Sharon Fonn

Report on consensus conference on cervical cancer screening and management

Anthony B. MILLER*, Saloney NAZEER, Sharon FONN, Assia BRANDUP-LUKANOW, Rakshanda REHMAN, Hennie CRONJE, Rengaswamy SANKARANARAYANAN, Valentin KOROLTCHOUK, Kari SYRJANEN, Albert SINGER and Mathias ONSRUD on behalf of the participants Division of Clinical Epidemiology, German Cancer Research Center, Heidelberg, Germany Department of Gynecology and Obstetrics, Hopitaux Universitaires de Geneve, Geneva, Switzerland Women’s Health Project, Johannesburg, South Africa WHO Regional Office for European Region, Copenhagen, Denmark Department of Gynecology and Obstetrics, Fatimah Jinnah Medical College, Lahore, Pakistan Department of Obstetrics and Gynecology, The University of the Orange Free State, Bloemfontein, South Africa Unit of Descriptive Epidemiology, International Agency for Research on Cancer, Lyon, France Geneva, Switzerland Department of Pathology, Central Hospital, Kuopio, Finland Department of Women’s and Children’s Health, The Whittington Hospital, London, England Department of Gynecology and Obstetrics, University Hospital of Trondheim, Norway

Workforce resources for health in developing countries

With increased globalization and interdependence among countries, sustained health worker migration and the complex threats of rapidly spreading infectious diseases, as well as changing lifestyles, a strong health workforce is essential. Building the human resources for health should not only include healthcare professionals like physicians and nurses, but must take into consideration community health workers, mid-level workers and strengthened primary healthcare systems to increase coverage and address the basic health needs of societies. This is especially true in low and middle-income countries where healthcare access is a critical challenge.There is a global crisis in the health workforce, expressed in acute shortages and maldistribution of health workers, geographically and professionally. This massive global shortage, though imprecise quantitatively, is estimated at more than 4 million workers. To respond to this crisis, policies and actions are needed to address the dynamics of the health labour market and the production and management of the health workforce, and to strengthen the performance of existing health systems. Schools of public health need to develop the range of capacity and leadership in addition to the traditional training of healthcare managers and researchers. Countries should first identify their health problems in order to properly address their health worker needs, retention, recruitment and training, if they are to come close to reaching the Millennium Development Goals (MDGs) for health.

Building capacity for public and population health research in Africa: the consortium for advanced research training in Africa (CARTA) model.

Background: Globally, sub-Saharan Africa bears the greatest burden of disease. Strengthened research capacity to understand the social determinants of health among different African populations is key to addressing the drivers of poor health and developing interventions to improve health outcomes and health systems in the region. Yet, the continent clearly lacks centers of research excellence that can generate a strong evidence base to address the regions socio-economic and health problems. Objective and program overview: We describe the recently launched Consortium for Advanced Research Training in Africa (CARTA), which brings together a network of nine academic and four research institutions from West, East, Central, and Southern Africa, and select northern universities and training institutes. CARTAs program of activities comprises two primary, interrelated, and mutually reinforcing objectives: to strengthen research infrastructure and capacity at African universities; and to support doctoral training through the creation of a collaborative doctoral training program in population and public health. The ultimate goal of CARTA is to build local research capacity to understand the determinants of population health and effectively intervene to improve health outcomes and health systems. Conclusions: CARTAs focus on the local production of networked and high-skilled researchers committed to working in sub-Saharan Africa, and on the concomitant increase in local research and training capacity of African universities and research institutes addresses the inability of existing programs to create a critical mass of well-trained and networked researchers across the continent. The initiatives goal of strengthening human resources and university-wide systems critical to the success and sustainability of research productivity in public and population health will rejuvenate institutional teaching, research, and administrative systems.

Aligning vertical interventions to health systems: a case study of the HIV monitoring and evaluation system in South Africa

BackgroundLike many low- and middle-income countries, South Africa established a dedicated HIV monitoring and evaluation (M&E) system to track the national response to HIV/AIDS. Its implementation in the public health sector has however not been assessed. Since responsibility for health services management lies at the district (sub-national) level, this study aimed to assess the extent to which the HIV M&E system is integrated with the overall health system M&E function at district level. This study describes implementation of the HIV M&E system, determines the extent to which it is integrated with the district health information system (DHIS), and evaluates factors influencing HIV M&E integration.MethodsThe study was conducted in one health district in South Africa. Data were collected through key informant interviews with programme and health facility managers and review of M&E records at health facilities providing HIV services. Data analysis assessed the extent to which processes for HIV data collection, collation, analysis and reporting were integrated with the DHIS.ResultsThe HIV M&E system is top-down, over-sized, and captures a significant amount of energy and resources to primarily generate antiretroviral treatment (ART) indicators. Processes for producing HIV prevention indicators are integrated with the DHIS. However processes for the production of HIV treatment indicators by-pass the DHIS and ART indicators are not disseminated to district health managers. Specific reporting requirements linked to ear-marked funding, politically-driven imperatives, and mistrust of DHIS capacity are key drivers of this silo approach.ConclusionsParallel systems that bypass the DHIS represent a missed opportunity to strengthen system-wide M&E capacity. Integrating HIV M&E (staff, systems and process) into the health system M&E function would mobilise ear-marked HIV funding towards improving DHIS capacity to produce quality and timely HIV indicators that would benefit both programme and health system M&E functions. This offers a practical way of maximising programme-system synergies and translating the health system strengthening intents of existing HIV policies into tangible action.

