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ECONOMICS CAPABILITY IN
AFRICA
Special Programme for Research & Training
/Wfc World Health
Organization
it/Li I
in Tropical Diseases (TDR) sponsored by
UNICEF/UNDP/World
Bank/WHO
-------
STRENGTHENING HEALTH
ECONOMICS CAPABILITY IN
AFRICA
SUMMARY AND OUTCOMES OF A REGIONAL
CONSULTATION OF EXPERTS AND POLICY-MAKERS
PROFESSOR DIANE MCINTYRE
SA Research Chair: Health and Wealth
Health Economics Unit, University of Cape Town, South Africa
STEVEN WAYLING
Scientist,
Research Networks Manager,
Special Programme for Research and Training in Tropical Diseases (TDR)
sponsored by UNICEF/UNDP/ World Bank and WHO.
Special Programme for Research & Training
in Tropical Diseases (TDR) sponsored by
UNICEF/UNDP/World
Bank/WHO
WHO Library Cataloguing-in-Publication Dara :
Strengthening health-economics capability in Africa : summary and outcomes of a regional consultation of experts and policy
makers.
1.Health economics. 2.Human manpower. 3.Delivery’ of health care - economics. 4.Africa. I.LINICEF/UNDP/World Bank/
WHO Special Programme for Research and Training in Tropical Diseases.
ISBN 978 92 4 156362 8
(NLM classification: W 74)
©World Health Organization on behalf of the Special Programme
for Research and Training in Tropical Diseases 2008
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Printed in France
ABLE
OF
CONTENTS
1.
INTRODUCTION
1
2.
THE ACUTE NEED FOR HEALTH-ECONOMICS CAPACITY IN AFRICA
3
3.
IS THERE A DEMAND FOR HEALTH-ECONOMICS CAPACITY
IN AFRICA?
5
4.
ATTRACTING RECRUITS TO HEALTH ECONOMICS: KEY ISSUES
7
5.
RETAINING HEALTH ECONOMISTS: KEY ISSUES
9
6.
CAPACITY-STRENGTHENING INITIATIVES: A BRIEF INVENTORY
7.
CONSOLIDATING AND EXPANDING CURRENT CAPACITY:
11
NEEDS AND RESPONSE
19
8.
THE WAY FORWARD
27
9.
APPENDICES
29
INTRODUCTION
This report provides an overview of health-economics capacity and capacity-strengthening initiatives
in Africa, and outlines a strategy for promoting further health-economics capacity in the region. It is
the result of a process initiated by the research capability strengthening (RCS) area of the UNICEF/
UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR).
Following discussions with TDR, the Swedish International Development Cooperation Agency (Sida)
lent support to this initiative.
Initially the report was drafted as a paper providing background information and ideas on health
economics capacity within the sub-Saharan African (SSA) region. It was intended to stimulate discussion
at the consultative workshop held in April 2006 to consider ways of promoting health-economics capacity
within the region {see Appendix A and B for workshop agenda and list ofparticipants). The background
paper was revised to capture additional issues discussed at the workshop. It was also circulated widely
among health economists working in Africa - their inputs ensure that it reflects the widest possible range
of views.
IN AFRICA
1
r
1
>> Cost and effectiveness of fixed-dose combinations for TB treatment.
2
THE ACUTE NEED FOR
HEALTH-ECONOMICS
CAPACITY IN AFRICA
The lack of financial and other resources to provide
efficient and equitable health services is a key chal
lenge confronting many health systems in Africa.
Government resources are particularly limited: the
health-sector share of total government expendi
ture is below 10% in about 60% ofSSA countries.
This is despite the Abuja 2001 commitment by
African heads of state that 15% of government
funds would be devoted to the health sector. There
is heavy reliance on donor funding, this provides
over 25% of total health-care funding in about
35% of countries.
Given the global focus on poverty reduction,
out-of-pocket payments’ status as one of the
single largest sources of financing is possibly
the greatest concern. These exceed 25% of total
health-care expenditure in more than 75% of
SSA countries. More than half of all health-care
expenditure is funded through out-of-pocket pay
ments in 40% of SSA countries.1 There is growing
recognition that out-of-pocket payments place a
considerable burden on households, restrict ac
cess to health services among poorer people and
threaten the livelihoods of vulnerable households
that seek and bear the costs of health care. This
has contributed to increased interest in health
insurance mechanisms, as evidenced by the 2005
1 All data drawn from McIntyre D, Gilson L, Mutyambizi V (2005). Promoting equitable health care financing
in the African context: current challenges and future pros
pects. Harare, Zimbabwe, Regional Network on Equity in
Health in Southern Africa (EQUINE f).
World Health Assembly resolution on sustainable
health financing, universal coverage and social
health insurance. There is mounting international
pressure for African countries to move towards in
surance funding for health services. Given the his
tory of inappropriate health policies imposed on
African countries, sometimes with serious adverse
consequences (e.g. user-fee policies of the 1980s
and 1990s), it is essential that there is local capac
ity to evaluate critically the health-care financing
alternatives appropriate within each country con
text. Health economics is a core discipline for such
evaluations.
Health economics is also of considerable impor
tance in promoting the efficient and equitable use
of the scarce resources available for health care. For
example, economic analyses promote:
► technical efficiency in health-service provision:
maximizing the number of services that can be
provided with the least amount of inputs (staff,
drugs, money etc.) without compromising qual
ity' of care;
► efficient allocation by' setting service priorities
and identifying the most cost-effective inter
ventions for addressing major health problems;
► equitable allocation of government and donor
funds and other health-care resources between
areas and groups according to relative need for
health services.
LITY I
3
There are more examples of the potential
application of health-economics analyses within
African health systems but already this discussion
has presented a convincing argument for health
economics capacity within African countries. This
requires capacity to undertake applied health
economics analyses of health policy and planning
challenges. There is also a critical need for capac
ity to develop conceptual and methodological
approaches to health-economics analysis that are
relevant to rhe African context.
IS THERE A DEMAND
FOR HEALTH-ECONOMICS
CAPACITY IN AFRICA?
The clear need for health-economics capacity has
not necessarily been translated into demand for
health-economics analyses. This is illustrated by the
extremely limited funding directed towards health
economics research and capacity-strengthening
initiatives. Also, national ministries of health usu
ally do not seek health-economics inputs to inform
health-policy development. Currently, international
organizations generate most of the demand for
health-economics research within African countries.
For example, research funders may suggest the
inclusion of an economic evaluation component
in specific projects; and various external organiza
tions have initiated and funded much of the work
on national health accounts (NHA).
Policy-makers and health managers appear to have
limited understanding of the range of potential
contributions that health economics offers to policy
development, implementation and evaluation;
and to service planning and management. Health
economists may have contributed to this lack of
understanding, through a heavy focus on econom
ic evaluation (cost-effectiveness, cost-benefit and
similar techniques) at the expense of other forms
of analyses (e.g. of health-system equity). Limited
engagement between researchers and ministry of
health (MoH) officials misses an opportunity to
promote the discipline. Even when these officials
understand the potential, demand may be muted
if there are too few skilled health economists avail
able to undertake the required analyses. Sometimes
officials do not have sufficient trust in the research
ers, their institutions or the quality and objectivity
of their research. To some extent, this is part of
the broader issue concerning the extent to which
MoH officials and policy-makers wish to base their
policies on evidence. However, some challenges
around researcher-MoH interactions are specific to
health economics (and other social sciences) — for
example, if there is a bio-medical dominance in
decision-making in the MoH. Another problem is
that researchers often are judged to have limited un
derstanding of policy processes. Even high-quality
technical work may be useless if it fails to address
key policy concerns or is presented in a way that is
neither appealing nor acceptable to policy-makers.
