Contributions June 2017

Newsletter June 2017 contributions

Why are health systems prone to corruption? Some reflections on current realities

The Global Corruption Report 2006 from Transparency International has a special focus on Health and Corruption.  In the chapter "Why are health systems prone to corruption?" written by William Savedoff and Karen Hussmann, the authors believe that the health sector is at especially great risk of corruption due to uncertainty, asymmetry of information, and a large number of dispersed public and private actors. These factors make it difficult for transparency and accountability initiatives to work. More than a decade later, this statement is still very much valid. The health system in developing countries is prone to corruption because it is often very much fragmented (public, private and informal sector) making control and oversight very much difficult, in particular for the informal health service delivery. Besides there are more and more actors and stakeholders engaged in the health sector (bilateral and multilateral agencies, international and national non governmental organizations and foundations, global initiatives, private institutions or organizations etc.), all of them are not always very well aligned and coordinated, causing a greater risk of corruption, through duplication, inefficiency, overstretch of and competition for already limited local resources in particular HR and skills. Moreover the growing number of actors in the health sector complicates accountability relationships, collaboration, and information sharing. Finally uncertainty can create incentives to over-supply services and asymmetry of information provides opportunities for biased decisions based on financial rather than public interest. These points, among others help to understand why risks arise from the perspective of market failures.

However since the publication of this Global Corruption Report in 2006, some positive changes in global policy priorities, the donor landscape, and the health systems governance have taken place, aiming in the long run to reduce risks of corruption. Following are presented a couple of changes.

First the most striking and recent shift is the adoption of the Sustainable Development Goals in 2015, which instilled a new paradigm characterized by more universality, multisectoriality, equity, sustainability and inclusiveness. The focus on sustainability can be translated into increased domestic funding, thus increasing ownership of national governments. We would expect that a bigger public financial share to the health sector budget would help reduce embezzlement, particularly in context where governmental income capacity is limited and any additional budget fiercely disputed between the different sectors and ministries. Parliament and other ministries, and civil society (to some extent) would have a greater authority for control and watchdog than when foreign money flows in parallel systems or directly to a specific sector or program. Moreover we tend to be more meticulous with our own money than with that of others, especially when we do not have much. The focus on inclusiveness means among others, better integration and participation of civil societies in the development strategy, decision-making and implementation. By empowering civil society organizations (CSOs), communities, youth, minorities and consumers in general, people will better lobby for their rights and make public health authorities accountable to them for their duties and responsibilities.  This can be achieved through capacity building, access to knowledge and information (internet) and better coordination and organization among CSOs and communities. Moreover the budget allocation within the health sector is made according to the needs of the population and not according to individual, political or financial interests, thus reducing misuse of resources and improving efficiency. Therefore the Sustainable Development Goals and other global governance initiatives can help to pressure governments to adopt transparency and accountability reforms and possibly provide models to share between countries.

Second a change in the donors' financing modalities has also occurred in the past years. Donors have moved from Paris and Agra declarations to Busan partnership for effective development that highlights national ownership and mutual accountability even more. However national ownership is often seen as a risk for corruption in the eyes of the donors. The donor loses control over their funds while the recipient government is suddenly accountable for the funds originating from taxpayers of any individual donor. This creates a complicated situation, especially for un-earmarked budget support, which becomes difficult to defend to the public. Thus donors often tend to pool funds (e.g. basket funds) in order to secure adequate resource allocation for agreed upon activities or programs. These mechanisms of pooling resources should enhance transparency in how, when, where and to whom the funds are disbursed. Additionally a shift of disbursement modalities towards a more results- or performance-based financing approach can create positive incentives for recipients to better perform and reduce risks of corruption. However more analysis of experiences are necessary to fully grasp the potential (positive as well as perverse) of such mechanisms.

There are many more other levers and mechanisms to control corruption like the need to understand well country-level institutional relationships as entry points for any reform. Indeed health markets continue to become ever more complex in terms of different payers, providers, and potential technologies, medicines, and types of treatment. And finally thanks to the constant growth in information technology, risks can be mitigated by remedying to the market failures caused by asymmetric information and the large number of players, but which also might bring new opportunities for abuse of power, or not help the poorest of the poor.

