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IntroductionAddressing attitudes is central to achieving sexual and reproductive health and rights (SRHR) as per the 2030 Agenda. We aimed to develop a comprehensive index to measure individual’s support for SRHR, expanding opportunities for global trend analyses and tailored interventions. MethodsWe used nationally representative data on attitudes towards different dimensions of SRHR, collected via a new module integrated into the World Values Survey in Ethiopia, Kenya, and Zimbabwe during 2020–2021 (N=3,711). Exploratory factor analysis of 58 items was used to identify sub-scales, combined into an overall index. Adjusted regression models were used to evaluate the index according to sociodemographic characteristics, stratified by country and sex.ResultsA 23-item, five-factor solution was identified and used to construct sub-indices reflecting support for: (1) sexual and reproductive rights, (2) neighborhood sexual safety, (3) gender-equitable relationships, (4) masculinity norms, and (5) SRHR interventions. These five sub-indices performed well across countries and socioeconomic subgroups and were combined into a comprehensive “SRHR Support Index”, standardized on a 1–100 scale (mean=39.19, SD=15.27, Cronbach’s alpha=0.80) with higher values indicating more support for SRHR. Mean values were highest in Kenya (45.48, SD=16.78) followed by Ethiopia (40.2, SD=13.63) and lowest in Zimbabwe (32.65, SD=13.77), with no differences by sex. Higher education and being single were associated with more support, except in Ethiopia. Younger age and urbanicity were also associated with more support among males only.ConclusionThe SRHR Support Index has potential to broaden SRHR attitude research from a comprehensive perspective – addressing the need for a common measure to track progress over time in contexts where such data are limited, including sub-Saharan Africa.While the index performed well, further validation is needed to assess its applicability in different settings and populations.

Background In 2019, Zambia introduced the national health insurance (NHI) as a healthcare financing strategy to increase universal access to health care services. The private health sector can complement public sector providers as service providers under the NHI. As such, the NHI Management Authority seeks to accredit for-profit private healthcare facilities in the NHI. Ascertaining factors that influence private-for-profit health providers to participate in the NHI is essential, but the evidence is lacking. In this study, we aimed to explore and characterize perceptions and experiences of for-profit private hospitals, dental clinics, eye clinics, diagnostic centres, and pharmacies regarding their inclusion in the NHI. Methods We conducted in-depth interviews with owners or management officers of purposively sampled private health care providers in Lusaka, Zambia (n = 22) between May and June 2020. Qualitative content analysis was used to analyse data. Results The findings highlight low awareness of the NHI among providers and a need to understand the NHI. Providers revealed their positions and views on the accreditation process and payment arrangements and stated that their participation would complement the NHI. They also cited conditions to participate in the NHI, highlighted opportunities and challenges of engaging in the NHI, and expressed a need for sustainable ways of governing the scheme. Conclusion The assessment of health providers’ inclusion in the NHI scheme is multifaceted. The results of this study surfaced factors such as raising awareness on the NHI among providers and how their concerns on aspects such as payments can be considered as inputs to enlighten consensual agreements between the NHI authority and health providers in leveraging the private health sector. Private providers’ concerns must be further understood and considered as the NHI strives to include this group as health care providers in the scheme.

The present Article and previous publications from the Global Burden of Disease Health Financing Collaborator Network clearly indicate the diminishing importance of development assistance for health (DAH) for financing services at the country level, even for disease areas commonly perceived as highly dependent on DAH 1,3,4 The projections to 2030 indicate that DAH will continue to be important in some low-income countries at the end of the SDG period, but this finding is more a consequence of the lack of growth in domestic spending than an effect of increasing DAH Vlad Sokhin/Panos Pictures In the present Article, the authors also present funding estimates for specifically relevant areas for SDG3—ie, HIV/AIDS, tuberculosis, malaria, and universal health coverage 1 Although these estimates might be useful for a global dialogue around how SDGs are prioritised in DAH, the approach is less relevant for increased understanding of, and improved decision making in, the health sector of countries included in the study [ ]the Article does not take a health systems approach to the data

