug distribution system and the patient and
health information systems at all levels of the health care system
It is therefore fair to discuss health systems strengthening in South Africa in the context of Yu et al‘s
framework of analysis which is an analysis that seemingly asks if South Africa managed to implement
the Comprehensive Plan as planned or wished. Like Yu et al (2008) observed for most countries in
the developing countries, many arguments on the relationship between HIV programming and
health systems dynamics are based on anecdotal, speculating and limited evidence, since many
programmes are still rolling and have not been fully evaluated. Other evidence has been based on
small pilots or on early stages of the projects whilst a number of systematic impact studies are still
underway (eg the early evaluation of the Rural Allowance in South Africa). An attempt has been
made to classify different papers under the thematic questions asked by Yu et al (2008).
An assessment of interactions between global health initiatives and country health systems. World
Health Organization Maximizing Positive Synergies Collaborative Group WHO 2009 Lancet 2009;
373: 2137–69. (Pg 18)
The publication is a collective effort of different authors worldwide on the interactions between the
GHIs and country health systems in the developing world. The authors contribute to ongoing debate
35
on whether the GHIs strengthen or weaken country health systems. A number of examples are
drawn from HIV programmes in Sub‐Saharan Africa. There exist about 100 Global Health Initiatives
(GHIs) currently although the major ones are only a few. In this analysis, four GHIs were discussed
(GAVI, Global Fund, PEPFAR and World Bank MAP). The Health systems in the LDCs were already
weak due to HIV and AIDS when the millennium development goals (MDGs) were proposed in 2000
and the GHIs emerged in that context. No robust studies of the partnership between GHIs and
health systems have so far been done. Large GHIs were formed within 10 years ago and it is too
early to assess their impact on health systems of countries. Also arrangements for increasing their
impact on health systems were not made hence there is no robust data to assess the relationship of
the two. Thirdly the scientific society has been too slow to realise the need to scrutinise the
relationship.
Health system definition ‐ “more than the pyramid of publicly owned facilities that deliver personal
health services”. These include faith based organisations (FBOs), nongovernmental organisations
(NGOs), and other non state sectors because 40‐70% of health care in Sub Saharan Africa is provided
by FBOs. There is no commonly agreed framework to assess and understand interactions of GHIs in
health systems. In this analysis the authors worked out the criteria to analyse the GHIs and
relationship with health systems, that is, it identifies distinct functions of health systems or their
building blocks – and another framework that analyses how the GHIs interact with health systems in
these building blocks (governance, finance, health workforce, HIS and supply and management
systems). Each of these is interlinked to the 6th item of service delivery. The central role of the
community is considered in the analysis although only recognised but not included in the six points
of interaction are the social, economic, political, environmental factors.
Health service delivery
This is the major aim of any health system and so GHIs activities should be assessed for this, that is,
if their goal is to strengthen health systems is leading to service delivery. Service delivery depends on
the other building blocks of health systems mentioned above. It is analysed by way of assessing
access, coverage, equity in services and quality.
Access: increased tenfold for ART in low income and middle income countries and it was 3million by
the end of 2007. Coverage of ART for PMTCT increased from 9% (2004) to 33% (2007. In TB
programmes the rate of detection rose from an all time 40‐50% in 2002 to 56% in 2006. Supplies to
malarial control programmes of bed nets were enough to protect 26% of the people in 37 countries
in Africa in 2006. In 18 countries in Africa 34% households owned an insecticide treated bed net and
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the number of children sleeping under a bed net rose from 3% in 2001 to 23% in 2006. Immunisation
for Hepatitis B nearly doubled from 2002 to 2006 (32% to 60%). However it cannot be claimed that
these increases were due to GHI activities only as there are also many forces that played. Increase in
access to targeted health services has been faster than to non targeted services, thereby creating a
health inequity.
Equity: The GHIs consistently mention equity of access as one of their key objectives. Equity refers to
access to health for those in need, whether they live in rural, urban areas with no discrimination
based on sex or socio‐economic status). [The PEPFAR analysis is based on four GHIs – Global Fund ,
GAVI, PEPFAR and World Bank MAP] that is whole article. There is an overall increase in equity in
access and outcomes for GHIs targeted interventions like HIV/ AIDS and TB. But countries inequity
exists in some countries. The use of targets may create inequity in the sense that urban areas targets
can be reached early and easily compared to rural areas resulting in funding flowing into urban
areas. Equity has been realised in Ukraine when the Global Fund provided funding for 11000
injecting drug users, 15000 sex workers, 7 000 MSM and 29 000 prisoners. Although GHIs have
equitably addressed funding issues on health and sex equity issues, a lot remains to be done relating
to directly addressing social determinants of health and factors that provide health inequity. GHIs
have tried to ensure no user fees are charged to clients for health systems. They also engage civil
society in planning and delivery of health systems which increases uptake of services in vulnerable
and socio economically disadvantaged communities.
Quality: Quality is maintained through focussing on few interventions, provisions of standardised
guidelines for prevention, treatment and care. Pre‐qualification of drugs, standardised packaging of
commodities and global procurement contribute to universal standards of care. However, pressure
to meet numerical targets interfered with quality of care in Nicaragua by the Global Fund. Anecdotal
evidence suggests that countries submit proposals even if they did not have capacity to implement
projects and others provide substantial quality services in order to meet targets but do not report
this. Poor quality is shown in emergence drug resistant TB and HIV whilst good quality is shown in
the decrease in infant mortality linked to expanded coverage of vaccines and insectcide treated bed
nets.
FINANCING
Amount: Overseas development assistance (ODA) in health doubled between 2001 and 2006 from
$5.6bn to 13.8bn per year. A third (32%) of ODA between 2002 and 2006 went into HIV/AIDS mainly
through GHIs for HIV, Malaria, TB and Childhood Immunisation including polio.
37
Domestic budget allocations: there is no evidence on whether national allocations to targeted
diseases /programmes by GHIs reduced, rose or did not change. In Kenya, Zambia, Rwanda, Malawi
and Tanzania between 2002 and 2006 funding from donors accounted for 75% of HIV targeted
expenditures.
Out of pocket expenditure: studies still show that poor people pay at points of delivery for
treatments and services and this represents the most widespread means of financing health care in
poor countries. It accounts for 60% of total health care spending compared to 20% of health care
spending in the developed countries. In Zambia people living with HIV spent 485% more out of
pocket in 2002 compared to 23% in 2006. In Rwanda it decreased from 257% to 28%, whilst in
Tanzania it went down from 136% to 75%.
GOVERNANCE:
Planning and coordination: GHIs have specific countrywide coordinating systems but poor alignment
between plans has been reported. Their focussed intensive planning processes with tight application
deadlines and heavy implementation conditionalities distract government leaders and planners from
their general duties and responsibilities. In many countries time frames for application for grants
were different from fiscal year budgeting, auditing and expenditure leading to incurring heavy
transaction costs. The GHIs’ strict measures also helped the countries to note that their health
systems were weak and needed strengthening. However, most of the planning by GHIs has been
independent of country plans leading to duplication, sub‐optimum communication and absence of
trust between government and NGO sectors. This suggests that the disease specific focus of the
main GHIs continues to put pressure on governments to meet the increasing demands of donors and
health services for HIV/AIDS. However, in some countries GHIs’ programmes have been integrated
into the country’s programmes (Rwanda). In other countries their planning led to innovative ways
and easing of regulatory frameworks in human resources for health such as task shifting in Malawi,
Zambia and Ethiopia – nurses could prescribe ARVs. GAVIs health system component for example,
includes requirements for sectoral oversight and for coordination and for the management of the
application process from the MOH’s planning department.
Community involvement: GHIs have improved community participation such as nongovernmental
actors (NGOs, FBOs). Almost 20% grants money from the Global Fund’s seventh round of funding
was channelled through NGOs whilst non state actors accounted for 50% of principal recipients or
38
sub recipients. In 2005 prime partners received 40% of funding while 70% went to sub‐partners.
“Non‐state, not for profit organisations have been effective recipients of GHI funds and have done
better than government recipients”. The proliferation of NGOs amid huge funds being channelled to
them coupled with decentralisation of health care services have raised concern in many countries. In
Uganda and South Africa, civil society has been very active in expanding service delivery.
HEALTH WORK FORCE
1.5 million new workers are needed in Africa and 4 million needed in the world. In 2004 93% of beds
in a primary hospital in Botswana were HIV related but after the introduction of ART this reduced to
52% in 2006. Disease specific interventions burden the already overstretched health workforce.
Most of the proposals sent to GAVI for health system strengthening mentioned workforce. However,
the proposals mainly include short‐term training and salary allowances and little demand for long
term interventions such as building and sustaining health workers, retention, planning and
production were presented. GHIs have greatly contributed to in disease specific service training.
PEPFAR is known for championing task‐shifting and disease specific training and creating mid level
cadres thereby increasing the human resources. GHIs have encouraged and trained informal cadres
such as community health workers (CHWs) with sometimes salaries and allowances outside national
payroll. In Kenya and Haiti GHIs have managed to improve integration of CHWs and the formal
health sector.
Distribution: the training of workers for disease specific interventions creates maldistribution of
health service workforce in the country in terms of equitable distribution of skills, targeted diseases
and geography. PEPFAR injected financial and non financial incentives (housing, transportation,
hardship and education) to promote improved distribution of health workers and underserved areas
(but increases in staff have only been recognised in urban areas in Zambia.
Retention: 43% of deaths or medical retirement in Mozambique, Zimbabwe, Ethiopia, Kenya and
Malawi were known or suspected to be from HIV and AIDS. 3‐4% of all nurses in Swaziland are lost
from work due to HIV deaths. In Kenya HIV/AIDS in the health workforce is twice the national
average. GHIs have supported programmes that included health workers. In some countries, 50% of
sites do not have basic infrastructure and supplies like soap, running water, gloves and post
exposure prophylaxis for HIV prevention. These are some of the issues associated with health
worker retention. Many health workers’ lives were saved in Malawi by ARVs. There is no data to
show that treatment of HIV infected health workers and declining HIV prevalence are having a
positive effect on retention.
39
HEALTH INFORMATION SYSTEMS
GHIs insist on linking inputs to quantifiable results which depend on functioning health systems.
Availability and accuracy: the biases in information on prevalence of HIV led PEPFAR to sponsor
national population based surveys of seroprevalence using national sampling frames. This led to a
downward trend in the number of HIV/AIDS infections globally. Information usually does not include
general state of health services and health in general since they are not disease specific.
Use and demand: GHIs have revealed the shortcomings of national health information systems
which led to efforts to strengthen them in many countries, especially those related to HIV. 20%
($120m) of funds requested by countries in round 8 of Global Fund applications were for improving
monitoring and evaluation systems. GHIs still pursue independent health information systems
despite efforts to harmonise and integrate country health information systems that are underway in
some countries. PEPFAR uses national HISs but maintains a separate HISs which also asks for more
information. This results in information burdens, system wide inefficiency and “failure to invest in a
rational, robust, efficient and independent framework for common data”. In Mali, a campaign
specific HIS for monitoring a neglected tropical disease resulted in 12 new forms for drug supply
management and 15 new forms for follow up and assessments of the distribution process. It
resulted in one more report per village, one per health centre and one per district every weak for
each drug distributed. The performance based funding results in health workforce reporting only on
GHI programmes and leaving other crucial national programmes behind. There are reports of
matching GHI indicators with national programme indicators for monitoring and evaluation.
Innovation: Anecdotal evidence shows that new electronic patient records are improving the
provider‐patient interaction. In Malawi a manual paper based system was replaced by an electronic
system. In Rwanda TRACnet has been extended from HIV only to TB and malaria in tracking patients
and keeping records. Smart cards in Zambia as from 2005 allow access to up‐to‐date medical
information for over 60 000 patients. It enables them to compile end of month reports faster than
paper records and also prevents patients from shifting from the first to second line drugs which are
expensive. Tracking pharmaceutical and other essential supplies has been enabled by innovative
HISs. Tendency towards concentrating on data gathering as opposed to data use calls for investing in
health information workers.
SUPPLY MANAGEMENT SYSTEMS
40
Procurement and distribution: GHIs have created a huge demand for bed nets, ARVs, vaccines,
drugs, laboratory materials, etc and have contributed to funding the procurement of these supplies
as well as strengthening the country’s procurement systems – leading to reduction in some prices of
some drugs (TB, HIV, Malaria and onchocerciasis). Bulk or pooled procurement mechanisms have led
to increased affordability of commodities like vaccines but not ARVs. Increase in the supplies
shipped to countries has not been matched by improvements in distribution of supplies.