Achieving Effective Cervical Screening Coverage in South Africa through Human Resources and Health Systems Development

Abstract South Africa’s cervical screening policy recommends three free Pap smears at ten-year intervals for all women over 30 years of age, aiming to achieve 70% coverage by 2010 by targeting the age group most at risk of developing pre-cancerous cervical lesions. Attaining wide coverage requires an adequate supply of motivated and supported public sector health workers with appropriate training and skills, working in a functional health system. Given the dearth of doctors in South Africa, professional nurses were tasked with performing the bulk of Pap smears at primary care level. Coverage remains sub-optimal and a significant proportion of women with precursor lesions do not receive treatment. Further, health system strengthening – essential for cytology-based screening – has not happened. Research to evaluate alternative screening technologies has proliferated in recent years, but regrettably, strengthening of the health system required to make the new technology work has not received similar attention. Using the South African experience, this article argues that technological interventions and innovations alone are not sufficient to improve cervical screening programmes. Task-shifting is limited unless other human resource concerns (e.g. training, increasing demands on personnel, attrition, and skills mix) are concurrently addressed within a comprehensive workforce development strategy, alongside work to make the health care delivery system functional. Résumé La politique sud-africaine de dépistage du cancer du col de l’utérus recommande trois frottis gratuits à dix ans d’intervalle pour toutes les femmes âgées de plus de 30 ans, afin d’atteindre une couverture de 70% d’ici 2010 en ciblant le groupe d’âge le plus à risque de développer des lésions précancéreuses. Parvenir à une large couverture nécessite des soignants du secteur public motivés et soutenus, dotés de compétences adaptées, travaillant dans un système de santé fonctionnel. Compte tenu du manque de médecins en Afrique du Sud, les infirmières ont été chargées de réaliser l’essentiel des frottis au niveau primaire. La couverture demeure sous-optimale et une proportion notable de femmes avec des lésions précurseurs ne sont pas soignées. De plus, le renforcement du système de santé, essentiel pour le dépistage cytologique, ne s’est pas produit. Les évaluations d’autres technologies de dépistage se sont multipliées ces dernières années, mais malheureusement, le renforcement du système sanitaire requis pour utiliser la nouvelle technologie n’a pas reçu une attention similaire. Se fondant sur l’expérience sud-africaine, cet article avance que les interventions et les innovations technologiques ne suffisent pas à améliorer les programmes de dépistage. La délégation des tâches est limitée, à moins que d’autres problèmes des ressources humaines (par exemple la formation, la charge accrue de travail, l’usure et le dosage des compétences) ne soient abordés en même temps dans une stratégie globale de développement de la main-d’łuvre, parallèlement à des activités pour rendre fonctionnel le système de soins de santé. Resumen En Sudáfrica, la política de tamizaje cervical recomienda tres pruebas gratis de Papanicolaou a intervalos de diez años para todas las mujeres mayores de 30 años de edad, con el objetivo de lograr el 70% de cobertura para el 2010 al dirigirse al grupo etario con mayor riesgo de presentar lesiones cervicales pre-cancerosas. Para lograr una amplia cobertura se necesita un suministro adecuado de trabajadores de salud motivados y apoyados en el sector público, con capacitación y aptitudes necesarias, que trabajen en un sistema de salud funcional. Debido a la escasez de médicos en Sudáfrica, las enfermeras profesionales efectúan la mayoría de las pruebas de Papanicolaou en el primer nivel de atención. La cobertura sigue siendo sub-óptima y una considerable proporción de mujeres con lesiones precursoras no reciben tratamiento. Además, aún no se ha fortalecido el sistema de salud, lo cual es esencial para el tamizaje basado en citología. En los últimos años han proliferado las investigaciones para evaluar otras tecnologías de tamizaje; lamentablemente, no se ha dado la misma atención al fortalecimiento del sistema de salud fundamental para lograr que funcione la nueva tecnología. Usando la experiencia de Sudáfrica, este artículo argumenta que las intervenciones e innovaciones tecnológicas por sí solas no son suficientes para mejorar los programas de tamizaje cervical. La reasignación de tareas es limitada, a menos que otros problemas de recursos humanos (p. ej. capacitación, aumento de exigencias del personal, rotación del personal y una mezcla de aptitudes) sean tratados simultáneamente en una estrategia integral de desarrollo del personal, junto con trabajo para lograr un sistema de salud funcional.