Objectives To explore availability, prices and affordability of essential medicines for diabetes and hypertension treatment in private pharmacies in three provinces of Zambia. Methods A cross-sectional survey was conducted in 99 pharmacies across three Zambian provinces. Methods were based on a standardized methodology by the World Health Organization and Health Action International. Availability was analysed as mean availability per pharmacy and individual medicine. Median prices were compared to international reference prices and differences in price between medicine forms (original brand or generic product) were computed. Affordability was assessed as number of days’ salaries required to purchase a standard treatment course using the absolute poverty line and mean per capita provincial household income as standard. An analysis identifying medicines considered both available and affordable was conducted. Results Two antidiabetics and nine antihypertensives had high-level availability (≥80%) in all provinces; availability levels for the remaining surveyed antidiabetics and antihypertensives were largely found below 50%. Availability further varied markedly across medicines and medicine forms. Prices for most medicines were higher than international reference prices and great price variations were found between pharmacies, medicines and medicine forms. Compared to original brand products, purchase of generics was associated with price savings for patients between 21.54% and 96.47%. No medicine was affordable against the absolute poverty line and only between four and eleven using mean per capita provincial incomes. Seven generics in Copperbelt/Lusaka and two in Central province were highly available and affordable. Conclusions The study showed that the majority of surveyed antidiabetic and antihypertensive medicines was inadequately available (

Globalising dynamics have had wide-ranging and pervasive impacts on nearly every form of human relatedness, which now include the bases upon which states calculate and express their political responsibilities. As the ‘reach’ of practical and normative pressures extends and their demands intensify, the compass of state responsibility is becoming a key pressure point for facing the challenges and mediating the tensions of our globalised and still globalising world. This theme is examined from a global health perspective. The general disposition of states toward their acknowledged political responsibilities is unlikely to change, but the combination of legal, normative, political and practical dynamics impinging on them have already begun to register, as both states and the international system adjust to a politics that now have global dimensions.

In the long history of global health efforts, universal health coverage (UHC) holds the promise of reframing the global health agenda by encompassing both the goal of “Health for All” as well as th...

The international development community is transitioning from the era of the Millennium Development Goals (MDGs), ending in 2015, to the era of the Sustainable Development Goals (SDGs), which have a 2030 target. Global development assistance for health (DAH) increased substantially in the MDGs era, from US $10.8 billion in 2001 to $28.1 billion by 2012 (in 2010 US dollars), and it played a crucial role in tackling global challenges such as HIV/AIDS and malaria. In this paper, we describe the likely health challenges of the SDGs era and the types of international assistance that will be required to help tackle these challenges. We propose a new way of classifying DAH based on considering the functions that it will need to serve in order to address these post-2015 challenges. We apply this new classification to the current health aid spending of one donor, Sweden, as a case study. Based on our findings, we suggest ways in which Sweden's DAH could be reoriented towards meeting the health challenges of the next two decades. (Less)

Development assistance for health (DAH) remains a significant and important source of health financing in many low and lower middle-income countries. However, this assistance has not been fully effective. This study explores the effect of currency exchange rate fluctuations on volatility of DAH in Zambia using a mixed methods approach. Data covering the period 1997-2008 were collected from various financial and programmatic reports, while six key informant interviews were conducted to validate and translate findings from the quantitative analysis. Results show fluctuations in the volume of funds disbursed to the Ministry of Health by donors due to changes in the exchange rates between non-US$ currencies and the US$, ranging from -11.1% to +13.4% during the period 1997-2008. The overall effect was a loss of US$ 13.4 million over the period 1997-2008 which is equivalent to an annual average loss of US$ 1.1 million per annum. There were also fluctuations in the US$ amount that was converted to the Zambian Kwacha to fund districts ranging from -22% to +22% over the same period. The monthly average loss that was incurred was US$ 302 214 per month, but large gains and losses were observed when individual months were analysed. Information from key informants suggest that currency exchange rate losses contribute to reductions in the health workforce, quantity and quality of health services, while currency exchange rate gains can contribute to reduced absorption capacity and/or low utilization of financial resources. The study concludes that fluctuations in currency exchange rates contribute to volatility in DAH, reduces financial stability and leads to unpredictability of DAH which ultimately affects health service delivery. For DAH to be effective, governments and donors should increase awareness and work systematically to mitigate currency exchange risks.

The 2030 Agenda for Sustainable Development was adopted by the United Nations general assembly in September 2015. The agenda encompasses internationally agreed development aspirations – the Sustainable Development Goals (SDGs). The health targets of the SDGs are not merely ambitious in themselves; they are configured with a very considerable range of other, hugely expensive global issues: 17 goals and 169 targets covering nearly every important aspect of human well-being, both physical and relational. Within the health sphere, by the end of the SDGs in 2030, the ambition is that the AIDS epidemic and other communicable diseases should have been ended, child and infant mortality should be significantly reduced, and universal health coverage with financial protection should be in place for all. But the Joint United Nations Programme on HIV/AIDS (UNAIDS) 5-year ‘Fast Track’ plan for front-loading resources in order to build on progress against the HIV/AIDS pandemic is already faltering – surely evidence of the squeeze being exerted by the most urgent non-health issues (eg, SDG 13: climate action), together with an unpropitious political climate for Official Development Assistance generally. Whatever political embarrassment it might provoke, we must confront the inescapable conclusion that the SDGs are aspirational rather than a compulsory commitment to a programme: the hard choices will become larger in number and more anguished. …