WHO Regional Office for Africa (WHO-AFRO)
has played an increasingly important role in raising
the profile of, and generating demand for, health
economics and (hence) health economists. For
example, an issue of the regional bulletin focused
exclusively on health-economics issues. In addition,
the WHO Regional Office for Africa has prepared
Health Monitor
Health Economics
Getting Value tor Money
>> African Health Monitor,
January-June 2005,
STRENGTHENING
VOLUME 6, NUMBER 2.
H-EC
CAPA
IN AFRICA
5
background documents for discussions on health
care financing at meetings involving Ministers of
Health from the region. The Regional Director has
also written to health ministers in member coun
tries in the region encouraging them to establish
health-economics units within their ministries.
The relatively low demand for health-economics
analyses needs to be addressed as part of a strategy
for promoting stronger health-economics capability.
It is likely that the greater emphasis on evidenceinformed decision-making will generate more
demand for health-economics analyses.
ATTRACTING RECRUITS
TO HEALTH ECONOMICS:
KEY ISSUES
Health economists have a range of primary de
grees - economics, other social sciences and health
sciences. While there was some debate about the
importance of holding an economics major within
the first degree, there is now some agreement that
the key defining features of a health economist are
formal postgraduate training or extensive exper
tise in health economics. Consistent work in this
subdisciplinc is necessary to develop and maintain
skills in a range of health-economics analyses.
A number of factors dissuade economists from
pursuing the health-economics subdiscipline.
Economists have numerous career options, many
of which are relatively highly paid (e.g. in financ
ing institutions). Economists most likely to be
attracted to the health sector - e.g. those with an
interest in applied or development economics — are
thus limited in number. In addition, African econ
omists are seldom exposed to the health-economics
subdiscipline during their undergraduate, or even
postgraduate, studies and are not aware of the
career opportunities. Those interested in working
in the health sector face still more difficulties in
obtaining training (e.g. limited bursary funding)
as well as difficulties in finding full-time jobs after
training is completed.
Similar constraints face aspiring health economists
from health science or non-economics social
science backgrounds. For example, few medical
graduates are interested in the public-health and
health-systems fields (as opposed to clinical work).
Social scientists who have neither economics nor
health backgrounds probably face the greatest con
straints in breaking into health economics.
Essentially, health economics is not highly visible
and it is difficult to attract new recruits if they are
never exposed to the subdiscipline.
STRENGTHENING H E ALTH-ECO N 0 MICS CAPABILITY IN AFRICA
7
RETAINING HEALTH
ECONOMISTS: KEY ISSUES
The lack of secure and adequately remunerated job
opportunities are possibly the greatest constraints
to retaining trained health economists within Af
rica. Recent graduates who are not provided with
opportunities to use their skills rapidly become
disillusioned and either seek work overseas or leave
the discipline.
At present, very few organizations have posts for
health economists; institutions that do offer these
posts often do not develop adequate career path
ways. Most available posts are largely soft-funded
(e.g. from research grants) and provided on short
term contracts. Many institutions are risk averse
and unwilling to establish health economics, policy
and other health-systems research groupings on
a soft-funded basis. In addition, institutional or
bureaucratic constraints within a parent institu
tion may impede the establishment of soft-funded
research groups; also soft-funded posts often do
not receive the same remuneration package benefits
as those that are core funded.
Very few institutions are willing to strengthen ca
pacity by employing recent graduates with limited
field experience. In some cases this may be due to
an inability to recruit the experienced staff neces
sary to support them. Many African institutions,
particularly universities, will employ only those
with a doctorate. This is exacerbated by the super
visory capacity constraints that limit the number
of PhD study opportunities. The establishment of
soft-funded posts is constrained further by limited
local demand for health-economics research and
restricted funding opportunities.
Within these institutions there is often limited
understanding of the subdiscipline of health eco
nomics. Potential opportunities to use the skills of
health economists are missed and there are numerous
anecdotal reports of colleagues in health-research
organizations developing proposals which would
benefit greatly from a health-economics compo
nent. Often, these are omitted because of lack of
awareness. Greater concern is caused by the all
too frequent reports of north-south collaborative
projects in which the northern institutions insist
on undertaking the health-economics component,
either excluding health economists from the southern
institutions or restricting their involvement to basic
data-collection activities. It should be noted that
this is not the whole experience — in some notable
exceptions northern institutions have contrib
uted significantly to developing capacity in their
southern partners, undertaking truly collaborative
research.
Given these constraints, frequently only one or two
health economists are employed within individual
institutions. This can itself create difficulties re
taining staff thus employed. A young health econ
omist working alone may feel isolated and unable
to develop further skills without engagement with
mentors and peers. A considerable concern is the
reluctance of some institutions to collaborate, al
though individually they may have limited health
economics capacity and may even be in close prox
imity. Collaboration could provide opportunities
for mutual support; to take on large-scale research
projects; and to undertake capacity-strengthening
initiatives that would not be feasible individually.
It is widely recognized that salary levels are extremely
low in health ministries, academic institutions and
other research organizations. In many instances,
these meagre incomes need to be supplemented, most
often by consultancy work. Sometimes, this leaves
very little time for large-scale health-economics
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
9
research projects or capacity-strengthening activi
ties. If relative priority is given to the more lucrative
consultancy activities, an institution may develop a
reputation for not delivering timely research con
tracts. Some consultancy activities are not related
to health economics and therefore detract from
maintaining and developing these skills.
African health economists are presented with en
ticing opportunities, particularly in academic in
stitutions in high-income countries or in multi- or
bi-lateral organizations. These offer considerably
higher remuneration than public-sector institu
tions within Africa, and many opportunities for
career advancement. It thus requires considerable
commitment to remain as a health economist in
an African research institution or MoH. Also, key
users of research findings fail to recognize the
potential contributions of health economics and
there is a lack of recognition of African research
in the international health-economics communi
ty. Although it is changing gradually, little of the
research conducted by African health economists
is published in peer-reviewed international jour
nals or presented at international conferences.
CAPACITY-STRENGTHENING
INITIATIVES: A BRIEF INVENTORY
Overall, there are major challenges for retaining
health economists within African institutions.
Previous sections have highlighted some of the
challenges facing the development and retention
of health-economics capacity within Africa. This
section provides an overview of health econo
mists working in Africa, followed by information
on training activities and capacity. Finally, other
capacity-strengthening initiatives are reviewed
briefly.
African health economists:
numbers and distribution
It is difficult to obtain an accurate estimate of the
number of health economists working in Africa.
The only information available was collated as
parr of an initiative for establishing an African
Health Economics Association. At the 2005
International Health Economics Association
(iHEA) conference, a meeting of African health
economists agreed to invite all their colleagues
working in Africa to forward their details for in
clusion in a database. Invitations were sent to all
who had attended the iHEA meeting, members
of the Health Economics and Policy Network
(HEPNet — see later information) and alumni of
health-economics Masters courses. These individ
uals were asked to circulate the invitation to other
health economists with whom they had contact
within their own, or at other, institutions. This
data-collection exercise has been repeated several
times over the last few months. To date, 80 people
have been included on the database but it is not
yet comprehensive and efforts will continue.
Table 1 provides an overview of the distribution
of health economists working in each country. It
appears that the greatest concentration of health
economists can be found in South Africa, Nigeria and
Uganda; followed by Kenya, the United Republic
of Tanzania and Ghana. It is likely that there is
under-reporting of health economists working in
Zambia. Unfortunately, their countries of origin
are not known but a small, yet significant, number
are working in African countries other than their
country of origin. The database contains details of
only five health economists of African origin who
are currently working in high-income countries;
there is considerable under-representation of this
category in the database.