Reproductive health services in South Africa: From rhetoric to implementation

Abstract Since its transition to democracy in 1994, South Africa had made some bold moves towards developing a health sector that better meets the needs of its population. The government is committed to reproductive health and womens development, but the challenge of translating these commitments into services on the ground still lies ahead. Based on data from a review of maternal health services and a research and implementation project in three South African provinces, this paper examines the current capacity of the health sector in South Africa to respond to womens reproductive health needs. The studies show that women want better quality from existing services and the opening of services where none exist. Obstacles to providing quality care throughout the provinces were identified, eg. perceived and actual problems with provider-client relations, staff workload, waiting times to be seen, in adequacy of infrastructure, lack ofphones and transport for referrals, and poor management of resources and staff, indicating poor health systems management overall. This paper argues that investing in improving the health care system as a whole is essential to achieving high quality reproductive health services.

Making Systems Work: The Hard Part of Improving Maternal Health Services in South Africa

As part of a multi-country study, maternal health services were reviewed in one health district in Gauteng Province, South Africa. Poor record-keeping, inadequate supervision, poor levels of clinical knowledge and under-utilisation of midwife obstetric units were found. Interventions identified by local health service personnel to improve maternity care were developed, implemented and evaluated, included programme-specific (training in prevention of mother-to-child transmission of HIV and neonatal resuscitation) and system interventions (improving interpersonal relations and system functioning, use of routine data for monitoring purposes, improving supervision skills). This resulted in some positive outputs. Health worker knowledge and patient records improved, and there was some indication that supervision improved. However, system-wide interventions that could improve programmes were less successful. To build a learning organisation, a new culture of monitoring and evaluation, including routine self-evaluation, is required as core skills for all health workers. These data should be used at the point of collection. Changing reporting lines between programme and district managers may improve co-ordination between different authorities, and there is a need to enhance the manner in which staff are assessed, appraised, promoted and rewarded. Professional bodies who oversee training curricula, institutions that offer training, and institutions that provide funding for training and development need to take on the challenge of health systems development and avoid promoting programme-specific interventions only. Résumé Une étude plurinationale a examiné les services de santé maternelle dans un district sanitaire de la province de Gauteng, Afrique du Sud. Elle a révélé une mauvaise tenue des dossiers, une supervision médiocre, de faibles niveaux de connaissances cliniques et un sous-emploi des services obstétricaux. Des interventions identifiées par le personnel des services de santé locaux ont été appliquées et évaluées. Ces mesures étaient spécifiques au programme (formation à la prévention de la transmission mère-enfant du VIH et réanimation néonatale) ou systémiques (amélioration des relations interpersonnelles et fonctionnement du système, utilisation systématique de données aux fins du suivi, amélioration des compétences de supervision). Leurs résultats ont été positifs sur les connaissances des agents de santé et la tenue des dossiers, et il semble que la supervision se soit améliorée. Néanmoins, les interventions systémiques susceptibles de corriger les programmes ont eu moins de succès. Pour construire une organisation apprenante, une nouvelle culture du suivi et de l’évaluation, et notamment une auto-évaluation systématique est requise comme compétences fondamentales pour tous les agents de santé, et des données doivent être utilisées au point de collecte. Modifier les modalités des rapports entre les directeurs des programmes et des districts peut resserrer la coordination entre différentes autorités et il est nécessaire de perfectionner les méthodes d’évaluation, de promotion et de récompense du personnel. Les organes professionnels qui encadrent les programmes de formation, les institutions qui proposent une formation et celles qui financent la formation et le développement doivent éviter de promouvoir uniquement les interventions circonscrites aux programmes. Resumen Como parte de un estudio realizado en varios países, se analizaron los servicios de salud materna en un distrito de salud de la Provincia de Gauteng, en Sudáfrica. Se encontraron registros deficientes, supervisión inadecuada, bajos niveles de conocimientos clínicos y subutilización de las unidades obstétricas de parteras. Las intervenciones identificadas por el personal de salud local para mejorar la atención de maternidad fueron formuladas, aplicadas y evaluadas, incluidas las intervenciones específicas a programas (capacitación en la prevención de la transmisión materno-infantil del VIH y la reanimación neonatal) e intervenciones de sistema (mejoras en las relaciones interpersonales y el funcionamiento de sistemas, uso de datos rutinarios para fines de monitoreo, mejoría de habilidades de supervisión). Esto tuvo algunos resultados positivos. Mejoraron los conocimientos de los trabajadores de salud y los registros clínicas, y hubo indicios de que mejoró la supervisión. Sin embargo, las intervenciones realizadas en todo el sistema que podrían haber mejorado los programas, fueron menos exitosas. Para crear una organización de aprendizaje, se necesita una nueva cultura de monitoreo y evaluación, que incluya la autoevaluación rutinaria, como habilidades fundamentales de todos los trabajadores de salud, y se deben utilizar los datos en el momento de la recolección. Al cambiar las líneas de informe entre los administradores de programas y distritos, posiblemente mejore la coordinación entre diferentes autoridades, y se debe mejorar la forma en que el personal es evaluado, valorado, ascendido y recompensado. Las entidades profesionales encargadas de los currículos de capacitación, las instituciones que ofrecen capacitación y las que proporcionan financiamiento para la capacitación y el desarrollo deben asumir el reto de desarrollar los sistemas de salud y evitar promover exclusivamente intervenciones específicas a los programas.