Contact: Viviane.Hasselmann@eda.admin.ch

Global Fund 37th Board Meeting


 


 


 

The 37th Global Fund Board meeting took place in Kigali, Rwanda from May 3rd to 4th 2017. This was the first board meeting under the 2017-2022 Strategic period and since countries were informed of their allocations for 2017-2019. This was also the last board meeting for Executive Director Mark Dybul, after a four year term. The Board approved the new Board Leadership candidates that had been elected separately by the Donor Group (for the Vice-Chair: US representative) and the Implementer Group (for the Chair: NGO representative from Bosnia & Herzegovina). The Board also approved of the revised process for selection of the next Executive Director and appointment of members of the Executive Director Nominations Committee, thus relaunching the search for Dybul's successor. Last year many elements of sustainability, transition and strengthening systems for health were successfully integrated into the strategic documents of the GF. With up to 70% of countries submitting grant applications in 2017, the way those elements are considered in the country consultations and integrated in grant proposals will determine the potential to achieve these strategic objectives. It will remain high on the agenda of the Swiss delegation, together with the strategic discussions to strengthen Country coordinating mechanisms.

Contact: Carla.Koch@eda.admin.ch

World Health Organisation 70th World Health Assembly

The 70th World Health Assembly took place in Geneva from 22nd to 31st of May 2017. It was the last for Director General (DG) Margaret Chan after her ten year tenure. Member States of WHO elected Dr Tedros Adhanom Ghebreyesus as the new Director-General of WHO, he will begin his five-year term on 1st of July 2017. Among the resolutions adopted this year, one welcomed the strategic approach proposed in the Global Vector Control Response (GVCR) 2017-2030. Also, after months-long debate on the health of refugees and migrants, Member States asked the DG to gather evidence and present a draft global action to the 72nd World Health Assembly in 2019. Finally, the programme budget for 2018-2019 for the amount of USD 4,421 billion was approved and, for the first time in 10 years, Member States agreed to increase the amount of assessed contributions by 3%.

Contact: 

Carla.Koch@eda.admin.ch

News from HPSS: Antimicrobial Resistance in Tanzania

Antimicrobial drug resistance (AMR) is a rapidly rising global threat. Every year over 700’000 people die due to AMR. The Health Promotion and System Strengthening project (HPSS) financed by the Swiss Agency for Development and Cooperation (SDC) together with the World Health Organisation (WHO) under the guidance of the Ministry of Health (MOHCDGEC) organized a 2-day symposium on AMR in Dar es Salaam. During panel sessions, data on AMR in Tanzania was presented, shared and vividly discussed. Working groups agreed on the way forward. The event raised awareness on AMR and facilitated translation of evidence into policy and action. As a highlight, the Tanzanian government launched the National Action Plan on AMR. The symposium was initiated following operational research by HPSS. Among many findings requiring attention, the most critical is the high use of antibiotics (66%). One study investigated knowledge, attitudes and practices in regard to antibiotic use including prescriber and dispenser of antibiotics and clients having received antibiotics. It found low awareness among providers and clients, frequent purchase of antibiotics without medical consultation and high use for animal growth. The irresponsible use of  antibiotics contributes to antimicrobial resistance in the country.

The objectives of the symposium were to provide a forum for addressing the challenges of global antimicrobial resistance (AMR), to understand the situation in Tanzania and its impact on health care and to present relevant research findings. Findings and gaps in evidence on AMR in the medical, veterinary, agricultural and environmental sector were presented. Participants discussed priorities and strategies that could be taken aboard in tackling AMR in Tanzania and identified important actors who would be trusted to implement feasible interventions in the ambit of the National Action Plan (NAP). Working groups made a number of recommendations which were grouped into five thematic areas: awareness and education, surveillance, infection prevention and control (IPC), stewardship, and governance.

The outcome of the symposium is a common and active platform of stakeholders concerned with AMR. Ongoing and planned activities will be streamlined and compliant with the NAP. The plan underscores the need for an effective “One Health” approach involving coordination among numerous sectors and actors.

Contact: Karin.Wiedenmayer@unibas.ch or Jacqueline.Matoro@eda.admin.ch

 


 

 

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AMR news by SwissTPH


 


 


 


 

More information on HPSS

Action research: Reducing stunting in Rwanda


 

With SDC’s decision, taken in March 2017, to phase out of the health sector in Rwanda by the end of 2018, the premises are given to envisage a phase of capitalisation of the lessons learned from SDC interventions in health, water and sanitation as well as hygiene. The phasing out is an opportunity for SDC to bank on its comparative advantages and current Rwandan priorities. SDC Great Lakes is planning an action research on application of horizontal learning in the districts where it previously intervened. The Action Research will be implemented from October 1st 2017 to March 31st 2019. Once the Horizontal Learning reaches most or all the Community health workers present in the three districts, close to 5’000 frontline workers will coach a process that enables parents to independently replicate practices to combat chronic undernutrition at the local level. The implications of the phasing out strategy/Action Research are:

 

  • Child stunting to be addressed and made visible, the proposed Action Research must be able to build on height for age measurements that complement the current weight for age compilations.
  • “Behavioural change”, the parents become the principal researchers and the CHWs the research assistants.
  • Prevention of stunting, the proposed approach is to identify good practices, to jointly appreciate them in terms of their stunting prevention potential, and then to replicate them with other parents.