Procurement and distribution: There are reports of GHIs and country systems working together and
also in some instances GHIs have duplicated and displaced country supply chains, poor coordination
leading to elevated operational costs. Poor coordination in planning between national medical
storage facilities but with no coordination has been reported in some instances in other countries
leading to poor storage planning. At districts levels parallel procurement systems lead to high
workloads for workers including opportunity costs and real costs for the health system.
Quality: GHIs increase country’s access to quality drugs.
RECOMMENDATIONS:
1. Infuse the HSS agenda with the sense of ambition and speed that has characterised the GHIs.
2. Extend the targets of GHIs and agree on indicators for HSS 3. Improve alignment of planning processes and resource allocations among GHIs and
between GHIs and country heath systems 4. Generate more reliable data for the costs and benefits of strengthening health systems and
evidence to inform additional and complementary investments to those of GHIs 5. Ensure a rise in national and global health financing and in more predictable financing to
support the sustainable and equitable growth of health systems.
Saving the lives of South Africa’s mothers, babies, and children: can the health system deliver?
Mickey Chopra, Emmanuelle Daviaud, Robert Pattinson, Sharon Fonn, Joy E Lawn. Lancet 2009; 374:
835–46.
In this second paper of a series of six papers in the Lancet devoted to South Africa’s health system,
authors analyse the high infant and maternal mortality in South Africa in relation to avoidable causes
or actions in the national health system. High maternal and infant mortality are attributable to
avoidable health systems factors as noted in the national audit reports (2500 mothers die, 20000
babies are stillborn, 52600 children die before 60 months) 46% mothers die of direct obstetric
41
causes whilst 44% die of pregnancy related infections including HIV. Thirty percent mothers die from
modifiable factors such as the administrative action like lack of blood for transfusion, lack of
transport between health facilities. Fifty‐eight percent of the deaths are attributed to modifiable
factors at primary health facility level 49% at secondary level, 30% at tertiary level such as not
adhering to standard protocols.
For stillbirths and neonates 8% deaths were attributed to administrator action such as personnel not
available or not sufficiently trained to monitor maternal hypertension. 13% stillbirths and neonates
were attributed to health provider action such as fetal distress not identified in labour, poor
response to hypertension.
Children aged 60 months and below recorded (the majority were children with HIV) 22% deaths
from avoidable administrative action such as lack of senior doctors and nurses and insufficient
paediatrics beds. Fifty‐three percent attributed to provider action such as Integrated Management
of Childhood Illnesses (IMCI) not used in clinics and poor assessment and management in hospitals.
District hospitals recorded the highest avoidable administrative related deaths for children which is
probably because they receive limited outreach support from regional hospitals which are also
overstretched with clinical work. It is estimated that nearly 50000 lives of infants and children up to
60months could be saved between 2008‐2015 if these avoidable health systems problems are
actually avoided through the implementation of effective and efficient coverage of interventions.
Such measures could also enable SA to meet the MDG4. Scaling up PMTCT with improved PMTCT
infant feeding is likely to save up to 37200 children’s lives yearly.
1. HEALTH SYSTEMS STRENGTHENING CONCEPTUAL FRAMEWORKS
Expanding access to priority health interventions: a framework for understanding the constraints
to scaling‐up. Kara Hanson, M. Kent Ranson, Valeria Oliveira‐Cruz and Anne Mills Journal of
International Development. 15, 1–14 (2003).
Following the Commission on Macroeconomics and Health (2001) which recommended increasing
funding to enable developing countries to strengthen their health systems, the authors conducted
an extensive literature review and presented a framework for analysing constraints to scaling
up/strengthening health systems for optimal efficient and sustainable delivery of services. The term
scaling up refer to expanding access to ensure they are universally available and accessible. The
42
authors define constraints as obstacles which are more than mere inputs as they cover systems,
processes, incentives, and values or norms that restrict desired goal achievement.
They argue that resource constraints constitute a limitation of health systems to achieve effective
care for the people. The conceptual framework they propose considers the close to the client health
system approach and analyses the range and intensity of constraints to the delivery of priority
interventions. A framework for scaling up health systems should be policy relevant so as to enable
the relaxation of constraints for capacity strengthening. They offer two levels of analysis:
1. The level at which a constraint operates: This is important to understand barriers to strengthening
capacity in a country at all different levels of care in the health care delivery system eg poor policy
as a constraint occurs at the higher level of government whilst administering ART occurs at the
health facility by doctors and nurses. Issues of sectoral control need to be identified and analysed
likewise since they affect health but cannot easily be relaxed by the health officials themselves eg
salaries of health care workers are usually decided by the public service office and health
infrastructure is put up and or renovated by public works department although they directly impact
on health system delivery. Health system constraints exist at the following levels [DIAGRAM]:
a) community and household level;
b) health services delivery level;
c) Health sector policy and strategic management level;
d) Public policies cutting across sectors;
e) Environmental and contextual characteristics
2. Amenability to improvement through additional funds: It is important to analyse constraints
according to their susceptibility to positive change through injecting additional funds in the health
service which the authors called relaxation of constraints. Generally lower level constraints are more
amenable to change than higher level constraints. Constraints due to lack of inputs are also much
more amenable to change by adding funds. Those related to performance of processes e.g. planning,
regulation, management can be strengthened through investment in development of new
procedures and systems. There are also constraints that do not change by adding additional funds
/reliance on donor funding such as environmental or geography which are not easily amenable. So is
government policy or structure or governance. Money is a necessary condition but unlikely to be
sufficient as socio‐political factors will bear on how this will be used. [DIAGRAM]
43
Overcoming health‐systems constraints to achieve the Millennium Development Goals
Phyllida Travis, Sara Bennett, Andy Haines, Tikki Pang, Zulfiqar Bhutta, Adnan A Hyder, Nancy R
Pielemeier, Anne Mills, Timothy Evans. Lancet 2004; 364: 900–06
The authors present a conceptual framework that they argue could enable the relaxation of
constraints to strengthen health systems in order that countries could attain MDGs. They offer two
major choices or strategies for health system strengthening (parallel programming and system‐wide
programming). The article which was first in a series, ahead of the Mexican Ministerial Conference,
was written to enable knowledge transfer and policy makers to make decisions on strategies of
health systems strengthening in the context of achieving the MDG targets. The key challenges to
achieving the three health MDGs in the developing countries is the health systems which currently
look fragile and fragmented to be able to deliver the volume and quality services that their
populations require. Major barriers to health systems strengthening include finances, human
resources, drugs, supply systems, generation and use of information. Political instability and policy
environment and quality of governance also pose policy and institutional constraints. The authors
observed one major limitation in the conceptual framework designed by Hanson et al (2008) and
used by different authors since its development. They noted that it only identifies the constraint but
does not trace it to identify its underlying causes that can help in addressing these constraints to
capacitate health systems. Again, constraints in health systems usually do not have a single cause,
but rather interconnected and multidimensional causes. Efforts to address health systems
constraints should consider the interconnectedness of such constraints, anything short of that may
lead to failure to fully address the constraint. The authors argue that the advantage of addressing
constraints through an intervention specific method targeting a specific health problem or disease
(which they called parallel programmes) is that it can yield quick results as compared to system‐wide
interventions which need long term plans to fully address the constraints. However such small
parallel interventions may lead to duplications in the system as there may lack coordination of
activities in the whole system. There may also be distortions through creating a separate cadre of
health workers who are better paid. This could only demotivate staff who are not benefitting from
that programme or may deplete staff from other parts of the health system to that better financed
programme. The authors also warn against the problem of disruptions of work as uncoordinated
programmes take workers off their work for training for several long periods of time. Sometimes this
may mean one worker may benefit from different programmes whilst their offices lag as they will be
attending trainings. Finally, distractions are common due to the specific and uncoordinated
reporting mechanisms and requirements from different players in the health systems. This may
distract them from their main job activities.
44
The disadvantage of system‐wide strategies include that workloads can increase for certain people
eg. as one employee can be required to undertake training for different diseases management
compared to maybe two training sessions for HIV only per year in parallel programmes. Secondly,
benefits take longer to accrue; they are unfocussed and may become unmanageable. The system
wide approach recognises the need to tackle the root causes of the problem, recognises the
complexity of health systems constraints and problems, but does not mean loosing focus on
outcomes, abandoning priorities and wanting to do everything simultaneously. It ensures benefits
accrue to many dimensions of health systems (not single priorities).
Global Health Actors Claim to Support Health System Strengthening—Is This Reality or Rhetoric?
Marchal B, Cavalli A, Kegels G (2009) PLoS Med 6(4): e1000059. doi:10.1371/journal.pmed.1000059
The authors conducted a literature review of the role of Global Health Initiatives (GHIs) in health
systems in developing countries. In this report the they reported that implementing GHI
programmes effectively requires well functioning Health Systems many of which are currently fragile
and unable to provide effective health services in developing countries. There is need for developing
countries to consider strengthening their health systems as their medium term goal towards the
achievement of higher order MDGs in future. One limitation is that the term HSS is vaguely defined
and its strategies are therefore misunderstood and different ideas are put forward on the role of HSS
towards public health. It is crucial to note that HSS approaches driven by Global Health Agencies are
selective as they target certain diseases which may undermine progress towards long term goals of
effective high quality and inclusive health systems.
The authors argue that many GHIs argue that they help to strengthen health systems yet their
activities only do the opposite as they undermine progress towards turning health systems into
“effective, high quality, inclusive” health systems. They argue that there is need to redefine HSS in
order to realign efforts towards strengthening HSS and also to launch a balance between HSS in
prevention and in treatment. The authors argued that HSS has become a buzzword for GHAs as
there is a clear gap in their terminology (HSS) and their activities. “Their HSS strategies are
essentially a means to deliver targeted interventions more efficiently, rather than being strategic
and directed towards the root causes of health system weaknesses. Therefore, HSS efforts of most
actors can be more accurately described as selective HSS interventions. ”
45
In 2006 WHO redefined its 2000 definition of HSS to ‘‘building capacity in critical components of
health systems to achieve more equitable and sustained improvements across health services and
health outcomes’’
The authors argued that the selective discourse of the GHAs weaken health systems. They noted
that duplication, interruptions and imbalances are noted where GHA programmes are implemented.
They adapted Travis et al’s categorisation of problems caused by the selective nature of GHIs. They
cite examples from Nepal where health workers preferred to leave the primary health care system
to join the national immunisation days where they were offered higher per diems thereby
interrupting service in the health system. In Cambodia, ongoing immunisation campaigns were
reduced by campaigns for HIV, TB, Malaria and birth spacing programmes.
Investment in HIV/AIDS programs: Does it help strengthen health systems in developing countries? Dongbao Yu, Yves Souteyrand, Mazuwa A Banda, Joan Kaufman and Joseph H Perriëns. Globalization and Health 2008, 4:8 doi:10.1186/1744‐8603‐4‐8
There is a huge debate on whether the introduction of GHIs and ART into the health systems weaken
or strengthen health systems in Africa. This introduction unravelled decades of neglect and
weaknesses of health systems. The WHO defines health systems as “all organisations, people and
actions whose primary intent is to promote, restore or maintain health” Its six building blocks are:
1. effective safe and high quality health services
2. Responsible workforce
3. Equitable access to essential medical products, vaccines, and technologies
4. A well functioning health information system
5. A good health financing system
6. Strong leadership and governance
HIV and AIDS increase the demand for health services and also reduce the ability of the health
services to respond to the care needs of the population. The advent and introduction of ART means
the easing of hospital beds. In Brazil, due to free ART, 40‐70% decrease in mortality; 60‐80%
decrease in morbidity; 85% decrease in hospitalisation and savings of USD1.2b in health costs were
recorded. HIV and AIDS programmes have strengthened primary health care efforts through the
provision of IMCI, FP, TB case finding. In many countries such as Zambia and Rwanda many HIV
programmes are integrated in or work closely with other primary health care programmes.
46
In Rusikisiki village in South Africa, ART programme led to infrastructural development which
includes huge improvements such as reliable electricity, water supply, telefax for clinics, whilst
building renovations have increased space for counselling and nursing services.