In this study, we analysed stakeholder perceptions of the process of implementing the coordination of health-sector aid in Zambia, Africa. The aim of coordination of health aid is to increase the effectiveness of health systems and to ensure that donors comply with national priorities. With increases in the number of donors involved and resources available for health aid globally, the attention devoted to coordination worldwide has risen. While the theoretical basis of coordination has been relatively well-explored, less research has been carried out on the practicalities of how such coordination is to be implemented. In our study, we focused on potential differences between the views of the stakeholders, both government and donors, on the systems by which health aid is coordinated. A qualitative case study was conducted comprising interviews with government and donor stakeholders in the health sector, as well as document review and observations of meetings. Results suggested that stakeholders are generally satisfied with the implementation of health-sector aid coordination in Zambia. However, there were differences in perceptions of the level of coordination of plans and agreements, which can be attributed to difficulties in harmonizing and aligning organizational requirements with the Zambian health-sector plans. In order to achieve the aims of the Paris Declaration; to increase harmonization, alignment and ownership--resources from donors must be better coordinated in the health sector planning process. This requires careful consideration of contextual constraints surrounding each donor.

Zambia introduced a sector-wide approach (SWAp) in the health sector in 1993. The goal was to improve efficiency in the use of domestic funds and externally sourced development assistance by integrating these into a joint sectoral framework. Over a decade into its existence, however, the SWAp remains largely unevaluated. This study explores whether the envisaged improvements have been achieved by studying developments in administrative, technical and allocative efficiency in the Zambian health sector from 1990-2006. A case study was conducted using interviews and analysis of secondary data. Respondents represented a cross-section of stakeholders in the Zambian health sector. Secondary data from 1990-2006 were collected for six indicators related to administrative, technical and allocative efficiency. The results showed small improvements in administrative efficiency. Transaction costs still appeared to be high despite the introduction of the SWAp. Indicators for technical efficiency showed a drop in hospital bed utilization rates and government share of funding for drugs. As for allocative efficiency, budget execution did not improve with the SWAp, although there were large variations between both donors and year. Funding levels had apparently improved at district level but declined for hospitals. Finally, the SWAp had not succeeded in bringing all external assistance together under a common framework. Despite strong commitment to implement the SWAp in Zambia, the envisaged efficiency improvements do not seem to have been attained. Possible explanations could be that the SWAp has not been fully developed or that not all parties have completely embraced it. SWAp is not ruled out as a coordination model, but the current setup in Zambia has not proved to be fully effective.

Summary The slow global response to the Ebola crisis in west Africa suggests that important gaps exist in donor financing for key global functions, such as support for health research and development for diseases of poverty and strengthening of outbreak preparedness. In this Health Policy, we use the International Development Statistics databases to quantify donor support for such functions. We classify donor funding for health into aid for global functions (provision of global public goods, management of cross-border externalities, and fostering of leadership and stewardship) versus country-specific aid. We use a new measure of donor funding that combines official development assistance (ODA) for health with additional donor spending on research and development (R&D) for diseases of poverty. Much R&D spending falls outside ODA—ie, the assistance that is conventionally reported through ODA databases of the Organisation for Economic Co-operation and Development. This expanded definition, which we term health ODA plus, provides a more comprehensive picture of donor support for health that could reshape how policy makers will approach their support for global health.

Introduction Sector-wide approach, or SWAp, is an increasingly popular approach to development cooperation for many bilateral and multilateral development agencies. While much has been published about the SWAp model itself, there is still limited research conducted on how it is applied in practice. This study aims at showing how the SWAp is translated as it is adopted in different local settings and it shows how these translations trigger changed practice in different ways. Methodology A three-layered comparative study of exemplary texts, country policies and interviews, was conducted in Uganda, Zambia and Bangladesh. An international literature review, comprising research articles, consultancy reports and government policy documents was undertaken. Also, a total of 64 interviews were conducted with representatives from the government, development partners and NGOs. Finally, 18 policy and donor meetings at national and district levels were attended and observed. Results The study showed that the definitions of the SWAp model are general and vague in character. Furthermore, it was observed that in all three countries, no serious effort has been made to define SWAp in country policies. Finally, the study revealed that partners in development translate SWAp differently in daily practice. The variations in understandings were found both between and within countries. Conclusions The SWAp is a clear label with unclear content. The meaning of SWAp is formed by the recipient government and its development partners through an active process of translation as the SWAp is adopted in a specific context. The introduction of the SWAp has limited potential to transform standards for how development aid should be pursued and practiced as much of the administrative structures in each country are still formed in line with a project focused approach. It is concluded that in order to create change, partners in development must work, not only on defining SWAp, but also on influencing the context surrounding the SWAp.