The majority of health economists recorded in
the database are working in African academic or
publicly funded research organizations (42%). Of
the rest, 30% are working in bilateral and multilat
eral international organizations; 15% in private or
ganizations (mainly private consultancy groups but
some NGOs); 9% in ministries of health; and 4%
in academic or private consultancy groups based in
high-income countries. It is likely that this presents
a biased perspective on the distribution of health
economists between different types of organiza
tions. For example, academics are more likely to
be interested in networking with their peers and
belonging to a disciplinary association than those
working in private consultancy organizations.
The database also indicates that the most frequently
cited areas of expertise of these health economists
are economic evaluation and health-care financing.
HENING HEALTH-ECONOMICS
6
Table 1. Geographical distribution of health economists
Country
No.
Angola
I
Burkina Faso
1
Cameroon
3
Congo (WHO Regional Office for Africa)
3
Gambia
1
Ghana
5
Kenya
7
Liberia
1
2
Malawi
Niger
1
Nigeria
10
South Africa
19
Uganda
10
United Republic ofTanzania
6
Zambia
3
Zimbabwe
2
African-origin working in high-income country'
5
Training activities and capacity
A. Masters-level health-economics
COURSES AND MODULES
A growing number of academic institutions in
Africa offer some form of postgraduate health
economics training, usually as a module within a
Masters programme (generally either public health
or economics). A survey of African institutions
produced the following information - this is not
comprehensive, but does illustrate the modules on
offer (contact details for each institution are noted in
Appendix C).
► School of Economics, University of Nairobi,
Kenya: offers health-economics module as part
of MA Economics (elective module in 12-module course). Also offers module in economic
evaluation. About 30 MA students have elected
to undertake dissertation research on health
economics topics in the past 10 years.
l> Department of Community Health, Univer
sity of Nairobi, Kenya: offers health-economics
module to Bachelor of Medicine (MBChB)
and Master of Public Health (MPH) students.
Masters module covers: demand analysis, pro
gramme planning, health-care financing and
economic evaluation.
> Department of Health Sciences, Uganda Mar
tyrs University: offers health-economics module
as part of MSc in Health Service Management.
Intends to develop a full Masters programme
(see Appendix C).
I> Makerere University Institute of Public Health
(MUIPH), Uganda: offers elective module in
health economics as part of MPH programme.
Includes one or more sessions on health eco
nomics as part of the public-health modules of
fered to undergraduate and Master of Medicine
(MMed) students (see Appendix C). The Fac
ulty of Economics and Management (FEMA)
at Makerere University also offers a module in
health economics within the part-time econom
ics MSc.
► University of Ibadan, Nigeria: offers health
economics module as part of the economics
MSc. Module attended by economists and by
health-sciences students (see Appendix C).
> Department of Economics, University of the
Free State, South Africa: offers elective module
in health economics as part of the Masters in
Economics.
t> Department of Health Administration and
Management, University of Nigeria Enugu
Campus: offers health-economics module for
both undergraduate and Masters students.
Module covers: applications of macro- and
micro-economics in the health sector, economic
evaluation and health-care financing. Intends to
start a Postgraduate Diploma in Health Man
agement, Economics and Policy (HMEP) in the
near future, followed by an MSc in HMEP and,
eventually, a PhD programme.
Research institutions, such as the Kenya Medi
cal Research Institute (KEMRI) and Navrongo
Health Research Centre, also make important
contributions to Masters-level health-economics
training. In particular, by providing supervisory
support to Masters students undertaking health
economics dissertation research in their field sta
tions (contact details for each programme are noted
in Appendix C).
► University of Nigeria Nsukka: offers health-eco
nomics module as part of a Masters programme.
This covers: introduction to health economics,
health-care financing, health-sector reforms and
the demand and supply of health care.
► Department of Community Medicine, Univer
sity of Zimbabwe and the clinical epidemiology
Resource and Training Centre (Harare) offer
a “semester subject” in Clinical Economics as
part of the MMed in Clinical Epidemiology.
Module focuses on economic evaluation and
aspects of health policy. Intend to increase the
health-economics component in the Masters
programme.
>> MPH STUDENTS AT THE UNIVERSITY
OF THE WlTWAT ERS R A N D .
t> Department of Economics, University of
Zambia (DoE-UNZA): offers elective health
economics module as part of MSc in Econom
ics. Module includes: nature of the health-care
market, health-care financing and economic
evaluation.
E> Centre for Health Policy (CHP), University of
the Witwatcrsrand: offers elective modules on
health-policy analysis and health economics
as part of the Masters in Public Health. Also
supervises some students undertaking disserta
tions for the Masters in Health Economics.
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
13
6
B. Masters degrees in health economics
The survey identified only two complete post
graduate health-economics programmes currently
offered by African institutions.
► CESAG (Centre Africain d’Etudes Superieures
en Gestion), Dakar, Senegal: offers a Diplome
d’Etudes Superieures Specialisees Economic
de la Sante (equivalent to a Masters in health
economics). Includes modules on micro
economics; macroeconomics; demography;
statistics; econometrics; health economics;
behaviour of producers and consumers; and
strategic planning.
I> Health Economics Unit (HEU), University
of Cape Town, South Africa: offers a Mas
ters in Health Economics. Includes modules
on: health policy and planning; theory and
application of economic evaluation in health
care; quantitative methods in health eco
nomics; microeconomics for the health sec
tor; macroeconomics, health and health-care
financing; research methods; two electives;
dissertation on a health-economics topic.
An indication of outputs was obtained from in
formation from the two African health-economics
Masters programmes and from a major health
economics Masters programme (that trains
a significant number of African students) in a
high-income country - the University of York in
the United Kingdom. The CESAG programme
is attended by about 25 to 30 students annually;
most are from Senegal although there is a growing
number of students from other Francophone westAfrican countries. The information for the HEU
and York programmes is summarized in Table 2,
according to country of origin. The distribution of
Masters graduates across countries is similar to the
distribution of health economists within countries.
Table 2: Distribution of Masters graduates in health economics
York
(1994-2005)
Country
HEU*
(1996-2005)
Angola
1
Eritrea
1
Ghana
6
2
Kenya
5
Lesotho
1
2___________
I
Malawi
>
1
1
Mozambique
Nigeria
6
South Africa
12
Uganda
16
United Republic ofTanzania
4
Zambia
12
Zimbabwe
5
High-income countries
7
TOTAL
78
2
2
3
2
15
Health Economics Unit, University of Cape Town
The majority of students are drawn from Uganda,
South Africa, Nigeria, Ghana and Kenya. The key
difference between the distributions in Tables 1
and 2 is the relatively large number of Zambians
who have received Masters-level training but are
not reflected in the database of health economists.
It is unclear whether this is because health econo
mists working in Zambia are under-reported in the
database or because many Zambians with health
economics training are not working within the
country.
With the support of TDR, two Masters-level pro
grammes (University of Ghana and The Institute
of African Studies, University of Nairobi, Kenya)
were initiated recently to develop skills in applying
social-science techniques to research on tropical
diseases. Both programmes include a health
economics component.
C. Doctoral-level training in health
economics in Africa
Doctoral-level training in health economics remains
limited in Africa. The African Economic Research
Consortium (AERC) offers an elective module in
health economics as part of its taught programme.