However it is feared that huge decreases in funding for family planning and reproductive health have
resulted due to shifting of funding to HIV programmes. In other programmes it was realised that
ART helps to keep health workers alive for continuing work in different primary health care
programmes and other health care work. For example in Malawi, it was reported that 250 of the
1022 health workers were kept working by enrolling for ART. There is also significant progress
reported elsewhere in sub‐Saharan countries (Ghana, Malawi, Kenya and Ethiopia). However, the
authors also noted localised brain drain from other primary health care programmes to ART and
NGOS offering HIV programmes.
Implementing comprehensive and decentralised health Systems: The quest for integrated care in
post‐apartheid South Africa. David Sanders and Mickey Chopra. International Journal of Integrated
Care – Vol. 1, 1 March 2001 – ISSN 1568‐4156 – http://www.ijic.org/ pp 1568‐.
The Mount Freire Project in Eastern cape is a case in point in which the UWC and Health Systems
Trust worked together with the Eastern Cape province in managing malnutrition whilst developing
the capacities of the health care workers and developing an efficient District Health System. A
multi‐sectoral approach informed by a comprehensive (instead of selective) primary health care
approach was applied. Provincial representatives came from the following sectors to form a steering
committee which oversaw the project: agriculture, education, environmental health, maternal and
child health, nutrition and welfare and a national representative from the Nutrition Directorate. At
the district level the Mount Freire Nutrition team included representatives from nutrition,
agriculture, education, local government, water affairs, and environmental health. Through
workshops they fostered team building and a common understanding on causes of malnutrition by
applying the planning cycle of assessment, analysis and action. The project successfully developed
capacity of public sector personnel in the poorest regions in the country. The hospital component
managed to see a reduction in case fatality rates from severe malnutrition inpatients. The
programme is sustainable without ongoing external support from UWC faculty. It is also replicable
in South African public health services. (add more information on the successes)
2. HAS HEALTH SERVICE DELIVERY BEEN EXPANDED?
47
Strengthening the Capacity of Traditional Health Practitioners to Respond to HIV/AIDS and TB in
KwaZulu Natal, South Africa. Melusi Ndhlalambi. AMREF Case Studies, 2009.
[The Comprehensive Plan stipulates that the health system acknowledges the presence and the work
of traditional healers in the fight against AIDS]. There is a high prevalence of HIV and TB in South
Africa, a high co‐infection rate of 60% and a high prevalence of HIV (36.2%) in Kwazulu Natal (KZN)
and a high health worker burden and a nurse‐patient ratio of 1:8333, doctor patient ratio of
1:155000 due to nurse vacancy rates, high attrition rates for doctors and nurses and a 50% nurse
absenteeism. It is against this background that in KZN there is s high proliferation of traditional
medicine for HIV related illnesses being used. South Africa enacted the WHO regulation to involve
traditional healers into the health system and over 60% people in KZN are believed to visit
traditional healers before they visit primary health care facilities. In a baseline survey conducted by
AMREF it was noted that traditional healers lacked a number of supplies for use in treating and
caring for patients with HIV such as gloves and razor blades in Mtubatuba sub‐district of
Umkhanyakude District. The traditional healers formed the Traditional Healers Project which then
worked with AMREF in Mtubatuba. AMREF set up a VCT centre in the community which served as a
link (and referral) between traditional healers and the health care delivery system. It successfully
helped to create the link between traditional healers and primary health care system by training 80
traditional healers in HIV, TB, VCT, ART, HBC, STIs, PMTCT, Community IMCI, care of OVC, project
and financial management, leadership, and ethics. In a follow up study a number of changes were
recorded in the work of traditional healers. Traditional healers put up infrastructure such as toilets
for safer waste disposal, building waiting shelters , shelves for drugs storage, they began using Oral
rehydration therapy in the treatment of dehydration, practised nutrition gardening and counselled
HIV and AIDS patients. In terms of referrals, 25 out of 30 healers interviewed mentioned that they
referred patients for VCT for HIV to a local clinic or hospital for TB whilst 17 referred patients for
HIV, nine for diarrhoea with others referring for different diseases. All traditional healers who were
interviewed reported that they could identify symptoms and signs of HIV and were referring to
primary health care and hospitals. Prior to project implementation none of the healers in the project
had ever referred patients to primary health care centres and none could identify signs and
symptoms of HIV. All were now using referral letters in referring patients. Each was referring at least
one and at most 4 patients per month whilst two were referring over 800 per year. There was
consensus among all health workers interviewed in the district that ART roll out had improved due
to the implementation of the project. Health care workers perception of traditional healers changed
from bad to fairly good and good. Overall about 2500 clients were referred for VCT between October
2007 and August 2008. [see report for qualitative findings].
48
Health system constraints to optimal coverage of the prevention of mother‐to‐child HIV
transmission programme in South Africa: lessons from the implementation of the national pilot
programme. Tanya M Doherty, David McCoy, Steven D African Health Sciences 2005; 5(3):213‐218.
The authors conducted an analysis of routine programme data on ANC and programme registers at
18 PMTCT pilot sites and interviewed health care workers and programme managers. The analysis
was aimed at assessing the performance and uptake of PMTCT elements at the pilot sites. Results
show a high uptake of VCT in Kwazulu Natal province which was attributed to the opt‐out approach
and the availability of lay counsellors. Provinces that recorded the highest number of VCT uptake
employed or subcontracted lay counsellors through NGOs. Whilst those provinces (North West and
Eastern Cape) which only relied on the service of the overstretched and busy nurses had few clients
who were counselled and tested for HIV.
In Mpumalanga, Eastern Cape and Free State there were reports of shortages and interruption of
test kit supplies and therefore reducing the uptake of VCT. The centralisation of the procurement
system through national tendering system was to blame as provinces had little control of the
procurement process. The uptake of nevirapine was 55% which was suboptimal. The health system
could have enrolled more mothers for nevirapine if they had a plan for identifying mothers except by
way of the stickers marking a mother’s HIV positive status which they latter removed as they
realised that they were stigmatising mothers in labour ward. The tracking system was poor. Mothers
disclose their status to the nurses during ANC but the labour ward was a different setting with
different nurses who did not have any information regarding their status and some mothers
considered their privacy and avoided telling different nurses in the labour ward. Some mothers
administered nevirapine themselves and therefore were not captured in the records which were
analysed.
The research showed that there were different training packages offered in the country regarding
infant feeding priorities. The decision to formula feed mirrored a province’s training and priorities in
infant feeding. KwaZulu Natal and Free State provinces whose health workers were trained in breast
feeding practices recorded 60% mothers opting breastfeeding whilst Gauteng and Western Cape
provinces in which staff were trained in formula feeding had a 80% formula feeding choice. Formula
feeding supplies were also running out at the collection centres and nurses were not aware of what
advice to give to mothers. In order to minimise loss of infants to follow up at 18months, national
government policy of testing infants at 18 months was relaxed and infants were tested at 12 months
49
and were again followed up at 18 months if they tested positive. There were however low infant
testing rates (10‐78%).
Overall, there is need to strengthen health system infrastructure to enable privacy in HIV status
disclosure. Also need for management capacity in running and improving PMTCT programme.
The double burden of human resource and HIV crises: a case study of Malawi. David McCoy,
Barbara McPake and Victor Mwapasa. Human Resources for Health 2008, 6:16 doi:10.1186/1478‐
4491‐6‐16
The paper analyses efforts taken to revive human resources for health and ART in particular in
Malawi after GHIs injected funds in the country. In Malawi there is an extensive use of clinical
officers, medical assistants and about 4500 community based health surveillance assistants (HSAs) as
a rescue plan in the face of brain drain of health care workers such as doctors, pharmacists and
nurses.
Clinical officers who receive 4 years training to do some surgery, diagnoses, treatment and
anaesthesia are alone serving the rural areas. Medical assistants (2 years training) provide medical
care in health centres and the OPD of district hospitals. Health assistants (HSAs) who receive 10
weeks training are engaged in conducting duties such as from health promotion activities to TB
defaulter tracing. With support from DFID and Global Fund, Malawi set up a six year emergency
human resources programme (EHRP) in 2004 valued at US$272m to boost staff level with the
following aims:
1. Improving incentives for recruitment and retention of public sector based hospitals through a 52%
salary top up for 11 professional and technical cadres and to recruit and re‐engage staff.
2. Expanding domestic training capacity, that is, to double the number of nurses (30x2 registered
nurses and between 300 and 500x3 enrolled nurses) and triple the number of doctors (20x3). It also
aimed to use international volunteer doctors and nurse tutors as short term measures to fill critical
posts while training locals.
4. Assisting the ministry of health in planning, management and development of human resources
for health.
5. Establishing a monitoring and evaluation capacity.
50
With the implementation of the programme, the government now bonds nurses after training for a
certain period. It also provided incentives for filling posts in rural and underserved areas. There was
no outcry from other public servants to the increased salaries of the health care workers as was
previously suspected. By July 2006 human resources in all disciplines had improved greatly in all
categories of staff, for example 162 posts of physicians of the planned 433 were filled; 3416 nurses’
posts out of 8440 were filled. By last quarter of 2005, 591 inactive staff had been recruited. The
medical school increased intake of doctors from 20 to 60 whilst trained health professionals
increased annually from 400/year to over 1000/year. However, a recent evaluation of the
programme showed many hurdles which include that rural and underserved areas still have
problems as retention rates were not improved. In the 2005‐6 only less than 8 medical graduates
joined the MOH and several other junior doctors resigned. In districts, nurses were also leaving the
hospitals. Retired nurses brought into the service had problems getting contracts while the promised
52% salary top up was taxed to the surprise of health workers who then got far less than they were
promised. NGOs or research projects still paid better than government for scarce skills. They offer
stipends in training and fieldwork activities which can increase monthly salary by 25‐40% according
to MSF.
The success of the ART: Despite the HS constraints mentioned above by end of 2006, there were
about 60 000 people on the ART countrywide and planning to reach 245 000 by 2010. The successes
were attributed to the following:
1. Rights based international advocacy movement
2. Earmarked funding for ART services from a range of donors
3. Support from international NGOs and research organisations to deliver ART services
4. Strong technical leadership and management within the ministry of health
5. A vertical management and delivery system which included the following:
i. Dedicated training programmes for various cadres of health workers
ii. A parallel independent system of financing, buying and distributing ARVs i.e. UNICEF buys
the drugs from India, ships them to Copenhagen (Denmark) for packing according to
individual clinic needs then ships them to Malawi for distribution to individual clinics.
iii. A parallel (independent) information system to enable high quality monitoring and
evaluation system
iv. Quarterly supervision and support visits at all ART clinics
51
6. A low cost approach which includes using a single first line and second line regimen for all
patients and providers using clinical staging (not CD4 count), fixed dose combination tablets and
clinical signs only to monitor treatment and response.
In the private sector, patients pay 500MK (1$:140MK) in addition to consultation, of which MK300
will go to the government which provides those drugs for free. This is a cost saving measure for
sustainability purposes on the part of the government. To register for ART, the private hospital
should undergo training of workers, their attachment to already running sites and assessment of
infrastructure. There are plans to task shift and decentralise ART to lay and professional nurses.
Operational effectiveness of single‐dose nevirapine in preventing mother‐to‐child transmission of
HIV. Mark Colvin, Mickey Chopra, Tanya Doherty, Debra Jackson, Jonathan Levin, Juana Willumsen,
Ameena Gogaf & Pravi Moodleye for the Good Start Study Group Bulletin of the World Health
Organization 2007;85:466–473.
The study sought out to determine the effectiveness of the South African PMTCT programme. A total
of 665 mother–infant pairs in which the mother was HIV‐positive were recruited at three sites
(Western Cape, KwaZulu Natal and Pretoria) and 588 were followed up at 3 or 4 weeks after birth to
determine the infant HIV status. The PMTCT programme showed that the quality of counselling was
related to the uptake of nevirapine. Better counselling was associated with a higher uptake of
nevirapine (0R 1.55; P=0.008). Ten percent of the mothers who were given nevirapine according to
the guidelines transmitted the virus to their infants compared to 13.4% (24) who were not given
according to the guidelines (either too early or too late) whilst there was a transmission rate of
14.2% in the 113 who were not given nevirapine although the difference was not statistically
significant. There were inadequate services for VCT in Rietvlei during the ANC attendances and most
pregnant women only got an opportunity for VCT in the labour ward. With the national coverage of
43% VCT it means that there is need to scale it up (See Baron et al 2005 HST). The study showed that
a substantial number of pregnant women attend health facilities and this can be a better
opportunity to enrol those deserving for longer regimens that could end up in better uptake of VCT
and nevirapine and adherence to treatment. Longer regimens which have greater efficiency can
reduce early transmission to rates that are as low as 1.1%. It is therefore recommended to scale up
PMTCT with ARV regimens which are efficacious.