 


While the Rwandan health sector evolved rapidly over the last decade, this has not been associated with a comparable improvement in undernutrition rates in Children. The average stunting rate across the country is of 38% for all children under five and exceeds 50% for children aged between 20-30 months.  Within SDC focus Districts of Nyamasheke, Karongi and Rutsiro in the Western Province of Rwanda, some of the sectors hold the highest average rates of stunting in the country: more than 50% of children are chronically undernourished.

Properly documented and disseminated, the results of the Action Research will be a main ingredient of a comprehensive strategy for the prevention of chronic undernutrition.

Contact: Theoneste.Twahirwa@eda.admin.ch or Schaltegger@innovabridge.org

The Safeguard Young People Programme (SYP) in the Southern Africa Region

SDC’s Regional Programme for Southern Africa (RPSA) co-finances since 2013 with UNFPA a programme called "Safeguard Young People Programme" (SYP). This programme has been renewed for a second phase this year. While sexual and reproductive health is fundamental to every person’s life, in particular for adolescents, it is still too often ignored. SYP commissioned a study to review laws, policies and related frameworks for Sexual Reproductive Health and Rights (SRHR) in 23 countries in East and Southern Africa (ESA) across nine areas which were found to create either impediments to or an enabling environment for adolescent SRHR:

1. Age of consent to sexual activity
2. Age of consent to marriage
3. Age of consent to health services
4. Criminalization of consensual sexual acts among adolescents
5. Criminalization of HIV transmission
6. Sexual and reproductive health services for young people further left behind
7. Cultural, religious and traditional practices that are harmful
8. Pregnant learner retention and re-entry law and policy
9. Provision of comprehensive sexuality education

The study resulted in the development of a harmonized regional legal framework which translates international and regional legal provisions into useful strategies to be adopted by countries. Drawing from regional and international instruments, the study provided a mirror with which States can individually and collectively assess how they are measuring up to their commitments.

The impact at the regional level was already evident in the formulation of a SADC Model Law on “Eradicating Child Marriage and Protecting Children Already in Marriage”. The regional Model Law trickled down to national level, adapted to national realities by countries like Zimbabwe, Zambia and Malawi. These countries aligned relevant laws and their constitutions to the provisions of the Model Law. At local level the enactment and realignment of laws informed campaigns against child marriage and continues to raise awareness. For example, in Malawi, Chief Kachindamoto is reported to have broken up 850 child marriages and banned sexual initiations of girls which can be attributed to this new awareness.


 

Much work still remains to be done as the study showed that despite promising gains in sexual and reproductive health, there are still disparities that persist across many countries, further highlighting that many young people continue to be left behind. The programme will strive to ensure that young people can count on a supportive legal and policy environment to ensure their right to sexual and reproductive health.  UNFPA ESARO Laws and Policy Review on ASRHR - 2017

Contact: Lawrence.Lewis@eda.admin.ch


 


 


 


 


 

 


 


 


 


 


 


 


 


 


 


 

​Emergency management training for health center staff in Albania

The management of emergencies is an integral part of primary healthcare. Being the first contact, especially those working in health centers operating 24/7, primary healthcare staff may encounter any type of emergency; from heart attacks and diabetes comma, to injuries due to car accidents or incidents at the workplace, to allergic reactions to medicine, plants or animal bites. Updated knowledge, communication and procedural skills, and appropriate organization skills are vital when it comes to saving patients’ lives. Unfortunately, the wide range of problems, lack of equipment and respective continuous training, make it difficult for primary healthcare staff in Albania to be updated and competent in providing proper prehospital emergency care. With this in mind, HAP is implementing a training plan and supplying with basic equipment for the staff of emergency units of five 24/7 health centers in Dibër (Klos and Maqellarë) and Fier (Cakran, Roskovec and Patos HC) qarks. The training will be on patient assessment, airway management, cardiac emergencies, trauma life support and medical emergencies. These topics and the list of equipment reflect the findings of a peer needs assessment conducted in year 2016. Seventy-five family doctors and nurses, divided into five groups, participated in the first training session, which took place in April-May 2017 and focused on patient assessment. These three-day training sessions addressed issues related to the personal safety, assessment of the scene of incident; assessment of the patient, anamneses in pre-hospital conditions; management of emergency cases, and procedures for transporting and referring the patient to the hospital care. An important part of the training was the hands-on practice sections that followed all the theory sections.

The participants expressed their appreciation for the training, its program and the way it was delivered. "This training was thorough and informative," said Dr Migena Brahimaj, family doctor at Patos Health center. "I am very thankful of HAP for offering us this opportunity, which is a great help in improving our skills and serving better to our communities.” At the end of the training, the participants received a certificate and 16 credits from Albania’s National Center for Continuing Education (NCCE).