The vast majority of African institutions that re
sponded to the survey indicated that they did not
have any health-economics PhD students. Those
that do, provide dissertation research doctoral
training. The University of Nairobi has had one
health-economics doctoral graduate and currently
has one registered health-economics doctoral stu
dent. MUIPH currently has two PhD students
undertaking research on health-economics topics
(one undertaking a cost-effectiveness analysis, the
other analysing equity of access to the minimum
health-care package). About five PhDs have gradu
ated from the University of Ibadan over the past
twenty years. The CHP at the University of the
Witwatersrand also has some health-economics
PhD students. Table 3 provides a summary of
health-economics doctoral graduates and of students
currently registered in institutions with larger
health-economics PhD programmes, according to
country of origin (2 PhD health economists from
Kenya graduated from the University of York but
are not reflected in the table).
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
Table 3. Doctoral graduates and (currently registered students)
Country
HEU
(1996-2005)
LSHTM*
(1995-2005)
Benin
Cameroon
Eritrea
Ethiopia
Gambia
Ghana
1 (I)
Kenya
Nigeria
I (1)
South Africa
1 (2)
2(3)
Uganda
(1)
(2)
United Republic ofTanzania
Zambia
(1)
High-income countries
1 (I)
TOTAL
7(7)
10(7)
* London School of Hygiene and Tropical Medicine
D. Postgraduate diploma in health
economics
Although no postgraduate diploma in health-eco
nomics programme currently exists in Africa, the
HEU at the University of Cape Town has offered
a distance-learning postgraduate diploma pro
gramme since the beginning of 2007. As indicated,
the University of Nigeria Enugu Campus intends to
start a Postgraduate Diploma in Health Manage
ment, Economics and Policy (HMEP).
E. Continuing education courses for
PROFESSIONALS AND POLICY-MAKERS
A number of short courses that focus, exclusively
or partly, on health-economics issues are offered in
a wide range of African countries. Most of these
courses are targeted at health managers or policy
makers, exposing them to basic health-economics
concepts and techniques. They play an important
role in creating greater awareness of the potential
contribution of health economics and may engen
der greater demand for health-economics research
among these groups.
These training programmes clearly contribute to
the development of health-economics capacity in
African countries. However, there appear to be
challenges for retaining this capacity - it is known
that a number of African health economists that
have participated in these programmes have not
remained in the region.
f. Other capacity-strengthening initia
tives: GRANTS, NETWORKS AND BILATERAL
ARRANGEMENTS
Grants
A number of other initiatives contribute (in various
ways) to strengthening health-economics capacity
within the African region. Some research-funding
opportunities explicitly include a capability
strengthening component - most notably the grants
offered and administered by TDR. For example,
the re-entry grants that fund research by those
completing postgraduate programmes to enable
them to utilize and develop skills gained from their
training. These grants provide three years of fund
ing and serve as important potential mechanisms
for launching young health economists’ careers;
they are not restricted to graduates whose training
was funded by TDR. The MIM/TDR capability
strengthening grants provide quite substantial
funding for research projects related to malaria
(including those focusing on health economics or
other social sciences) that contain postgraduate
training and other capability strengthening
opportunities.
Networks
Regional networks contribute in various ways to
health-economics capability strengthening. For ex
ample, the Partnership for Social Sciences in Ma
laria Control (PSSMC) has developed a resource
centre in Ghana that assists interested groups and
individuals to locate material on social science and
malaria research. It has also contributed to short
course training programmes and facilitates network
ing between those interested in social science and
malaria research.
Another relevant regional network has been in
existence for over six years. HEPNet’s main pur
pose is to contribute to capacity strengthening and
retention in order to support health-policy devel
opment. It involves ministries of health, research
institutes and academic institutions in contribut
ing collaboratively to health-sector development in
five countries: South Africa, Uganda, the United
Republic of Tanzania, Zambia and Zimbabwe,
and is currently expanding into other countries.
HEPNet has undertaken a range of activities, par
ticularly developing capacity for health-economics
training and certain research skills - e.g. writing
and quantitative analysis skills (see Appendix D for
a more detailed overview of the organization and its
activities).
Bilateral engagement
Sida funds bilateral engagement between specific
health-economics institutions - another critical
capability development initiative. For example,
the Swedish Institute for Health Economics (IHE)
in Lund has been funded to provide ongoing sup
port and collaborative inputs to the DoE-UNZA
for over a decade. Bursaries have been provided
for postgraduate health-economics training for
UNZA and Zambian MoH staff; staff exchanges
between IHE and UNZA; and collaborative
>> Professor Di McIntyre, University of Cape Town.
research between IHE, UNZA and the MoH. For
the past few years Sida has also supported a similar
(but more limited) bilateral collaboration between
the HEU at the University of Cape Town and the
Karolinska Institute in Stockholm. A new bilateral
initiative is planned between Ugandan and Swed
ish institutions.
on key issues relating to health economics. The
establishment of this committee has demonstrated
a commitment to place health economics on the
policy agenda. In turn, this will be important in
generating demand for health economics among
policy-makers, and strengthening capacity in the
discipline.
Policy forums
The African Health Economics Advisory
Committee (AHEAC), established by the WHO
Regional Office for Africa, is another recent initiative
that could contribute to capacity strengthening and
retention. The primary purpose of this committee
is to advise the WHO Regional Director for Africa
This range of initiatives is vital for expanding
the opportunities to undertake health-economics
research — ensuring funding and promoting de
mand from policy-makers; providing the ongoing
skills development, collegial engagement and in
stitutional capacity development that are critical
for capacity retention.
>> Executive board room, WHO, Geneva.
CONSOLIDATING AND
EXPANDING CURRENT CAPACITY:
NEEDS AND RESPONSE
7
This section is based entirely on discussions at the
consultative workshop. It focuses on the demand
for health-economics; training needs; strategies to
strengthen training capacity and retention; and
institutional capacity development issues.
How can demand for health
economics and health
economists be promoted?
Workshop participants identified three key areas
for stimulating demand for health economics and
health economists: sensitizing governments and
others to the discipline of health economics; devel
oping tools to respond to demands from sensitized
stakeholders; and developing skills and systems to
use these tools appropriately. WHO (particularly
the Regional Office for Africa) and other inter
national organizations are seen as key players in
stimulating demand. Specific issues raised during
discussions are shown below.
Sensitizing governments and others to
HEALTH ECONOMICS
V> It was recognized that there is a current global
focus on, and interest in, strengthening health
systems research. Health economics is a compo
nent of this so it may be useful to raise awareness
of its potential contribution as an integral part
of high-level advocacy around health-systems
research.
t> WHO Regional Office for Africa plays a key role
in raising the profile of health economics through
its engagements with the New Partnership for
Africa’s Development (NEPAD) and regional
economic bodies (e.g. the Southern African
Development Community - SADC).
1> WHO Regional Office for Africa and the
WHO country offices need to engage with
ministers and ministries of health (and finance)
to sensitize them to health-economics issues
and the importance of institutionalizing health
economics within ministries. The ministries
could be encouraged to develop policies/strategies
on health-economics capacity and to review
their staffing and job specifications to enable the
incorporation of health economists. Ministries
could also be encouraged to demonstrate in
stitutional commitment to health-economics
capacity development, for example by fund
ing staff attendance on postgraduate health
economics training programmes, guaranteeing
a secure post on their return and an identified
career pathway. One strategy could be to offer
an externally funded MoH internship for recent
health-economics graduates for one or two years;
these interns could promote health economics
and demonstrate its usefulness.
t> It is important to identify the key policy chal
lenges and issues facing health (and finance)
ministries and to frame health-economics
sensitization within that context. For example,
NHA have been important in alerting ministries
STRENGTHENING HEALTH ECONOMICS CAPABILITY IN AFRICA
19|
to the value of health economics as a vehicle for
enabling assessment of health-sector financ
ing and spending patterns and areas for policy
intervention. Advocacy of the Abuja target to
devote 15% of government spending to the
health sector could be another means of sen
sitizing policy-makers (NEPAD is planning a
workshop around this target). WHO made a
specific request for the NHA database to sepa
rate donor and government funding in order
to monitor progress towards the Abuja target.