P16. Reply to what about health system strengthening and internal brain drain? Lancet 2008 14
december Authors: Zachariah R, Ford N, Philips M, Draguez B, Harries AD.
52
The authors argue that the disparities in salary payments between the public sector and private
sector does not mean that NGOs and private sector are bad and not contributing to health system
strengthening since they do contribute to national health goals. Employees would not go back to
the public sector if the NGOs release them; they will rather go overseas. They argue that it is better
that these health professionals are employed by NGOs and private sector serving local health needs
rather than going abroad where the nation would not access their invaluable contribution to HRH.
“The creation of relative islands of excellence in seas of insufficiency” is not deliberate and the
problem is not the island itself but the insufficiency that surrounds it. It is the public sector which
does not pay adequately and it is a democratic right of an individual to choose where they want to
work. Blaming NGOs and research institutions does not solve the problem of internal brain drain,
rather, adequate remuneration can solve the problem as happened in Malawi when health care
workers were brought back into the service after government started paying salary top ups. In fact,
NGOs and private sector prevent international brain drain. NGOs can and do collaborate with the
government as is seen in many countries to strengthen heath systems , conduct operational
research with government, advocate international health. They also possess powerful weapons of
advocacy for health. However, they should also exist to respond to other health problems other than
HIV in their countries of operation.
In support of parallel programmes, the authors argued that despite WHO’s emphasis on global
health systems strengthening and integration of care the reality is that health systems consist of
individual parts which in sum make a system. In this argument the authors support ART delivery in
parallel programmes. They argue that waiting until all constraints to health systems in health care
delivery are solved before rolling out ART (as argued by some proponents of horizontal approaches)
would not yield, as many benefits would have been lost if that approach had been taken. Each
component of the system, if improved, does help to improve the system of health delivery.
Strengthening Research Capacity In South Africa: An Audit of Provincial Health Research
Committees. Elizabeth Lutge and Thokozani Mbatha. November, 2007. Health Systems Trust.
Durban: Health Systems Trust.
The South African Health Research Policy (2001) stressed the need for conducting health
research to influence policy. It also paved way for the establishment of Provincial Research
53
Committees mandated to coordinate all health research in the province, manage priority
setting in provincial health research and review preliminary and final research reports in the
province. The authors set out to assess if the provincial health research committees were formed
and were functional in each province by 2006 and by 2007. Interviews were held with committee
members and or other members responsible for the establishment of the committee in each
province. It was noted that a few provinces had managed to formulate them whilst others were still
to formulate and begin working. Lack of resources was singled out as a limitation to this process.
Other problems include lack of dedicated staff since the positions or work had no budgets allocated
to them. In other provinces it was noted that reviewing of health research was conducted by
academic institutions and not the provincial health research committees. North West and Eastern
Cape managed to form the committees with good working relationships with academic institutions.
All provinces mentioned lack of funding for the committees to function. All provinces highlighted the
need to capacitate their members on research ethics for them to be able to review projects in their
provinces although ethics review was regarded as not urgent business for the committees. The
political atmosphere in the Western Cape was also reason for delaying implementing this policy as
there was scepticism regarding the policy objectives and the provincial government and academic
institutions had not forged working relations. There is need to give adequate time to the committees
to fully function.
Paediatric HIV management at primary care level: an evaluation of the integrated management of
childhood illness (IMCI) guidelines for HIV. Christiane Horwood, Kerry Vermaak, Nigel Rollins, Lyn
Haskins, Phumla Nkosi and Shamim Qazi. BMC Pediatrics 2009, 9:59 doi:10.1186/1471‐2431‐9‐59
The study aimed at describing the validity of the IMCI /HIV algorithm when used by IMCI experts and
the use of IMCI/HIV guidelines by IMCI trained health workers in routine clinical practice. Authors
observed 77 workers at 74 facilities in two provinces. Also observed were consultations with 1357
sick children, each child was reassessed by IMCI expert to check correct findings. In 50 out of 74
facilities visited children were observed in private area as per guidelines (IMCI/HIV). Observed health
workers were nurses with average 32.2 months experience after training in IMCI. Nineteen out of 77
nurses (24.7%) were trained in previous algorithms of which 8 out of 19 (42.1%) had received
training on the updated version. The HIV component of IMCI is frequently not used by workers
working in the programme in routine clinical practice. Health workers misclassified children leading
to missed opportunities to include for ART. Lack of current training on updated algorithm is also to
blame for these missed opportunities. Heath workers should be taught to understand that the
algorithm only screens and does not to test for HIV and that those screened are send for testing and
54
most may test HIV negative and this should also be expected. The study shows that the PMTCT
programme is not being implemented well, as children born to mothers who tested HIV positive had
not been tested (despite being exposed to HIV). Many clinics were not testing for HIV in under fives.
The study shows a higher rate of undiagnosed HIV in children in the PHC clinics with most having
advanced disease.
3. HAVE HEALTH SECTOR HUMAN RESOURCES BEEN EXPANDED?
Patient satisfaction with antiretroviral services at primary health‐care facilities in the Free State,
South Africa – a two‐year study using four waves of cross‐sectional data Edwin Wouters, Christo
Heunis, Dingie van Rensburg and Herman Meulemans. BMC Health Services Research 2008, 8:210
doi:10.1186/1472‐6963‐8‐210
The study set out to describe patient satisfaction with ART services at 16 sites in Free State province.
The study interviewed patients of 18 years and older who were on ART or ready to receive ART after
certified by the doctor to assess if they were satisfied with the following services: medical care,
complaint procedure, cleanliness of the facility, privacy during examinations, confidentiality of
medical records respect shown by nurses, health information about HIV/AIDS, information provided
by nurses on ARV medication, opportunity to ask questions, language used during consultations,
facility opening hours, and waiting time before consultation. It was found out that patients were
overall satisfied with the general services and nurses services they received at the hospitals. They
were much less satisfied with the waiting times in 5 districts. At one site patients were highly
satisfied over time and other sites it did not change (generally high) over time. Waiting times were
the most important determinant of patient satisfaction. The study demonstrated a strong negative
association (r = ‐0.438, P < 0.001) between nurse vacancy rates and mean satisfaction levels with
ART services performed by nurses at baseline survey time as patients who were attending facilities
with low professional nurse vacancy rates reported significantly higher satisfaction with nurses'
services than did those attending facilities with higher vacant nursing posts.
Building capacity in health research in the developing world. Mary Ann Lansang & Rodolfo Dennis.
Bulletin of the World Health Organization 2004;82:764‐770.
The authors analyse ways of building research capacity in the developing world. They argue that sub
Saharan Africa operates on a background of very limited funding for health research capacity. In Sub
Saharan African countries, health research is allocated less than 0.5% of national health budget with
55
health budgets being funded less than 1% of the GDP. UNESCO estimated that researcher:
population ratio was 3: 10 000 in less developed countries compared to 1: 1000 for developed
countries. They reviewed literature and proposed the following approaches for developing capacity
in human resources for health:
1. Training of individual researchers and research users at masters, PhD and post doctoral
levels. There are many fellowships offered by funding agencies eg. Forgarty International,
Welcome Trust, US NIH which help to build human capacity in research.
2. Learning by doing approaches are crucial for providing ongoing residential programmes as
they effectively complement degree offerings. In India and Thailand such methodologies
have successfully been applied. Such programmes help to train the apprentice by the
mentor who is knowledgeable and who also learns in the process of supervising the
apprentice which the authors described as co‐learning.
Due to the fact that there is huge brain drain, the above two programmes which are individual
based may alone prove unsuccessful to national goals. The approaches which relate to an
institutional capacity building will work better in the face of brain drain. These approaches are
described below.
3. Collaborations between developed and developing countries or south‐south corporation e.g.
for research and training in tropical diseases (WHO/TDR).
4. Creating centres of excellence in less developed countries to work with well funded global
research programmes e.g. USNIH
Although training is acceptably good the big challenge is to create a research environment to
maintain the interest of the researchers and those who use research results. A study that examined
post doctoral experience in Pakistan revealed the problems facing the country as inadequate
enabling environment, lack of competent leaders and funds for research and salaries and poor
career structure. In Africa the problem is that of inequities in the research environment. African
based researchers are said to over rely on developed countries for money, the problem of huge
differences in salary scales between national and global entities, inadequate dissemination and
uptake of research results.
Routine checks for HIV in children attending primary health care facilities in South Africa:
Attitudes of nurses and child caregivers Christiane Horwood , Anna Voce, Kerry Vermaak, Nigel
Rollins, Shamim Qazi Social Science & Medicine (2009), doi:10.1016/j.socscimed.2009.10.002
56
The authors set to assess the implementation and performance of the IMCI/HIV integrated
programme on sick children who were presenting at clinics. Focus group discussions were conducted
with trained nurses who were involved in the IMCI programme and with mothers attending first
level facilities. Nurses expressed negative attitudes towards routine checking of HIV status on
children. They reported that it was unnecessary and unacceptable to mothers; they lacked the skills
to implement the programme and feared adverse reactions from mothers if they wanted to or if
they checked HIV issues. They especially felt it was unnecessary to check if the child had no signs of
illnesses. Nurses reported that they felt that their training inadequately prepared them to conduct
HIV checks, diagnosis and counselling. Some nurses who had not attended the two weeks course on
HIV reported that they simply referred children to an HIV counsellor. However, some nurses who
had some knowledge of conducting the checks reported that they checked the baby’s card for HIV
information on the mother and child. Overall, health professionals lack skills to implement the HIV
component of the IMCI. Nurses recommended more coverage of the information and counselling in
IMCI training (e.g. information on diagnosis, signs and symptoms).
Building Capacity without interrupting health services: Public health education in Africa through
distance learning. Lucy Alexander, Ehi Uche Igumbor and David Sanders. Human Resources for
Health 2009:7 (28 2009
The school of public health of the University of the Western Cape offers quality public health
education from certificate to master level education to students without disrupting learners from
their work through a system called distance education. The school which used to recruit 100% South
Africans as shown by 2000 statistics has however reduced to 68% the number of South African
nationals or citizens in 2003 and to 33% in 2007. Currently foreign students dominate the pool of
students.
Health Research Capacity Building in South Africa: Current knowledge and practices
Sphindile Magwaza, Vuyiswa Mathambo, Bongani Magongo, Elma Kortenbout Ntombizodumo Mvo
and Nonhlanhla Makhanya. June 2003 Health Systems Trust, South Africa.
57
The authors conducted a national review to identify interventions from which lessons can be drawn
to influence and give support to the national health research committee in strengthening and
implementing their policy for South Africa. The review was conducted by sending questionnaires to
different health research institutions identified. The cores skills that the researchers found out as
critical to the development and strengthening of research capacity include proposal writing, data
collection, analysis, and report writing. Training occurs through formal postgraduate education,
hands on practice in internship programmes and both formal and non‐formal research education.
The main challenge to scaling up is lack of financial resources for research capacity building
programmes. Other problems cited include brain drain of critical research skills, inadequate
understanding of research and health system by academics, researchers and health officials at all
levels. It was also highlighted that there was need to make nurses aware of the importance of
research. Data collectors should also be knowledgeable of other research processes beyond just the
collection of data which is the only known process by most data collectors. Research capacity in
South Africa mainly focus on building capacity but not considering skills retention, motivation, and
utilisation of skills and capacity. It was also recommended that after graduating from training
courses, graduates should be given an opportunity to practice the skills they learnt and should be
directly involved in the research process. Although efforts to strengthen networks in research were
noted, there is need to strengthen such efforts in districts and communities.
Why do nurses abuse patients? Reflections from South African obstetric services. Rachel Jewkes, Naeemah Abrahams and Zodumo Mvo Soc. Sci. Med. Vol. 47, No. 11, pp. 1781±1795, 1998
The authors conducted ethnographical work at maternity hospitals in areas serving African Black,
coloured and white population and held semi‐structured interviews with pregnant women attending
antenatal care clinics and also discussions with nurses at the hospitals in Western Cape province.