Contact: Ina.Xhani@hap.org.al or Sokol.Haxhiu@eda.admin.ch


Conflict sensitive programme management (CSPM) in Tajikistan

SDC chose the Medical Education Project in Tajikistan that is implemented by Swiss TPH to take part in a CSPM visit and workshop 1-3 May 2017 to assess potential conflict issues in Primary Health Care in a pilot district (Vatosh and Tursunzade). Aspects such as tension between family doctors and narrow specialists and perceived insufficient support of family doctors by Primary Health Care (PHC) managers, were then analysed and proposals for action made. Conclusions reached were: (a) There may be a lack of deep understanding about Family Medicine in both managers and specialists. Therefore the project coordinator will hold meetings with the PHC managers and narrow specialists, to allow any misunderstandings to be aired and fears to be expressed. (b) The coordinator will review with the PHC manager their responsibilities for the project and more widely for upholding Family Medicine. (c) It was agreed the Association of Family Medicine may have a role in interceding on behalf of family doctors locally. (d) Greater education of local population remains needed, using local media, leaflets, and involving health workers themselves to explain what Family Medicine can do.

The SDC team was led by Ms Laurence Strubin (CSPM Workshop lead), Nathalie Barbancho, Dr. Mouzamma Djamalova, Shodiboy Djabborov (for Transversal theme), and MEP team by Dr. Greta Ross and Shakhlo Yarbaeva.

Contact: Mouazamma.Djamalova@eda.admin.ch or Greta.Ross@swisstph.org

​Implementation of joint human and animal health campaigns for mobile pastoralists in Danamadji district of Southern Chad

The Support Project for the Health Districts in Chad - Yao and Danamadji (PADS) is implemented by the consortium Swiss TPH - CSSI (Centre de Support en Santé Internationale) and funded by the Swiss Agency for Development and Cooperation. Its first phase will last four years and started in Nov. 2014.
The project combines operational research, workshops, capacity building, investment and financing activities.

To contribute to the outcome on improved maternal and child health, the project started the implementation of joint human and animal health campaigns for mobile pastoralists in Danamadji of Southern Chad. These campaigns involve both animal and human health services. This activity was conducted with the Ministry of Health (that hosts the National Programme on health for nomads) and recommends to foster the provision of vaccination, antenatal examinations, nutrition, and health information among nomadic populations.

Three vaccinations were conducted between November 2016 and April 2017, whereby the first and third round was together with the veterinarians. In the first round 18’923 cattle were vaccinated against pasteurellosis (numbers of the third round are not yet available), a total of 2’337 nomadic women was vaccinated against tetanus (including 401 pregnant women who also received an antenatal examination) and 6’511 children were vaccinated and have received in addition anti-parasitic mebendazole and a dose of vitamin A. More than 700 impregnated mosquito bed nets were given to nomadic families. Loss to follow-up from first to second anti-tetanic vaccination of women was around 40% and for children of 45% from 1st to 3rd vaccination, which is comparable to similar outreach campaigns. All this was possible because of a successful communication campaign including the use of the pictures like the on explaining that only three vaccinations fully protect the child and the family (see Figure below: Communication tool to explain the 3 steps of vaccination to nomadic population: from left to right: starting construction of house for family, building protection, complete protection).


 


 

Joint campaigns allow improving access to health services for nomadic populations because the health personnel can reach out to the communities and demonstrate their services. In the long run, nomads should increasingly use the existing health services given that they have received more information, but also the health services will better include the mobile populations in their planning. 

In the Central Chadian Yao district similar integrated campaigns will start in May 2017 for communities who have hardly ever had access to health services.

Contact: Olivier.Koullo-Ndena@eda.admin.ch


 

Swissmedic Marketing Authorisation Procedure for Global Health Products information event

In the context of strengthening regulatory systems for medical products in low and middle-income countries, SDC and Swissmedic, the Swiss Agency for Therapeutic Products, organised an event in Geneva. The meeting focused on the the Swissmedic Marketing Authorisation Procedure for Global Health Products.
The procedure is closely linked to the African Medicines Regulatory Harmonisation initiative (AMRH) which is also supported by SDC and Swissmedic. While SDC and Swissmedic provide financial support and technical expertise to the AMRH, the Swissmedic marketing authorisation procedure offers National Medicines Regulatory Authorities and the WHO a unique possibility to participate in the Swissmedic evaluation of submitted medicinal products for diseases that disproportionately affect low- and middle-income countries. The expectation is to accelerate subsequent WHO pre-qualification listing and national evaluation and registration of the same products.

Contact

: Alexander.Schulze@eda.admin.ch