Health-care financing options are another area
of current policy concern that provide a useful
entry point, although it would be important to
link them explicitly to the Millennium Devel
opment Goals.
t> Short courses or workshops (generally offered
by training institutions) that provide a general
introduction to health-economics concepts and
tools play a critical role in sensitizing policy
makers and health managers to the discipline.
1> It would also be useful to identify policy cham
pions for health-economics - a minister of
health, director of health services or another
highly placed official. However, it is important
to select sensitization workshop participants for
their interest in (and support for) health eco
nomics, rather than their positions.
Developing tools to respond
TO DEMANDS
I> Academic institutions can play a key role in
developing cutting-edge conceptual and meth
odological approaches, appropriate to the Afri
can context, for health-economics analyses. A
major constraint is the complete lack of funding
for conceptual research activities.
I> WHO could take a lead in coordinating the de
velopment of applied tools by drawing in part
ners. Academic and other research institutions
should consult with future users to develop
methodological and other tools. These must be
flexible to allow for adjustment to meet the needs
of different contexts.
► A central repository for health-economics tools
is required; WHO Regional Office for Africa
should collaborate with WHO in key roles. It
was suggested that a web page could be devoted
to health-economics tools (developed with
WHO support and directly downloadable) and
links to other relevant web sites.
Developing skills and systems
TO USE TOOLS
£> Workshops or short courses should be held to
develop skills. This could include a WHO Re
gional Office for Africa workshop to sensitize
senior MoH staff to health-economics tools and
country-level workshops for other MoH offi
cials.
!> Information systems need to be developed — for
example, findings from initial NHA rounds
could be used to advocate the establishment of
information systems that compile these routinely.
Health ministries could make recommendations
to central statistical offices (e.g. to include key
health-related questions in routine household
surveys) and finance ministries. As some of the
routine household surveys relevant to the health
sector are developed and coordinated at global
level (e.g. living standards measurement surveys;
demographic and health surveys) organizations
such as WHO, the Global Forum for Health
Research and the Alliance for Health Policy and
Systems Research (AHPSR) should be involved
in such advocacy.
Multilateral organizations such as WHO were seen
to have key roles in stimulating demand for health
economics, but health economists in academic and
other research institutions will be critical in meet
ing demand (e.g. through large-scale research and
>> Masters in health economics students, University of Cape Town.
technical-support activities), particularly at region
al levels. Health economists within health minis
tries will focus primarily on meeting country-level
needs and demands, in collaboration with those in
academic and research institutions.
It was also noted that an increase in the supply
of health economists is necessary to stimulate de
mand for health economics. Demand will increase
as more policy-relevant research is undertaken and
disseminated. However, this demand will decline
if it is not met with a comparable increase in the
supply of health economists.
Finally, there is a need to manage demand. For
example, there is already a demand for health
economists within the private sector (e.g. pharma
ceutical companies) and from multilateral and other
international organizations. If most of the trained
health economists are absorbed by these organiza
tions, training institutions and the public-health
sector likely will have insufficient numbers to sus
tain training of future health economists or to meet
important policy-related health-economics research
needs. Therefore, particular attention should be giv
en to stimulating public-sector demand for health
economists and providing job opportunities and
z'-' v'' z
career pathways in these institutions. There should
/X
also be more emphasis on instilling a commitment? •
to social responsibility during training.
v
,o*
STRENGTHENING HEALTH-ECONOMIC
Identifying and meeting health
economics training needs
The discussion focused on identifying the key needs
of health-economics training; current constraints
on increasing training activities; and strategies for
overcoming these constraints and meeting train
ing needs. As TDR is particularly interested in
supporting postgraduate programmes, much of the
discussion around strategies for expanding training
activities focused on these. However, it should be
remembered that health-economics training in
terconnects with health-economics research and
policy support. Research and policy-support activi
ties can feed into the training programmes neces
sary to train more health economists to undertake
the necessary research and other health-economics
activities (e.g. research findings can provide the
basis for case studies and other training materi
als; policy-support activities inform curriculum
development to ensure that graduates are able to
undertake policy-relevant work).
Training needs
t> Economics undergraduate courses should con
tain some exposure to health economics. This
would sensitize young economists to the pos
sibility of applying their skills within the health
sector, and thereby recruit them to the subdisci
pline.
Short courses, targeted at health (and finance)
ministry officials, are important for raising
awareness and developing a basic understand
ing of health economics.
t> One or more health-economics modules in
Masters programmes can play an important role
in raising awareness and also develop basic skills
in applying key health-economics tools.
> Postgraduate diplomas in health economics (par
ticularly distance learning) can provide a solid
basis for those wanting to specialize in health
economics, who can then proceed to Masters
degrees through dissertations. In addition, PhD
candidates who have not attended a dedicated
health-economics Masters programme can
audit one or more modules for “re-tooling” in
areas relevant to their research.
► There is a need for dedicated Masters
programmes and PhD training for those who
wish to work full-time in health economics.
Such training should be limited to a few insti
tutions that have an explicit regional training
focus.
► Greater capacity within training and research
institutions is required in order to provide
health-economics training to others. It is as
sumed that all those working in health econom
ics within these institutions will have received
some Masters-level health-economics training.
The provision of short-course training would
develop specific competencies among these staff
members, e.g. detailed economic evaluation,
quantitative techniques for health-economics
analysis etc. The development of speci fic compe
tencies can also be accomplished through audit
ing one or more modules in a distance-learning
postgraduate diploma. PhD programmes are
critical for enabling staff to develop detailed re
search skills and specialist knowledge to be able
to teach confidently in their area of specializa
tion. Finally, it is important to develop the gen
eral teaching skills of such staff (e.g. curriculum
development, developing learning objectives,
case-study development, interactive teaching
processes, learner-assessment techniques, etc.)
> Health economists working within health min
istries primarily would require training within
a health-economics Masters programme. PhDlevel training would not be essential but might
be appropriate if doctoral research is used as an
opportunity to address a key policy issue.
Finally, postdoctoral programmes would enable
health economists to develop further skills for
independent research and detailed expertise.
Work in areas outside their doctoral research
would equip them to undertake high-quality re
search on a broader range of health-economics
issues.
Key constraints on expanding health
economics TRAINING
t> Issues related to the design and implementation of
training programmes including inadequate skills
in curriculum design, teaching and assessment
methods as well as a lack of training materials,
quality control and external examination capac
ity.
0 Insufficient health economists (Masters and
PhD graduates) working within academic insti
tutions at present.
► A range of institutional constraints include
lack of space, limited library resources and
bureaucratic obstacles (e.g. delays in registering
new courses).
► Inadequate funding. Some African universities
are able to use vacant posts to employ more
health economists to provide additional health
economics training, but many require core salary
support. As a minimum, funds are required to
pay external lecturers (e.g. health economists
working in the MoH). Financial resources are
also needed to develop appropriate infrastruc
tures (e.g. purchase of computers and key texts,
establishing reliable Internet connections, etc)
and to cover the costs of dissertation research
for Masters and doctoral candidates.
t> Demand and supply constraints operate to some
extent. There may be insufficient well-motivated
and appropriate candidates interested in health
economics (although most institutions reported
more applicants than places) and some recent
graduates have been unable to find suitable jobs.