Unprofessional work ethics such as violence against pregnant women (verbal, slapping, neglect) and
women in labour were common. The health system which was characterised by shortages of
supplies such as testing kits which only helped to demotivate health care workers (nurses) leading
them to displaying negative attitudes and behaviours against pregnant women and women in
labour. For example pregnant women had to wake up early morning (3am) to join a queue for ANC
services at 4am only to be served from 730am for blood testing whose results would be taken
outside the clinic for laboratory testing (830am) and results would be available at the end of the day.
This led to some women not getting tested for HIV and other conditions. Scolding, beating,
58
humiliations, lack of privacy on one’s sexual life and illness, vulgar and sexual language, neglect,
characterised nurses interaction with pregnant women and women in labour ward. Nurses were
dissatisfied with bottlenecks in the health system such as lack of adequate machinery and technical
devices to use, bureaucratic procedures, heavy workloads as well as their own personal educational
part time work as they sought to get promotions. The study revealed a high magnitude of problems
in the health system which translated in poor service delivery and client dissatisfaction with services
offered.
THE RURAL ALLOWANCE STUDY
The South African Treasury allocated R500m for rural allowances in 2003. The programme was
aimed at solving the problem of the maldistribution of health professionals between rural and urban
areas in South Africa by injecting financial and non financial incentives to recruit and retain health
professionals. Despite the Rural Recruitment Allowance having been instituted in South Africa in
1994, it failed to recruit and retain health staff. Community service for all health professionals has
also failed to redistribute health staff to deserving rural areas. In order to assess the success of the
Rural Allowance programme at its inception, Interviews were held with health professionals in rural
hospitals before the inception of the programme and two months after the inception. It was shown
that health workers changed their career plans for the year 2005 because of the inception of the
programme. Despite the fact that it is too quick to judge the impact of the study, it showed that
incentives can change health workers intentions to move. It was also not possible to determine the
effect of confounding variables such as the introduction of the Scarce Skills Allowance. Generally, the
study does not inform us whether the rural allowance worked or not.
Managerial competencies of hospital managers in South Africa: a survey of managers in the public
and private sectors. Rubin Pillay. Human Resources for Health 2008, 6:4 doi:10.1186/1478‐4491‐6‐4
This survey compared skills and competencies between hospital managers in public sector and
private sector in South Africa. Questionnaires were mailed to all provinces and 215 public sector
managers and 189 private sector managers responded. Three provinces did not respond and an
overall 52% response rate was recorded. Hospital managers in the private sector reported higher
managerial competency in a likert scale than public sector managers. A total of 55.3% public sector
managers had medical/health related background while the majority in the private sector had a
commerce/management or other (67.2%) background. More Public sector managers (74.8%)
received formal training in health management than private sector managers (41.9%). Similar
differences were observed in reception of informal health management training. Both categories of
59
managers perceived themselves as reasonably competent in all facets of management (means>3)
whilst more public sector managers reported needing further management development training
than private sector managers. In 6 out of 7 items in the questionnaire public sector managers felt
less competent than private sector managers (p=0.009) in conducting their managerial business. The
majority of government managers had less than five years of experience in current position
compared to private sector managers in which the majority had more than 5 years of experience in
current position.
Work satisfaction of professional nurses in South Africa: a comparative analysis of the public and
private sectors. Rubin Pillay. Human Resources for Health 2009, 7:15 doi:10.1186/1478‐4491‐7‐15
A survey of 569 professional nurses across South Africa showed that private sector nurses were
generally satisfied while public sector nurses were generally dissatisfied with pay, workload and
resources available to them in the conduct of daily business. Overall professional nurses were
marginally satisfied (mean 2.935).
BD/PEPFAR LAB‐STRENGTHENING INITIATIVE MARKS PROGRESS IN FIGHT AGAINST HIV/AIDS AND
TB IN SUB‐SAHARAN AFRICA PEPFAR 2009 news release. CAPE TOWN (July 19, 2009
PEPFAR DB collaboration has made significant progress in improving the skills of laboratory
personnel and laboratory conditions in the fight against HIV/AIDS, TB in Sub Sahara Africa. Their
collaboration which is worth US$18m is implemented mainly through the Centres for Disease
Control (CDC) of the USA. The programme involved a series of training programmes in Uganda,
South Africa and Mozambique to strengthen the laboratory systems under the auspices of the 5 year
programme to fortify health care systems in countries severely impacted by these two pandemics. In
Uganda 94 health care workers were trained in a series of workshops and laboratory worker tests
scores showed an improvement of 151%. Training was also offered in Global Positioning
System/Global Information System technology to ensure laboratory specimens from remote areas
promptly reach the laboratory for processing. The system is working well in Uganda; more than 200
samples have been referred through this innovative specimen management initiative. Twenty‐two
microbiologists from South Africa, Ethiopia, Ethiopia and Namibia, Nigeria were trained to improve
their ability to detect and identify mycobacterium TB.
Task shifting: the answer to the human resources crisis in Africa? Uta Lehmann, Wim Van Damme,
Francoise Barten and David Sanders. Human Resources for Health 2009, 7:49
doi:10.1186/1478-4491-7-49
60
In this commentary, the authors argue that there is evidence to show that task delegation from
doctors to non‐physician clinicians including nurses, from nurses to nursing assistants or aides or non
professional or lay health care workers and patients can improve access, coverage and quality
healthcare services at a cost that is cheaper than or similar to traditional models of health care
delivery. However, this requires greater government and political backing. There is need to change
scopes of practices and regulatory frameworks, enhanced training infrastructure, etc into
mainstream health system. Preconditions for successful task shifting include commitment and the
need to be clear about levels and extent of participation. Without government leadership in
ensuring an enabling regulatory environment and credentialing system, task shifting will be exposed
to the changes in financial, leadership and policy fashions and become fragile and unsustainable.
P16. Reply to what about health system strengthening and internal brain drain? Lancet 2008 14
december Authors: Zachariah R, Ford N, Philips M, Draguez B, Harries AD.
The authors argue that the disparities in salary payments between the public sector and private
sector does not mean that NGOs and private sector are bad and not contributing to health system
strengthening since they do contribute to national health goals. Employees would not go back to
the public sector if the NGOs release them; they will rather go overseas. They argue that it is better
that these health professionals are employed by NGOs and private sector serving local health needs
rather than going abroad where the nation would not access their invaluable contribution to HRH.
“The creation of relative islands of excellence in seas of insufficiency” is not deliberate and the
problem is not the island itself but the insufficiency that surrounds it. It is the public sector which
does not pay adequately and it is a democratic right of an individual to choose where they want to
work. Blaming NGOs and research institutions does not solve the problem of internal brain drain,
rather, adequate remuneration can solve the problem as happened in Malawi when health care
workers were brought back into the service after government started paying salary top ups. In fact,
NGOs and private sector prevent international brain drain. NGOs can and do collaborate with the
government as is seen in many countries to strengthen heath systems , conduct operational
research with government, advocate international health. They also possess powerful weapons of
advocacy for health. However, they should also exist to respond to other health problems other than
HIV in their countries of operation.
In support of parallel programmes, the authors argued that despite WHO’s emphasis on global
health systems strengthening and integration of care the reality is that health systems consist of
individual parts which in sum make a system. In this argument the authors support ART delivery in
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parallel programmes. They argue that waiting until all constraints to health systems in health care
delivery are solved before rolling out ART (as argued by some proponents of horizontal approaches)
would not yield, as many benefits would have been lost if that approach had been taken. Each
component of the system, if improved, does help to improve the system of health delivery.
Motivation and retention of health workers in developing countries: a systematic review. Mischa
Willis‐Shattuck, Posy Bidwell, Steve Thomas, Laura Wyness, Duane Blaauw and Prudence Ditlopo
BMC Health Services Research 2008 2008, 8:247 doi:10.1186/1472‐6963‐8‐247.
The authors conducted a systematic review of literature on motivation and retention of health
workers in developing countries. They report that in order to advance the MDGs, African health
systems need at least one million health workers to offer basic services needed to meet the MDGs.
Seven themes were identified as motivational factors
1. Financial allowances and salaries which was reported in 18 out of 20 papers reviewed
2. Career development, that is the possibility to specialise which was reported in 17 out of 20
papers
3. Continuing education: the chance for one to further their education, seminars and training.
This was reported in 16 out of 20 papers.
4. Hospital infrastructure which relates to the physical condition of the health facility or work
environment out of twenty papers.
5. Resource availability ‐ equipment, medical supplies as inputs for good performance of their
duties which was reported in 15 out of 20 papers reviewed.
6. Hospital management (16/20 papers)
7. Personal recognition and appreciation ‐ (14/20 papers)
8. Fringe benefits
In South Africa rural allowances were found to have little effect on retaining workers (see Reid 2004
HST). In Cameroon and Zimbabwe financial incentives were perceived as unequally distributed
between health care workers. In South Africa, nurses with children under 18 years and in the ages
from 30‐49 years were more likely to be considering going overseas compared to the younger and
older nurses.
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Strengthening capacity for health research in Africa. James A G Whitworth, Gilbert Kokwaro,
Samson Kinyanjui, Valerie A Snewin, Marcel Tanner, Mark Walport, Nelson Sewankambo. Lancet
2008; 372: 1590–93.
Authors describe opportunities for strengthening capacity that can be implemented in Africa. The
Initiative to Strengthen Health Research Capacity in Africa (ISHReCA) identified 9 crucial
requirements to strengthen health research capacity in Africa. These are grouped into three
categories as follows:
Improve the research environment by:
1. Ensuring an enabling legal framework
2. Raising the profile of science and health research
Support individuals by:
3. Promoting school and college services education
4. Creating career pathways, developing critical mass and recruiting and retaining talented
scientists
5. Supporting senior scientists to act as research leaders and role models
Support institutions by:
6. Developing competitive grant and fellowship schemes administered by the African
institutes
7. Providing institutional support for infrastructure management, technical services and
strategic development planning
8. Promoting networks and partnerships especially between African institutions
9. Using funding mechanisms as drivers of change at African institutions
The current African researchers are ageing and there is need to identify younger talented ones who
can take over. This can be done through secondary school science education and the training of
teachers in science.
Lack of a career path to attract and retain science researchers is a set back to health research.
Authors recommend opening up and starting attractive research focussed career pathways within
key institutions in Africa to address this problem. More opportunities for PhD and post PhD
education should be encouraged and established in Africa and competitive individuals should be
63
encouraged to go beyond the PhD. Such a strategy will need incentives for success through research
funds, travel grants, salaries and career posts. African institutions often lack the recruitment of
women and empowerment of junior scientists in capacity building programmes. Makerere University
has a well funded junior clinical scholarship positions programme that attracts, monitors and retains
junior researchers whilst in many African institutions junior researchers develop their careers on
their own.
The role of leadership in HRH development in challenging public health settings. Judith Schiffbauer,
Julie Barrett O'Brien, Barbara K Timmons and William N Kiarie. Human Resources for Health 2008,
6:23 doi:10.1186/1478‐4491‐6‐23
The South Africa Institute of Race Relations says the public sector had only 7645 doctors of the 30
000 registered that is 0.7 doctors per 1000 population between 1994 and 2004. A national
programme of community service program has contributed to a decrease in 3800 migration of new
graduates who could have migrated out of the country but were deployed in the rural areas.
Human resource development and antiretroviral treatment in Free State province, South Africa.
Dingie HCJ van Rensburg, Francois Steyn, Helen Schneider and Les Loffstadt. Human Resources for
Health 2008, 6:15 doi:10.1186/1478‐4491‐6‐15
[Introduction: The comprehensive plan intends to provide ART to more than one million of the 5.7
million HIV patients. The Plan’s central aim was to “strengthen the national health system overall” in
terms of absolute numbers and relative to the population. South Africa has fewer numbers of health
care staff that it had a decade ago. Therefore other means of dealing with shortage in the context of
an additional burden of HIV and ART have to be applied such as use of lay and mid level workers to
relieve pressure on the professionals –task shifting and task delegation.]