Innovation to improve health care provision and health systems in sub-Saharan Africa – Promoting agency in mid-level workers and district managers

Initiatives to address the human resource crisis in African health systems have included expanded training of mid-level workers (MLWs). Currently, MLWs are the backbone of many health systems in Africa but they are often de-motivated and they often operate in circumstances in which providing high quality care is challenging. Therefore, assuming that introducing additional people will materially change health system performance is unrealistic. We briefly critique such unifocal interventions and review the literature to understand the factors that affect the motivation and performance of MLWs. Three themes emerge: the low status and inadequate recognition of MLWs, quality of care issues and working in poorly managed systems. In response we propose three interrelated interventions: a regional association of MLWs to enhance their status and recognition, a job enrichment and mentoring system to address quality and a district managers’ association to improve health systems management. The professionalisation of MLWs and district managers to address confidence, self-esteem and value is considered. The paper describes the thinking behind these interventions, which are currently being tested in Kenya, Nigeria, South Africa and Uganda for their acceptability and appropriateness. We offer the policy community a complementary repertoire to existing human resource strategies in order to effect real change in African health systems.

Sexual and reproductive health and rights in public health education.

Abstract This paper addresses the challenges faced in mainstreaming the teaching of sexual and reproductive health and rights into public health education. For this paper, we define sexual and reproductive health and rights education as including not only its biomedical aspects but also an understanding of its history, values and politics, grounded in gender politics and social justice, addressing sexuality, and placed within a broader context of health systems and global health. Using a case study approach with an opportunistically selected sample of schools of public health within our regional contexts, we examine the status of sexual and reproductive health and rights education and some of the drivers and obstacles to the development and delivery of sexual and reproductive health and rights curricula. Despite diverse national and institutional contexts, there are many commonalities. Teaching of sexual and reproductive health and rights is not fully integrated into core curricula. Existing initiatives rely on personal faculty interest or short-term courses, neither of which are truly sustainable or replicable. We call for a multidisciplinary and more comprehensive integration of sexual and reproductive health and rights in public health education. The education of tomorrows public health leaders is critical, and a strategy is needed to ensure that they understand and are prepared to engage with the range of sexual and reproductive health and rights issues within their historical and political contexts.

Exploring corruption in the South African health sector

Recent scholarly attention has focused on weak governance and the negative effects of corruption on the provision of health services. Employing agency theory, this article discusses corruption in the South African health sector. We used a combination of research methods and triangulated data from three sources: Auditor-General of South Africa reports for each province covering a 9-year period; 13 semi-structured interviews with health sector key informants and a content analysis of print media reports covering a 3-year period. Findings from the Auditor-General reports showed a worsening trend in audit outcomes with marked variation across the nine provinces. Key-informants indicated that corruption has a negative effect on patient care and the morale of healthcare workers. The majority of the print media reports on corruption concerned the public health sector (63%) and involved provincial health departments (45%). Characteristics and complexity of the public health sector may increase its vulnerability to corruption, but the private-public binary constitutes a false dichotomy as corruption often involves agents from both sectors. Notwithstanding the lack of global validated indicators to measure corruption, our findings suggest that corruption is a problem in the South African healthcare sector. Corruption is influenced by adverse agent selection, lack of mechanisms to detect corruption and a failure to sanction those involved in corrupt activities. We conclude that appropriate legislation is a necessary, but not sufficient intervention to reduce corruption. We propose that mechanisms to reduce corruption must include the political will to run corruption-free health services, effective government to enforce laws, appropriate systems, and citizen involvement and advocacy to hold public officials accountable. Importantly, the institutionalization of a functional bureaucracy and public servants with the right skills, competencies, ethics and value systems and whose interests are aligned with health system goals are critical interventions in the fight against corruption.