Strategies for overcoming constraints
AND MEETING NEEDS
I> The first step is to establish the critical mass nec
essary to introduce or expand health-economics
training activities. Exploration of the possibility
of greater cross-faculty and cross-university col
laboration is a key strategy (e.g. students could
choose from two modules in health econom
ics from their own department or university
or two different modules from a collaborating
department or university. Each of these modules
would offer full credits). Country-level networks
of health economists should be used to draw in
teaching expertise from those working in non
university research institutions, health minis
tries or the WHO country offices. In addition,
non-university research institutions can play an
important role in supervising Masters and PhD
dissertation research.
0 Training opportunities for faculty members.
PhD training would develop a critical mass of
skilled health economists within an institution
but there is also a need to develop training skills
(interactive training, learner evaluation, dis
sertation supervision, etc.). Faculty members
might also need to expand their knowledge of
health-economics issues, e.g. by participating in
postgraduate diploma programmes.
► Northern institutions and global networks or
resources can provide valuable input, particu
larly during the initial stages of developing new
postgraduate training. Post-doctoral fellows or
senior academics on sabbatical may be willing
to work in an African country to assist dur
ing the programme-development phase; there
could also be staff-exchange programmes (north
south and south-south). There is considerable
potential for collaboration with international
academic institutions for PhD training (e.g.
two PhD students are currently registered with
MUIPH, co-supervision is provided by the
Karolinska Institute as part of a bilateral col
laboration initiative). This is even more feasible
when staff are based full-time within an African
institution (e.g. L.SHTM has seconded two staff
members-one at KEMRI, one at the University
of the Witwatersrand - on a full-time basis to
supervise African health economists undertak
ing PhD studies work in African institutions).
> It is important to phase in the expansion of
health-economics training. For example, a uni
versity that currently offers a health-economics
module as part of a generalist Masters programme
can add one or more specialist health-economics
modules each year (as capacity allows) until a
dedicated programme has been achieved.
C> Regional networks (such as HEPNet) could
play an important role in supporting the expan
sion of health-economics training. For example,
it could offer training of trainers (TOT) work
shops, facilitate rhe sharing of training mate
rials and staff exchanges, offer short courses
to upgrade skills in certain areas and provide
a mechanism for drawing on international
human resources (e.g. as HEPNet’s primary
funder, Sida could facilitate support via Swedish
academic institutions).
t> Considerable advocacy with bilareral and
multilateral organizations will be required
to secure the financial resources necessary to
initiate and sustain these training activities.
Bilateral organizations already committed to
health-economics capacity development could
play a particularly important role by stimulat
ing interest among other bilateral and multilat
eral organizations to fund the training of health
economists within African institutions and
support the development of local institutional
capacity. In addition, there should be advocacy
to encourage governments and NEPAD to fund
the training of health economists. Governments
that pay for training may have greater owner
ship of rhe products/graduates.
t> It is necessary to find a mechanism for coor
dinating these capacity-strengthening initia
tives.
Stimulating north-south
and south-south collaborations
The strategies discussed above will also assist the
development of health-economics research capac
ity (e.g. postgraduate training with dissertation
research components). Opportunities for research
collaboration should be strengthened, particularly
collaboration within the African region. This could
be facilitated by more seed funding for developing
collaborative research proposals. Networks such as
HEPNer could play an important role in stimulat
ing collaborative research.
As indicated earlier, there is also a need to upgrade
information systems (e.g. improve the health com
ponent of national household surveys and routine
health-information systems) given that African
health economists’ ability to undertake research
is constrained by the continual need to collect
primary data. Finally, workshops to strengthen ca
pacity in research dissemination are critical. These
should cover skills in writing for international
peer-reviewed journals and for presenting research
findings in ways that are accessible and appealing
to policy-makers.
Retaining capacity within
the African region
The availability of job opportunities on graduation
is a key issue in retaining health economists within
the region. One possibility is to offer postgraduate
opportunities primarily to those working within
academic or research insriturions or a health ministry.
However, these institutions would need to guarantee
re-employment on graduation. Institutions may
wish to consider some form of bond to ensure that
sponsored staff members return after graduation.
This should be combined with an institutional
commitment to provide mentorship and support
and appropriate career pathways. External funders
of postgraduate training could request a detailed
reintegration plan from the training institution
near the end of a course to inform their considera
tion of how to retain the graduate.
There is undoubtedly a need to provide more
employment opportunities within African
institutions. Within health ministries, job
opportunities are linked with the earlier discussion
on sensitizing officials to the discipline and
promoting the creation of posts for health
economists. In universities and research organiza
tions, it may be necessary to explore the possibil
ity of soft-funding health economists’ posts on a
long-term basis. This has been shown to be pos
sible within the region but does require a strong
sense of institutional commitment and for all staff
in the institution to contribute to raising funds.
It would be helpful to have some core funding
(possibly from external sources) for senior staff
who bear the greatest load in capacity-building and
fund-raising activities. However, pressure should be
applied at the highest levels within universities and
research institutions to reallocate posts to health
economics (e.g. from biomedical areas). This re
quires the profile of health economics within in
stitutions to be raised substantially. Funders could
help to exert this pressure, for example by seed
funding some posts if the university or research or
ganization agrees to take over funding after a cer
tain time. Many academic institutions offer posts
(institutionally- or soft-funded) to PhD graduates
only, a practice that should be challenged. Insti
tutions should be willing to contribute to capac
ity strengthening and not just reap the benefits of
capacity development. More emphasis should be
placed on employing Masters graduates, provid
ing them with opportunities to develop skills and
undertake PhDs while contributing to the teaching
and research activities of an institution.
Retention packages for health economists working
in health ministries, universities or research organi
zations should include the strategies listed below.
C> Some degree of job security — even if a post is
soft-funded, explore the possibility of providing
an open-ended (rather than very short-term)
contract.
> Access to the full range of remuneration ben
efits (pensions, etc.) - even for soft-funded
posts, institutions may allow contract staff to
receive remuneration benefits identical to those
of staff funded directly by the institution (if full
remuneration package is soft-funded).
t> Acceptable salaries - there are limited oppor
tunities for securing higher core salaries but
pressure could be applied within the context of
current regional discussions on retention strate
gies for health workers. Many health economists
working in academic and other public institu
tions undertake consultancy work to supplement
their core incomes. This is understandable but
it must be recognized that too much time spent
on consultancies impacts adversely on training
and other institutional activities. Each institu
tion needs to develop a strategy for combining
institutional commitments and consultancy
activities, e.g. strict limits on time spent on con
sultancies; income-share with the institution,
etc.
E> Clear career pathways - staff need a sense of
their career-development prospects.
i> Mentoring for young staff - a supportive envi
ronment is key for retaining recent graduates
within an institution, particularly opportunities
for guidance and input from more senior staff.
> Opportunities for senior health economists —
e.g. for international engagement; or growth
through paid leave (e.g. sabbatical) for concep
tual development.
C> Opportunities and support for publishing re
search.
> Strong and supportive institutions - large-scale
long-term (minimum five years) core support
would allow investment in capacity strengthen
ing (rather than fund-raising).
[> Research grants — particularly re-entry grants
for recent graduates and funding to enable
them to undertake further analysis and write up
publications (often not covered adequately in
research grants). Also, funding for conceptual
and methodological work, not just empirical
research.
> Strong countrywide networks of health econo
mists — to provide a community for returning
graduates. Increased collaboration between in
stitutions within individual countries would pro
vide a greater critical mass for mutual support.