Background The increasing resources available for and number of partners providing health sector aid have stimulated innovations, notably, the Paris Declaration on Aid Effectiveness, which aim to improve aid coordination. In this, one of the first studies to analyse implementation of aid coordination below national level, the aim was to investigate the effect of the Paris Declaration on coordination of health sector aid at the district level in Zambia. Methods The study was carried out in three districts of Zambia. Data were collected via interviews with health centre staff, district managers and officials from the Ministry of Health, and from district action plans, financial reports and accounts, and health centre ledger cards. Four indicators of coordination related to external-partner activity, common arrangements used by external partners and predictability of funding were analysed and assessed in relation to the 2010 targets set by the Paris Declaration. Findings While the activity of external partners at the district level has increased, funding and activities provided by these partners are often not included in local plans. HIV/AIDS support show better integration in planning and implementation at the district level than other support. Regarding common arrangements used for fund disbursement, the share of resources provided as programme-based support is not increasing. The predictability of funds coming from outside the government financing mechanism is low. Conclusion Greater efforts to integrate partners in district level planning and implementation are needed. External partners must improve the predictability of their support and be more proactive in informing the districts about their intended contributions. With the deadline for achieving the targets set by the Paris Declaration fast approaching, it is time for the signatories to accelerate its implementation.

In the global health community of donors recipient countries and policy makers there is a strong consensus about the need for greater capacity to produce a better evidence-base for health-system strengthening. However missing clarity on future directions calls for more attention and better analysis in the following areas in health-system strengthening. First a lack of consensus on what health-system strengthening means and consequently on how it should be done and evaluated result results in fragmented efforts. Specifically the work done by institutions such as the GAVI Alliance PEPFAR and the Global Fund demonstrates that it is possible to negatively distort equity in developing countries. Second health systems are highly contextual. Health problems and needs vary across countries and regions as do the systems to respond to these problems. Robust responsive and efficient health systems are needed to reach the Millennium Development Goals (MDGs); this commentary describes some important initiatives and resources for addressing arising challenges.

A renewed focus on health systems strengthening (HSS) in global health has emerged in recent years. The World Health Organization (WHO) and others have promoted HSS as essential to attaining the Millennium Development Goals and to improving global health outcomes [1],[2]. This recent increase in interest is highlighted by the organization of the First Global Symposium on Health Systems Research, held in November 2010 [3]. Additionally, numerous funding opportunities with an emphasis on HSS have been established, including a collaborative effort between the Global Alliance for Vaccines and Immunization (GAVI Alliance), The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and the World Bank [4], as well as US President Obama's Global Health Initiative [5]. Despite the growing consensus for the need for HSS, there is little agreement on strategies for its implementation [6]. Widely accepted guiding principles could provide a common language for strategy development and communication in the global community. Without a set of agreed-upon principles, frameworks for policy, practice, and evaluation may be unclear, overly narrow, or inconsistent [7], limiting the ability for collective learning, innovation, and improvement. Here we suggest a list of ten guiding principles necessary for effective HSS.

Background In the past decade the sector-wide approach (SWAp) model has been promoted by donors and adopted by governments in several countries. The purpose of this study is to look at how partners involved in the health SWAp in Bangladesh define ownership and coordination, in their daily work and to analyse the possible implications of these definitions. Methodology The study object was a process of decision-making in the Government of Bangladesh in 2003. Information was collected through participant observations, interviews and document review. Results During the study period the Government of Bangladesh decided to reverse a decision to unify the two wings of the Ministry of Health and Family Welfare. The decision led to disagreements with development partners, which had serious implications for cooperation between key actors in the Bangladesh health sector leading to deteriorated relationships and suspension of donor funds. The donor community in itself was also in disagreement which led to inconsistencies in the dialogue between the development partners and the Government of Bangladesh. Conclusion The case shows that main actors in the Bangladesh health SWAp interpret ownership and coordination, fundamental aspects of SWAp, differently. As long as work ran smoothly, the different definitions did not create any problems, but when disagreements arose they became an obstacle. It is concluded that partners in development should devote more effort to their working relationships and that responsibilities within a SWAp need to be more clearly delineated.