The paper assesses the resource mobilisation for ART programme (2004) in Free State after the
introduction of ART. It evaluates the goal of strengthening HR capacity through establishment of
extra posts, appointment of extra personnel and the enhanced training of staff. The authors
assessed the impact and dynamics of the introduction of ART in Free State province on health care
workers at ART facilities and outside. Data were collected by auditing professional nurse posts
created and filled after the ART programme started in the first 38 sites for ART in 3 districts in Free
State province, facility survey for two years and reviewing government database for human
resources for health. It was found that nearly 80% nurses posts for ART were filled by transfers from
other programmes within the facility or other clinics in the district. Between 2004 and 2006 nurse
64
recruitment did not meet need, HIV prevention and demand for care led to uneven nurse‐patient
ratio and workloads in the province. In 2003 only 59.3% (7176) posts of health professionals in Free
State province were filled. By mid 2006, professional nurse vacancy rates in ART had gone down to
half (15.8%) that of the PHC system as a whole (37.1%). By November 2006 85% of the 115
professional nurse ART posts were filled. The political support the ART program enjoyed made it
possible to attract nurses. In 2005 all professional nurse posts were promoted to senior level and
also received better remuneration packages. 20.6% new appointments came from outside the
province and 43.2% moved from a neighbouring (non ART) facility in the same district to the ART
providing facility. A quarter of the new recruits came from another division (intra facility mobility).
37 out of 40 nurses had received training before the ART programme roll out.
Task shifting: Due to shortage of doctors a nurse initiated and monitored model of ART at PHC
facilities (indirect substitution) was pursued. The strong reliance of ART on pharmaceutical services
called for shifting pharmacist tasks to nurses who were generally available. Regarding other staff,
administration clerk posts were filled quickly leaving a vacancy rate of 7% (of the 78 posts that were
created). Most of the lay professionals (85%) who were assisting nurses received training by second
follow up. The lay professionals ended up assisting patients with drug readiness for ART, once a
responsibility of professional nurses only. Lay counsellors were lured into the ART programme by the
stipends which amounted to a double remuneration previously received.
From 2004 to 2006 a total of 1393 health care workers were trained in ART. The brain drain (in the
primary health system and in general) to ART could generally weaken the health system in the
country. Rural areas which were already underserved were the most affected by this internal brain
drain. Compulsory community service starting in 2008 to professional nurses upon finishing their
training will mean 2000 nurses will be deployed yearly to under resourced sites. This also helps to
cope with ART demands. The vertical ART programme is rigid as it calls for national accreditation
before a site can dispense ART. A centralised ARV dispensary in Free State alleviates professional
nurses of dispensing workload as patients from rural clinics may get drugs from this outlet. It also
helps to counter shortage of pharmacists.
4. HAS THE HEALTH INFORMATION SYSTEM BEEN STRENGTHENED?
65
Challenges for Routine Health System Data Management in a Large Public Programme to Prevent
Mother‐to‐Child HIV Transmission in South Africa. Kedar S. Mate, Brandon Bennett, Wendy
Mphatswe, Pierre Barker, Nigel Rollins. PLoS ONE 4(5):e5483 doi:10.1371journal.pone.0005483
The authors conducted a study to assess data accuracy and completeness for 6 elements of PMTCT
in 2007 from all 316 clinics and hospitals in 3 districts in KwaZulu Natal province. Visits were done to
selected clinics to assess the same. Data were reviewed for completeness and health workers were
interviewed about the data they compile and send. Completeness was measured by assessing if all
12 months were reported on each data item. It was noted that data elements only recorded 50% of
the time and were accurate in only 12.8% of the time. The most accurate data was that which shows
“ANC clients tested for HIV” (19.8%) whilst the least accurate was “HIV PCR testing of baby born to
HIV mother” (5.3%). It was noted that clinics report more complete data than hospitals. The study
shows that there are major defects in the completeness and accuracy of data in the District Health
Information System. There was highly inaccurate data transfer from clinic registers to monthly
summary sheets. There was infrequent data transfer by clinics for capture in the DHIS.
An evaluation of the district health information management system in rural south Africa. Garrib
A , Stoops N, McKenzie A, Dhlamini, L. Govender T, Rhohde J and Herbst K. South African Medical
Journal 2008, 98:549‐522.
The increase in demand for information to make decisions and make policy means that data should
be accurate. The study sought to evaluate the District Health Information System in a rural district in
South Africa. Available routine data were analysed and interviews were held with health workers.
Findings show that there was a highly perceived work burden linked to collection and collation with
some data collation tools not being used appropriately. Generally, there was good collection and
collation process but there was less data interpretation, analysis and use. 2.5% data were missing,
25% outside expected ranges with no explanation given. Duplication of data collected on chronic
patients, (TB, HIV) PMTCT and immunisation was noted. The format of data differed with clinics, tally
sheets were poorly used. The burdensome and differences in data could be attributed to the fact
that data were collected for national offices and well as for district use with different formats. There
was no computerisation and electronic submission of data making the process laborious and costly.
There were very limited validation checks for completeness or accuracy of data and there was no
discussion of data in staff meetings. As part of the research the research team presented the data to
the health care workers who were involved in collecting and collating information. However, no
clinic staffs were able to calculate the indicators presented whilst most were able to interpret
66
graphs. Although the clinics had targets that they had set, they did not use the data to monitor these
targets and align their performance to meeting these targets. Clinics do not receive any feedback on
data from the district offices and this mean that there was no information of the clinic’s
performance in relation to other clinics or national targets. Generally there is severe shortage of
health informatics knowledge and there is a culture of reporting but not of using the information.
Health information system reform in South Africa: developing an essential data set. Vincent Shaw.
Bulletin of the World Health Organization 2005;83:532‐539.
The paper is a report on how the South African District Health Information System (DHIS) evolved
from a district’s efforts to drop a primary health care essential data set through removing some
unnecessary information. The vision of the South African DHIS is “to support the development of an
excellent and sustainable health information system that enables all health workers to use their own
information to improve coverage and quality of care within our communities.” An essential data set
is a set of the most important data elements, selected from all PHC vertical programmes that shall
be reported by health service providers routinely to generate indicators for monitoring the provision
of services in an integrated manner. Two key principles of the creation of an essential data set are:
(1) limiting indicators to between 100‐150 data elements for primary health care and hospital
services and enabling the calculation of 80‐120 indicators; (2) integrating the reporting requirements
of various programme managers so that their needs are included in a set of essential data elements
and indicators.
What prompted the need for an essential data set was the finding that in one rural district in the
province in Eastern Cape, the district information seemed inappropriate for the management of
essential health services. Data were submitted routinely (quarterly) to the national office from which
no feedback was received. Although data requirements were spelt out long back, no revisions to
accommodate the changing nature of health had been considered all along. Health workers removed
some data elements that were agreed to be unessential to the management of the health services
and were left out with 70 elements which were used to calculate 75 indicators essential for
monitoring quality service delivery. With the experience from one district other districts imitated
and later other provinces until. In June 2002 a national workshop adapted an essential data set for
the country’s district health information system. It is important to note that this process was a
bottom up approach that was successful through decentralisation of decision making powers in the
health care delivery system.
67
5. HAS HEALTH FINANCING BEEN IMPROVED?
Health Care Reform and the Crisis of HIV and AIDS in South Africa. Solomon R. Benatar. New
England Journal of Medicine 2004. 351;1
The author offers an analysis of health care reform and response to HIV in the first decade of self
rule in South Arica. The redistribution of resources saw a reduction of funds in tertiary hospitals and
an increase in primary health care clinics and other areas. He lists major challenges that face the
health care system as lack of human resources, finance and poor administration. Despite the
expansion of access to health care, within a district based system of primary health care,
nationalisation of health laboratory services, greater regulation of health care workers
compensation for occupation injuries, there still remain huge disparities in access to health care.
There was a shift from racial discrimination to discrimination based on class as most best health
services could be accessed by the economically advantaged in the private sector where most doctors
are serving. National budgeting has shifted more budgeting from wealthier (Western Cape and
Gauteng provinces) to poorer provinces (Eastern Cape and KwazuluNatal provinces) which led to
more suffering among the poor and uninsured citizens owing to the reduced budgets in these
wealthier provinces. Despite the increase in population by 8% in the Western Cape province
between 1995 and 2000, the reduction of the budget (from 14.3% of total national budget in 1995‐
1996 fiscal year to 12% in 2003‐2004) resulted in a reduction of 3601 beds (24.4%) and by 9282
health and support personnel (27.9%)in the public sector. In terms of health care in the hospitals
significant reductions in patient satisfaction and increasing bottlenecks in health care delivery were
recorded. For example, the waiting time for women who needed a breast cancer surgery increased
from 2 weeks to 8 weeks, full time staff at the Groot Schuur in Cape Town reduced from 43 in 1990
to 27 in 2003; in 2007 elective surgery was suspended for 6 months at Wits University’s major
academic hospitals in Gauteng.
The denial of the link between HIV and AIDS by the government (1994‐2004) is to blame for the
accelerating effects of AIDS on the population and the health system which also took time to
respond to the problem. Initial treatment was ineffective, PMTCT had been badly ineffective. The
author listed the current bottlenecks in scaling up HIV treatment as inadequate healthcare
infrastructure, resistance to adopting bottle‐feeding, potential adverse effects of ART in poor and
vulnerable population, fear of not meeting constitutional requirements for equity, and concern
about promoting drug resistance.
68
The Treatment Action Campaign’s civic engagement with the government and the Constitutional
Court’s judgement which called the government to roll out PMTCT and ART are commendable. It
shows the power of civil society in holding the government responsible for the health of the people.
The government is commendable for its recent budget of US$1.7b or ART for five years and between
US$2.4 and US$3bn is required by 2010. The fact that VCT is not accessible in 56% of health facilities
and condoms in 87% of health facilities shows that there is still a lot of work to be done in the health
systems. In order to strengthen health systems, there is need to inject more funds in the health
system which could only come from GHIs since other alternatives such as borrowing from the IMF;
reallocation of budget from other departments such as the military or increasing personal and
corporate tax seem impossible.
Negotiating the New Health Care System in Cape Town, South Africa: Five Case Studies of the
Acutely Chronically Ill. Diana Gibson. Medical Anthropology Quarterly, New Series, Vol. 15, No. 4,
Special Issue: The Contributions of Medical Anthropology to Anthropology and Beyond (Dec., 2001),
pp. 515‐532.
The author offers an anthropological analysis of five chronically ill patients residing in the Cape Flats
area who died due to health system bottlenecks in Western Cape province following the
restructuring and redistribution of financial budgets in post apartheid South Africa. The author
interviewed patients, their relatives who cared for them, and hospital workers (doctors, nurses,
laboratory technicians and hospital managers). The health systems in the independent South Africa
posed great problems to the chronically ill people due to problems in the health system such as the
red tape, queues, paper work, and lack of adequate health infrastructure. Four of the five patients
died while negotiating their way or waiting to access health care. The deaths were due to gaps in
structural, technical, financial and staff inadequacies. These deaths, which resulted from modifiable
health system bottlenecks, could have been avoided. The reduction of budgetary allocations to the
Western Cape through the medium term Expenditure framework (MTEF) which determined levels of
funding to provinces was also to blame for the suffering faced by people as they try to access health
care. Health care workers at the clinics were overwhelmed with work including treatment and
paperwork and they could not deliver the best health care to the patients as required. Due to a
69
stressed ambulance service in the hospitals, relatives had to resort to transporting their chronically
ill relatives by wheelbarrows or if they can afford, hire some private cars although some with no
options could only queue up and wait for the unpredictable ambulance. Budgetary cuts crippled
secondary hospitals and this led to problems accessing basic and other technologies such as ECGs.
Comparative health systems research in a context of HIV/AIDS: lessons from a multi‐country study
in South Africa, Tanzania and Zambia, Suraya Dawad and Nina Veenstra. Health Research Policy and
Systems 2007, 5:13
In this commentary, the authors analyse South Africa’s preparedness to implement global aid money
in addressing HIV and AIDS problem especially in Kwazulu natal with experiences in Zambia and
Tanzania. In the last decade, South Africa experienced an influx of HIV support which the health
systems was not prepared for which led to collisions between NGOs and the government. For
example, in KZN the Global Fund allocated some funds to the districts without the knowledge and
approval of the latter. This could be described as a clash between decentralisation and centralisation
of health care approaches to delivery. Doward and Venstra reported that district health managers
did not know which nongovernmental organisations were operating in their geographical spheres
and performing what activities in the HIV and AIDS programmes. This happened when South Africa
was still learning to manage donor support. Such confusion and chaos led to the introduction of the
National Health Act in 2003 which specified the functions an roles of the National Department of
Health’s provinces and districts in managing district health services. The authors report that their
action research assisted to improve relations between government and the NGOs in the country
such as the Treatment Action Group which was viewed with great suspicion and was marked as an
enemy of the government yet they were helping the government. Their comparative research did
this by explaining to the government that South Africa was not the only country that was facing the
problem as other southern African countries were having the same problem of beginning to work
with NGOs and strengthening their health system.