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
25
► Involvement of regional networks such as
HEPNet and/or an African health economics
association - could be important in building a
professional community which will also con
tribute to retention of health economists within
Africa.
► North-south collaborations — could provide
opportunities for using the health-economics
skills of recent graduates in research projects,
and developing further skills. Bilateral funders
could be instrumental in promoting such col
laborations.
It was recommended that a survey of African health
economists be undertaken to identify other issues
that could strengthen retention within the region.
This could be combined with a proposed survey
of African health economists to assess their experi
ence, and identify the constraints, of publishing in
peer-reviewed international journals.
Developing institutional
capacity for health-economics
training and research in Africa
While it is easier to develop the capacity of indi
viduals, it was agreed that a concerted effort is re
quired to build strong African institutions within
which health economists can work. A number of
intangible elements contribute to developing and
sustaining institutional capacity: inspirational
leadership; critical mass within a particular disci
pline; staff with strong commitment to the institu
tion and developing the capacity of others (rather
than an exclusively individualistic perspective); a
collegial and supportive environment. Skilled hu
man resources are critical to institutional capacity
(particularly at senior level - to provide leadership
and contribute to capacity strengthening) but it
is also necessary to invest in infrastructure (e.g.
working space, reliable Internet access, etc.).
Funding (particularly long-term - five-year mini
mum) is required to develop institutional capacity.
The need for both financial and general commit
ment to institutional maintenance must also be rec
ognized, as each organization has fragilities. It is
particularly important to ensure that institutions
do not hinge on one person; a group of senior staff
should share leadership and other responsibilities.
An alliance of funders to support different parts of
the institutional capacity development package is
a possibility that should be explored. It should be
recognized that it is difficult to stimulate funders’
interest in resources to support institutional-ca
pacity development as often the outcomes are not
easily measurable. Institutions that receive support
also require mechanisms for encouraging greater
accountability to funders.
It is important to create networking opportunities
for well-established and developing institutions
within the region. Ideas can be exchanged on
dealing with bureaucratic authorities; balancing
core- and soft-funding; and developing collegial
interactions and a supportive environment etc. It
is also important for African institutions to draw
on their northern collaborative partners to sup
port institutional capacity development. In reality,
northern institutions need the African institutions
which therefore are in a potentially strong position
to leverage benefits. An increased profile for health
economics is critical to the development and main
tenance of strong institutions. It is worthy of sup
port as a prestigious discipline that contributes to
important health-policy issues.
Some specific strategies and activities recommended
to advance this initiative are detailed below.
THE WAY FORWARD
Developing training capacity and post
graduate TRAINING PROGRAMMES
O A meeting between CESAG and HEU would
enable detailed discussion of the two existing
health-economics Masters programmes (to
compare curricula, share training materials and
ideas on appropriate quality-control measures,
etc.)
► Increase output from thecurrent health-economics
Masters programmes. Current primary constraint
is insufficient bursaries.
► Provide support for more institutions to initiate
health-economics Masters programmes.
B> Provide support to implement a distance
learning postgraduate diploma and/or Masters
programme as soon as possible.
t> Support the development of a health-economics
PhD programme at one or more African aca
demic institutions. This should probably take
the form of a “3 +1” programme, whereby
there is ’’frontloading” of research skills and
specific health-economics skills development
(e.g. through auditing Masters’ modules) and
opportunities to assess a candidate’s ability to
undertake PhD-level research. Supervisory
skills could be developed more widely within
the region by encouraging co-supervision by a
health economist in the candidate’s country of
origin and/or a regional health economist with
specialist expertise in a particular aspect of health
economics related to the PhD research.
C> Establish regional initiatives to facilitate the de
velopment of more health-economics training
activities. These should include wider exchange
of training materials (in both English and
>> HEU, University of Cape Town.
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
271
8
French); networking ro develop curricula and
training materials; supporting TOT workshops
to develop training skills; and facilitating re
gional peer review and accreditation and quality
assurance of training programmes.
► Regional networks could be instrumental.
HEPNet is requested to consider its potential role
and the possibility of expanding to include other
African countries with substantive involvement
in health-economics capacity-strengthening ac
tivities (e.g. Ghana, Kenya, Nigeria, Senegal).
► In order to ensure that these recommendations
are taken forward, training institutions and re
search organizations within each country should
hold detailed discussions about their five-year
plans for postgraduate health-economics train
ing. Concrete proposals and business plans
should be developed. It may be possible to secure
limited seed funding for this.
Securing funding
► The activities listed above require considerable
new funding, particularly to ensure core fund
ing for soft-funded staff involved in training
programmes; cover institutional overheads; and
develop ICT and library resources in training
institutions initiating or expanding these post
graduate training activities.
► It is not feasible for a single funder to provide
support for the development of all postgraduate
training programmes and institutional capacity.
For this reason, this report will be circulated to
a wide range of organizations for their consid
eration and input. The key issues discussed here
have been, and will continue to be, raised at
various forums, including:
• HEPNet;
• AHPSR;
• TDR, Global Forum for Health Research
and the Council on Health Research for
Development (COHRED) joint meeting on
research. February 2007;
• Meetings of key bilateral agencies.
Finally, it was recommended that a follow-up
meeting should discuss proposals for the further
development of health-economics capacity streng
thening within the African region.
APPENDIX A
GENDA FOR CONSULTATIVE WORKSHOP ON
ECONOMICS CAPABILITY STRENGTHENING IN AFRICA
CAPE TOWN, 24-26 APRIL 2006
PRIL 2006
9:00- 10:30
Welcome
Introductions
Purpose of workshop
Brief presentations (10-15 minutes per participant) on health
economics capacity and training activities within their institutions and
countries
10:30- 1 1:00
Tea
1 1:00- 12:30
Brief presentations (continued)
12:30- 13:30
Lunch
13:30- 15:00
Facilitated discussion — Issues relating to the demand for health
economics
15:00- 15:30
Tea
15:30- 17:00
Facilitated discussion — How to assess and monitor health-economics
capacity within Africa
I
I TUESDAY 25 APRIL 2006
9:00- 10:30
Facilitated discussion — Health-economics training needs, constraints
and strategies
10:30- 11:00
Tea
1 1:00- 12:30
Facilitated discussion - Health-economics training needs, constraints
and strategies (continued)
12:30- 13:30
Lunch
13:30-15:00
Facilitated discussion - Health-economics training needs, constraints
and strategies (continued)
15:00- 15:30
Tea
15:30-17:00
Facilitated discussion - Health-economics research-capacity
development issues
MICS CAPABILITY IN AFRICA
29|
APPENDIX A
WEDNESDAY 26 APRIL 2006
9:00-- 10:30
Facilitated discussion — Health-economics capacity-retention strategies
10:30 -11:00
Tea
1 1:00 - 12:30
Facilitated discussion - Health-economics institutional-capacity
development strategies
12:30 - 13:30
Lunch
13:30 - 15:00
Facilitated discussion - Integrating the health-economics capacity
strengthening strategies
15:00 - 15:30
Tea
15:30 - 17:00
The way forward
APPENDIX B
LRTICIPANTS AT CONSULTATIVE MEETING
LECONOMICS CAPACITY, 24-26 APRIL 2006
Man©
in
e-mail address
Dr Patricia Akweongo
Navrongo Health Research Centre,
Ghana
akweongo@yahoo.com
Mr Caesar Cheelo
DoE-UNZA
ccheelo@yahoo.com
Dr Jane Chuma
KEMRI, Kilifi, Kenya
chumajc@yahoo.com
jchuma@kilifi.mimcom.net
Dr Par Eriksson
Sida
par.eriksson@Sida.se
Professor Lucy Gilson
CHP, University of the
Witwatersrand, South Africa and
LSHTM, England
lucy.gilson@nhls.ac.za
Fr Hyacinth Ichoku
University of Nigeria Nsukka,
Nigeria
hichoku@yahoo.com
Dr Dick Jonsson
Sida & WHO, Uganda
jonssond@ug.afro.who.int
Mrs Elizabeth Kiracho
Institute of Public Health, Makerere
University, Uganda
EKRELIOO1 @mail.uct.ac.za
Dr Joses Kirigia
WHO Regional Office for Africa
ki rigiaj @afro. who. i n t
Dr Felix Masiye
DoE, UNZA
fmasiye@yahoo.com
Professor Di McIntyre
HEU, University of Cape Town,
South Africa
dimac@heu.uct.ac.za
Ms Sofia Norlin
Sida
sofia.norlin@Sida.se
Dr John Odaga
Faculty of Health Sciences, Uganda
Martyrs University, Uganda
jodaga@postmasterl.umu.