Castro‐ Leal et al 2000 Bull WHO 78 (1)
An analysis of public health spending on health care in Africa shows that resources meant for the
poor do not really benefit the poor but the rich community. The greater percentage of rich people
compared to the poor often define themselves as ill and receive treatment at primary health care
70
and district hospitals in Cote d’ Ivore, Ghana, Guinea, Madagascar, South Africa, Tanzania. Of all the
people who consult the traditional healers, most of them are the poor.
GOVERNANCE AND LEADERSHIP
The role of leadership in HRH development in challenging public health settings. Judith Schiffbauer,
Julie Barrett O'Brien, Barbara K Timmons and William N Kiarie. Human Resources for Health 2008,
6:23 doi:10.1186/1478‐4491‐6‐23.
The emergency workforce planning in South Africa to correct the out migration of HRH from South
Africa using the WHO HRH toolkit saw a reduction in migration of new graduates, 3800 of whom had
been deployed to rural areas. The community service managed to keep rural areas served by health
students before they can be registered by the medical professions councils (Medical and Dental
board of South Africa and the South African Nursing). At first the policy was unpopular. [ADD MORE
INFORMATION ON South African government role in AIDS issues]
OTHER DATA
Prevention of mother-to-child transmission of HIV in Africa: successes and challenges
in scaling-up a nevirapine-based program in Lusaka, Zambia. Elizabeth M. Stringer,
Moses Sinkala, Jeffrey S. A. Stringer, Elizabeth Mzyece, Ida Makuka, Robert L.
Goldenberg, Pascal Kwape, Martha Chilufya, and Sten H. Vermunda,. AIDS. 2003 June
13; 17(9): 1377–1382. doi:10.1097/01.aids.0000060395. 18106.80
This paper is a report on a nevirapine (NVP)-based perinatal HIV prevention program
initiated in Lusaka, Zambia in November 2001 with USD221000 (for supplies, salaries,
training, incidentals) although some supplies such as the HIV test rapid kits were donated
free of charge. The first 12 months of the programme saw 178 district health employees being
trained (midwives were trained for 10 weeks) in voluntary counselling and testing. A total of
17 263 pregnant women received group short talk (on pregnancy, HIV prevalence in women,
risk of transmission to baby) and counselling for HIV whilst 12 438 (72%) were tested, and
of these 2924 (24%) tested positive to HIV. A total of 1654 (57%) mothers and 1157 (40%)
babies enrolled for NVP. An estimated 190 infants have been spared of HIV infection in this 71
programme. Satellite centres were established for PMTCT programmes which refer patients
needing specialised services to the clinics. The project also benefitted from task shifting;
nurse midwives have been trained in rapid testing to assist the laboratory technicians in the
clinics when necessary. In the satellite antenatal clinics that do not have laboratories, the
nurse midwives were performing all of the rapid testing. The cost of administering the entire
program (excluding start up capital) is US$9.34 per patient counselled, US$12.96 per patient
tested, US$55.12 per seropositive woman identified, or US$848.26 per infection averted.
Strengthening Human Resources for Primary Health Care. Uta Lehmann. In: Barron P,
Roma-Reardon J, editors. South African Health Review 2008. Durban: Health Systems Trust;
2008. URL: http://www.hst.org.za/publications/841
A number of health legislation and policies took effect in the post apartheid era. The National
Health Act (Act 61 of 2003) redefined the training of health workers, who were traditionally
trained in tertiary hospitals, to include training in primary care facilities and communities.
The National Human Resources Plan which was finalised in 2006 repeats the need for a
strong focus on training and continuing the development of human resources in South Africa.
Other policy initiatives in the post apartheid era include a new Nursing Act (Act 33 of 2005),
which reviews the South African Nursing Council and gave birth to community service for
nurses. The period has also seen the development of new qualifications under the South
African Qualifications Authority, the introduction of community service which sought to
improve the provision of health services to all citizens and to provide an opportunity to
develop skills in young professionals. There has been the introduction of rural and scarce
skills allowances to attract and retain health workers in rural and underserved areas. The
National Community Health Worker Policy Framework (NCHWPF) was introduced to cater
for the availability of generalist CHWs who are attached to primary care facilities throughout
the country. An Occupation Specific Dispensation for nurses was introduced in March 2008
to provide for a new wage structure for nurses. The introduction of clinical associates has also
been agreed to, and the first 24 clinical associates are presently being trained at the Walter
Sisulu University, in Umtata. The author argues that despite a much better health worker:
patient ratio that South Africa enjoys relative to most African countries, the internal
72
disparities [public-private, urban rural and urban based provinces (such as Western Cape) -
rural provinces (such as Limpopo) differences] are still highly pronounced. There has been a
dramatic decrease in the national average ratio of professional nurse: patient from the 1990s
to the 2000s, that is from 251 to 110.4 per 100 000 population showing a decrease of over
50%. Most of the policies above are still in their early stages of implementation and therefore
it is too early to judge their impact on health care delivery.
Availability, equity and distribution of health personnel: Since 2001 there has been an
improvement in vacancy rates in the country although a third is still to be filled with some
provinces such as Mpumalanga having as high as 42.5% vacancy rates. The distribution of
community service doctors has improved the numbers and service delivery in the country
since its inception in 2006 until 2007. Due to the fact that the internship course was extended
for two years the figures dropped in 2008. Almost 2000 nurses are in community service
countrywide, mainly in Gauteng, Western Cape and Eastern Cape. A worrying fact in the
demographics of registered nurses in the service is that only 3% is under 30 years of age
while 40% will be expected to retire in the next 5 to 10 years. Both enrolled and auxiliary
nurses follow the same trend with registered nurses. In total nearly 70 000 nurses (more than
a third of the entire nursing population) will retire in the next 5-10 years.
Training and support: Primary health care in South Africa is almost entirely served by
nurses and most clinics are run by nurses with support from clerical and general and
community health workers. The country needs at least 3000-a-year production rate for nurses
to adequately cater for the health needs in south Africa at the current rate of brain drain,
retirement, death and disease. The doctors’ increase rate is slow and may fall short of the
projected 2400 per year in the National Human Resources Plan for Health Plan in 2014. In
1994 medical students were 1000 nationally and by 2005, they were only about 1400 (see
graph).
Appropriate skills for Primary Health Care: Graduates in community service:
community service doctors report that they work in isolation without seniors to guide them
and that their training in the tertiary hospital does not fully prepare them to work in rural
clinics.
73
Introduction of new cadres: South Africa has midlevel nurses (enrolled nurses and enrolled
nursing assistants) and pharmacy workers which have been used for many years in the health
field. Other than nursing, the first profession to introduce this level was pharmacy. Medical
middle level workers called clinical associates are being trained at Walter Sisulu University
although their positioning in the medical field still needs to be discussed. With regards to
community health workers, there have been contestations and they have remained at the
sidelines of the health care system as in many countries. Since the mid-1970s there have been
community health workers managed by NGOs working in water and sanitation related issues
and community development. With the growing need for human resources for health due to
HIV in the 2000s the Department of Health moved towards the introduction of the
community health workers but managers in provinces and districts are not regularising and
regulating their use leaving the NGOs to train and engage them for a stipend. They are
estimated at many tens of thousands. Their challenges include that some are not trained, do
not know if they are employed or volunteers and the system is insufficiently established and
integrated. “An evaluation of practices and regulation of the sector is clearly urgent given its
size and importance for community and primary care”p186.
The author finally recommends increasing the numbers of students in training hospitals and
colleges develop skills and reorient curricula towards meetings primary health care goals,
task shifting from doctors to nurses and from nurses to CHWs, accelerating and standardising
mid level workers and CHWs.
Tanner, M. Strengthening District Health Systems. Bull WHO 2005. 83 (6) 403-404
The author comments on the results from a demonstration project in Tanzania show some
successes in scaling up progress with GHI funding in a project named Tanzania Essential
Health Interventions Project. Two large districts in Tanzania in 1997 sought how to
efficiently use limited resources in view of the forthcoming policies on sector wide
approaches to decentralize district funding. In 5 years the project managed to improve the
mix and quality of primary health care services, increase coverage and use of services and
reduce infant mortality of under fives 40%. This was made successful by donor funds and use
of a tool kit with ten tools and strategies at various elements of the health system. Success
was also attributed to the decentralization of services to the district level by firstly
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strengthening their capacity in management and administrative skills; finances were also
managed at a district level. Services delivery was ensured by setting priority goals through
the use of a tool kit that integrated health informatics (sentinel household surveillance
systems) into health information systems. The project was a success also because there was
local ownership of the process and control of resources by the community. It was also learnt
that system gains are not quick fixes as there is need for longer periods for incremental
change.
Analysis of Human Resources for Health Policies and Planning. National Health
Insurance: Human Resources Requirements. Sanders D and Lloyd B.
In this paper, the authors argue that despite the development of good policy documents, the
Department of Health continues to support and sustain an overwhelmingly medical/clinical
model of health service delivery which primarily uses doctors and nurses. They note that the
health system has been hampered by the inadequate numbers of health workers, inequitable
distribution of health workers, both private and public, rural and urban and an increasing
burden of disease. Government will need to consider task shifting and see how it can be done
to respond to the country’s needs. It has to properly recognize the existing and new cadres of
health, to redefine the scope of practice for new and existing cadres. They should avoid
duplication of roles and should also consider revising the training curriculum of health
professionals (old and new) and to initiate an effective mechanism to ensure retention of
health professionals in the public sector. There is need for the government to urgently
consider how community health workers can be used more effectively to help in delivering
services at the community level.
Although it is known that health human resources in South Africa are inadequate and affected
by distribution imbalances, there is a dearth of information on human resources with respect
to distribution in the provinces such as rural urban although there is data on provincial totals.
It is also difficult to get information according to level of care and sector. There are wide
75
differences between the numbers of health professionals registered with the Health
Professions Council of South Africa and the numbers of professionals who are actually
practising in the country’s public sector. Of the 34687 medical practitioners registered with
the Health Professions Council of South Africa, only 10653 are working in the public sector.
In the Western Cape in particular, of the 7396 registered with the HPCSA, only 1418 are
practising in the public sector while out of the registered 1714 in Western Cape, only 609 are
working in the public sector. The difference is accounted for by the fact that many are
practicing abroad, in the private sector or are working in non clinical positions such as in
research and academic institutions.
The WHO suggested a minimum of 200 nurses per 100 000 people (Solidarity Research
Institute, May 2009). The WHO also suggests that countries with less than 230 health
providers (physicians, nurses, midwives) per 100 000 were likely to fail to meet the health
MDGs. Based on this statistic and the population of South Africa of 48,7m the country
should then have a total of 97400 nurses. The South Africa Health Review of 2008 estimated
that South Africa has a total of 178404 nurses (professional, enrolled and assistant nurses.)
thereby implying that South Africa is above the minimum stipulated by the WHO. The
country has 104 571 nurses working in the public sector (where 85% of the population access
health services) as shown in the personnel salary administrative system. However, this is an
overestimate because nurses are often registered but they are not employed and some will be
off sick considering the HIV prevalence of 15.7% in the health workforce. The greatest
problem is therefore maldistribution of health workforce across and within provinces, rural
and urban, sectors. Lehmann (2008) suggested that 40% of registered nurses will retire in
the next 5-10 years. The country has experienced a dramatic decrease in the number of nurses
since 1994. There was an average of 251 nurses per 100000 in 1994 and this went down to
110.4/100000 in 2007 (Lehmann 2008). In order to maintain the current level of health
workforce, South Africa needs to scale up the production of all categories of nurses.
District Management Study: A National Summary Report: a review of structures,
competencies and training interventions to strengthen district management in the
national health system of South Africa. Health Systems Trust. 2008
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The aim of the study is to undertake a national assessment of existing district management
structures, competencies and current training programmes in order to inform a national
strategy and plan to strengthen district management capacity to ensure effective delivery of
primary health care in South Africa. Information on managers and district management
structures within the South African health system is limited and this has prevented and
inhibited managerial workforce planning monitoring and development. Last formal national
evaluation of health management training was undertaken almost a decade ago and reported
in the 1998 South Africa Health Review. Key competencies required by district managers
were subsequently defined by the national department of health in 2002. Limited use of
competencies as a framework for developing training course content and with the
proliferation of courses to health managers there is concern about both quality and content of
many of the courses.
Human resources delegations: In the Eastern cape district managers can approve
appointments up to level 12. Centralized management of posts using consultants proved a
failure. In the Free state district managers can neither advertise posts nor appoint staff. In
Gauteng province, acting district managers were unable to approve appointments resulting in
administrative delays and sometimes loss of good applicants.
What impact do Global Health Initiatives have on human resources for antiretroviral
treatment roll-out? A qualitative policy analysis of implementation processes in
Zambia. Hanefield J. Musheke M. 2009. Human resources for Health 2009, 7:8.
Like many countries in southern Africa Zambia faces a huge burden of and has inadequate
human resources for health. It receives significant amounts of funding from the GHIs for
ART through both public and private sectors. Results of their study show that GHIs do not
provide additional resources for human resources. GHIs successfully retrain a large number
of health workers. Evidence suggests that they successfully deplete the pool of skilled human
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resources by recruiting them into their private sector programmes. Due to attrition there is
rapid turnover of staff, high staff absenteeism and unequal distribution of staff between rural
and urban areas. There is great need for laboratory technicians, followed by pharmacists,
doctors, nurses and data monitors.
Zambia has a remarkable success in scaling up access to ART in the public sector. The
Human Resources Strategy in 2005 introduced by the government sought to address the
shortfalls in human resources. At the time this research was conducted the only targeted
human resources programme that was receiving support was rural retention programme
which was funded by PEPFAR. It included an incentive to attract doctors into rural areas
including better housing, a car and a cash allowance. Zambia receives most of the GHI
funding from Global Fund, PEPFAR and MAP. In 2006, PEPFAR money alone made up
63% of all funding for HIV in Zambia. Much of the funding supporting public sector
programmes is channelled through NGOs or the private institutions and not directly to the
government, and this makes it difficult to map the flow of funding provided by individual
GHIs in the country. A recent study suggested that less than 5% of PEPFAR funds were
channelled through the government. Data on actual expenditure to recipients at the country
level is not easy to get since PEPFAR and the World Bank MAP do not publicly share this
information.
While GHIs do not provide direct financial support to human resources, they contribute to
human resources strengthening through training of health care workers and volunteers in all
aspects required to support the treatment programme. They also provide allowances such as
salary top ups or payment of expenses especially for volunteer counsellors or treatment
support to workers.
Impact of salary top ups: top ups are either overtime payment for shift work in the ART
clinic or transport costs for meetings for those working for PEPFAR funded health
programmes. These incentives go a long way motivating public health workers to work in the
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art clinic. An official in the ministry of health observed that malaria TB and HIV had taken
90% of time and most of the budgetary money to the extent that non communicable diseases
are being neglected. Provision of short term incentives such as top ups may also have
implications for sustainability, including quality of care in the longer term. Provision of top
ups may also have negative implications for sustainability in the long run. In one study it was
found out that only 7% of non-HIV staff had received top ups, this raising questions in the
disparities in payments in the health workforce.
Training and mentoring of health care worker for ART provision in Zambia: health
workers are attracted by the training and per diems to work in the ART programmes and this
adds to the potentially distorting effects of top ups. The courses which are usually intensive
take workers away from their clinical work and this causes further strain to the day to day
running of the ART program. Lack of staff adds to the already strained sector risking the burn
out and ultimately contributing to making programme efforts less sustainable.
Scaling up the stock of health workers: A review. Dussault G, Fronteirai, Prytherchh, Poz
MR, Dal, Dorothy Ngoma, Juliana Lunguzi, WyssK. 2009.
Scaling up refers to systematically expanding the coverage of priority health interventions as
a strategy to improve health outcomes. It may refer to scaling up resources needed to deliver
care or scaling up the performance of health services. The later improves equity of access,
effectiveness and efficiency of services, responsiveness of services and the protection offered
to users against the impoverishing effects of ill health. Scaling up resources needed means
strengthening health information systems, upgrading the number and competencies and
health workers, augmenting the number and competencies of health workers. Augmenting the
number of providers amounts to scaling up the stock of HRH which can be accomplished by
improving retention, integrating unemployed and retired personnel, recruiting from other
countries and creating a mix of cadres. Sub-Saharan Africa with 11% of the world’s
population and 24% of global health burden of disease has only 3% of the world‘s human
resources commanding less than 1% of world’s expenditure (WHO 2006). With the
increasing availability of ART due to drug price drop, human resources shortages began to be
79
increasingly felt much more than before. Strategies to increase the shortage of health
workforce include producing increased numbers, improving retention rates, harnessing
unemployed, inactive or retired health workers and importing health workers.
Augmenting production of new worker: increasing high classes is one method as was done
in Tanzania, Swaziland and the Philippines, This can be done by ensuring that the private
sector is optimally harnessed for the training of health workers through providing subsidies
for existing institutions or through creating incentives for opening new ones, creating
networks of distance learning, intensifying and shortening learning, facilitating the
registration process with professional bodies after qualifying to avoid delays. However,
scaling up production in schools requires additional capacity in form of infrastructure,
learning materials and qualified trainers more workers. It does not also necessarily address
issues of skills mix, geographical imbalances, retention or poor performance. Many countries
fail to enforce bonding schemes. Thailand successfully runs a bonding programme in which
two thirds of graduates continue rural placements after compulsory training.
Incentives: nonfinancial incentives such as involving health staff in decision making and
management processes can be beneficial as far as incentivising workers is concerned. In
Swaziland, salaries which were increased by 60% helped to retain some nurses and
physicians in the public sector and also helped to attract some more staff.
Importing health workers is not common in developing countries. Swaziland however used
GHI funds to employ nurses from other African countries. In Malawi agencies such as the
German organization CIM recruit volunteer medical specialists and nurse tutors to fill critical
gaps until more Malawians are trained. This strategy has problems such as communication
difficulties and retention problems. Scaling up health workforce needs to be closely aligned
with support for pension of other key resources. In Swaziland, challenging working
conditions such as excessive workloads, lack of drugs, essential material and equipment, poor
80
infrastructure were main sources of dissatisfaction among health staff ahead of salary and
remuneration concerns.
Extension and role of nurses or midwives to tasks traditionally performed only by
physicians: In Ghana and Zambia trained nurses provide anaesthesia for surgical operations.
A life saving skills training project trained midwives in rural areas to carry out delivery
related tasks that were previously done by physicians.
Direct substitution of an existing profession by a new cadre is another dimension:
cadres undertaking general medical care which range from diagnosing to advanced surgical
procedures like caesarean sections. In Mozambique surgical technicians were introduced in
1984 during the war when many surgical specialists emigrated from the country. Intra
medical skills delegation whereby some tasks traditionally performed by specialists are
delegated to general practitioners as happened in West Africa postgraduate medical college.
An Overview of Health and Health care in South Africa 1994 – 2010: Priorities,
Progress and Prospects for New Gains. A Discussion Document Commissioned by the
Henry J. Kaiser Family Foundation to Help Inform the National Health Leaders’ Retreat
Muldersdrift, January 24‐26 2010. David Harrison December 2009.
(See framework of analysis diagrams)
The paper gives a summary of the South African health care system, its accomplishments and
shortcomings from 1994 to 2009. The health care system’s successes were recognized as both
in health policies and health delivery as follows:
Legislation and gazetted policies
1. Free primary health care, 1994, 2006
2. Essential drugs programme, 1996, 1998, 2003…and further updates
3. Choice on termination of pregnancy, 1996
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4. Anti‐tobacco legislation, 1993, 1999
5. Community service for graduating health professionals
Better health systems management
6. Greater parity in district expenditure
7. Clinic expansion and improvement
8. Hospital revitalization programme
9. Improved immunization programme
10. Improved malaria control
The author listed ten challenges and shortcomings as relating to insufficient control and
prevention of epidemics, which include limited effort to curtail HIV/AIDS, emergence of
MDR‐TB and XDR‐TB, lack of attention to the epidemic of alcohol abuse. Secondly, the
persistently skewed allocation of resources between public & private sectors which
include, inequitable spending patterns compared to health needs and insufficient health
professionals in the public sector. Lastly, the country has Weaknesses in health systems
management which include: poor quality of care in key programmes; operational
ineffectiveness; insufficient delegation of authorities; persistently low health worker morale;
insufficient leadership and innovation.
The paper notes that the establishment of the district based system was a huge milestone in
the post 1994 health care delivery in that it ensured resource distribution more equitably
while responding to local health problems. In retrospect, its success has been constrained by
the inability to decentralize authority fully, and by the erosion of efficiencies through lack of
leadership and low staff morale. “Retooling district health management to improve local
service delivery would seem to be an example of a ‘breakthrough strategy’ that could be
fairly easily accomplished”p2. As a way of reducing mortality in South Africa there is need
to introduce a heavily equipped high impact prevention programme at a macro scale. The
incidence can be halved within five years if the existing programmes are fully scaled up.
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However, the management of HIV and AIDS programmes should not be done at the expense
of the other chronic problems such as TB and alcohol abuse.
The primary health care was made free to pregnant women and under 6 children on 24 May
1994 and free of access to health in public health facilities was later declared to all users on
April 1 2006. It is estimated that a 10% real increase in the price of cigarettes in South Africa
resulted in a drop in demand of 6‐8% (Peer et al 2009). The introduction of a one year
community service for newly graduating health workers has improved the availability of
health staff in the public sector.
Regarding the shortcomings, HIV mortality will continue soaring in the country. Even with
ART the number of deaths from AIDS will continue to exceed 300 000 per year for the next
5-10 years because ARVs help to prolong life for a period of time. It was observed from a
cost effectiveness study in Khayelitsha that ART may be considered cost effective if South
Africa is prepared to pay R10 400 for each life years gained (Cleary et al 2006). Given that
the Commission of Macroeconomics and Health proposed that health is very cost effective if
it costs less than per capita GDP and South Africa’s GDP is R47000, therefore it can be cost
effective to implement ART in South Africa.
...............................
McPake notes that South Africa has about 5.3 health workers (doctors, nurses and midwives) per
1000 population and have an HIV burden of about 18%. The country needs about 0.4% of human
resources for health requirements for full population coverage with ART according to Smith (2005).
A Lancet editorial (2004; 364) noted that the 10/90 gap reminds us of the research infrastructure
that are needed for capacity building and strengthening which are an investigator and an institution
that has appropriate facilities that support research work; and good policies which facilitate
research and implementation of research results and recommendations. To achieve more with
limited or current resources, greater political will is needed. The editorial comments that this lack of
political will and leadership was witnessed in South Africa in the first decade of SA’s independence, a
time when HIV and AIDS were claiming huge numbers of people due to lack of treatment for those
83
infected. The government discredited the work of the Medical Research Council on the impact of HIV
and AIDS on adult mortality.
Another Lancet Editorial (364; 2004 1555‐56) noted that in order to meet the health MDGs the role
of the health systems strengthening is critical as also noted in the Mexico Ministerial Statement. The
HSS is still inadequately recognised.
Ndinda 2002) remarked that South Africa should be praised for being able to strengthen the capacity
of the historically disadvantaged universities through the activities of the MRC.
Coovadia and Hadingham (2005) argue that KZN province had about 150000 deliveries per year and
PMTCT increased from 10% in 2001 to 78% in 2003‐2004 due to the expansion of IEC, more rapid
testing methods, enhanced record keeping, and drug technological advances. (Read the KZN Dpt of
Health 2004 for the PMTCT uptake at maternity hospitals June 2001‐2004.)
Whysonge and Volmink remark that the 10/90 gap means that less than 10% of world resources
spent on health research are devoted to the less developed countries which shoulder 90% of global
disease burden.
Barnighausen and Bloom 2009
After a period of 10 years, doctors of rural origin were more likely to practice in rural areas.
Goudge et al 2009
Barriers to accessing chronic care inability to pay for costs, limited availability of inputs and
services for chronic care, weaknesses in diagnosing and prescribing at clinics, interrupted drug
supplies, inadequate ambulances/poor patient provider relationship, weak referral system.
LITERATURE TO CONSULT
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Grimwade K, Sturm W, Nunn AJ, Mbatha D, Zungu D, Gilks CF. Effectiveness of cotrimoxazole on
mortality in adults with tuberculosis in rural South Africa. AIDS 2005; 19: 163–68.
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