ac.ug
Dr Obinna Onwujekwe
College of Medicine, University of
Nigeria Enugu Campus, Nigeria
onwujekwe@yahoo.co.uk
Professor Daniel
Reidpath
Brunel University, England
(providing support to the
establishment ofTDR-funded
Masters in Social Science for Health
programmes in Ghana and Kenya)
daniel.reidpath@brunel.ac.uk// /" c~
//.x / v-
Qu
CEL
,o
I STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
APPENDIX B
Professor Mamadou
Moustapha Thiam
CESAG, Dakar, Senegal
mmthiam@sentoo.sn
moust@refer.sn
Dr Michael Thiede
HEU, University of Cape Town,
South Africa
mthiede@heu.uct.ac.za
Professor Joseph
Wang’ombe
Department of Community Health,
University of Nairobi, Kenya
wangombe@todays.co.ke
Mr Steven Wayling
WHO/TDR, Geneva
waylings@who.int
■■
MMBENDIX C
I
University
.Master.-'-level training programme provided as a module within the Masters of Science in Health Service
Management degree. Institution plans to start a full health-economics Masters programme.
■Module lasts for 3 weeks (100 hours - interactive time with students).
Topics:
01. Economics: definition and introduction
02. Health economics and health planning
03. Mechanisms of demand and supply
04. Market economy: can the provision of health services be regulated by market laws?
05. Disease and economics: the cases of trypanosomiasis, malaria and hiv/aids
06. Role of the state in the provision of health services
07. Role of the private not-for-profit sector in the provision of health services
08. Role of the private for-profit sector in the provision of health services
09. Techniques of economic evaluation: cost-effectiveness and cost-benefit analysis
11. Financing health services: current health spending in developing countries
12. Financing of health services: community financing, health saving accounts, external aid
13. Financing health services: tax-based funding, user fees
14. Financing health services: social and private insurance
15. Objectives and strategies for health financing in Uganda
18. Economic development, economic stability, poverty and health
19. Structural adjustment policies
20. Ethics and philosophy of health economics
21. NHA
22. Efficiency in health care
23. Costing health-care provision etc.
Student profile
On average, trains 15 to 20 students every year. Applications for the programme vary from 20 to 30 per year.
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
33
APPENDIX C
Institute of Public Health,
(http://www.iph.ac.ug/)
Module in MPH:
brief introduction to economics (micro and macro) covers concepts such as market theory, demand
and supply, market failure in health, scarcity, choice, opportunity cost, inHation;
• economic evaluation (cost-benefit and cost-effectiveness analyses);
• health financing options.
•
Department of I
(http://www.ui
'
-
Module in MSc (Economics):
• definition and scope of health economics and its significance
• health and economic development
• microeconomic applications in health
• determinants of health and the human-capital model
• cost of health services and health-care financing
• NHA
• health-policy reforms
• government and health
• economic evaluation of health-care interventions
• statistical tools for health economics.
Learning objectives of health-economics module:
• understand what health economics is and how health economics informs health policy;
• explain the role of burden-of-disease statistics in informing health policy and health economics;
° appraise rhe links between health and development with a view to understanding health and develop
ment policy;
° appraise policy questions related to the demand for health and health care;
• appraise policy questions related to the supply of health care;
° evaluate the policy implications of market failures in markets for health and health care;
• describe the health-care financing system in South Africa;
• evaluate and compare different sources of health-care financing in terms of criteria for a good health
care financing system;
° assess different provider-payment systems in terms of their implications for the goals of health-care
policy;
• assess health-care policy in the context of the characteristics of health-care markets in developed and
developing countries;
• explain how economic evaluation can be employed to evaluate health-care programmes and inform
health-care policy;
• appraise the links between social capital and health and health-care delivery with a view to enhancing
health care.
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
35
APPENDIX C
j
HEU, University of Cape Town
(http://www.heu.uct.ac.za/)
Masters in Health Economics
The programme is offered on a full-time basis and comprises two semesters of coursework with a further
six months for completion of a dissertation, although it is also possible to take rhe course on a part-time
basis. The first semester runs from early February until the end of June, the second semester starts in
mid-July and ends in November. All students are required to complete a minimum of eight modules:
six core modules and two electives. The dissertation is started once the coursework has been completed
successfully.
Overview of core modules
Health policy and planning
Aims to provide students with an understanding of rhe key objectives of health-care systems; main tenets
of planning; key issues in monitoring and evaluating the impact of health-sector reforms; and equity in
health care. It also aims to enable students to develop analytical skills for assessing policy development and
implementation; strategic management of stakeholders; option appraisal; and programming and budget
ing, with special emphasis on human resources and pharmaceuticals.
Topics include;
• introduction to health systems;
• introduction to health policy and planning;
• stakeholder analysis;
• global influences on domestic health policy;
• equity in health care;
• planning human resources;
• regulation of the pharmaceutical market;
• resource allocation;
• approaches to budgeting;
• public-sector capacity and implementation;
• monitoring and evaluation/research to policy.
Theory and application of economic evaluation in health care
Aims to enable students to understand and apply current methods to economic evaluation in health care.
The main objectives are to gain insights into the economic theory underlying economic evaluation in
health care; develop skills in designing and conducting cost-effectiveness, cost-utility and cost-benefit
analyses; and to use these skills to inform policy-formulation and implementation processes. At the end
of this module, students should also have an understanding of the importance of modelling in economic
evaluation.
The module enables students to develop skills by combining taught sessions with practical case studies of
the application of economic evaluation to developing-country interventions. Methodological and practical
issues surrounding each evaluation technique (e.g. annuitization, discounting, sensitivity analysis) are
explored critically.
Topics include:
• welfare economics and economic evaluation;
° economic framework for economic-evaluation techniques;
• critical review of economic-evaluation techniques;
• costing in economic evaluation;
• discounting and annuitization;
• outcome measurement and valuation;
• valuim; health-care benefits in monetary terms;
cost-; ! fectiveness, cost-utility and cost-benefit analyses;
ethic..1 issues in economic evaluation;
“ uncci lainty in economic evaluation;
• modelling in economic evaluation;
• pharmacoeconomics.
Aims to introduce students to the fundamentals of statistics and quantitative techniques as they apply to
health economics. At the end of the course, students should have a good understanding of basic statistics
and the essentials of epidemiology/biostatistics. They should also be able to perform specific mathemati
cal, statistical and econometric operations on health data. Different data sets are used throughout the
module.
Topics include:
• descriptive statistics;
• introduction to probability theory and probability distributions;
• estimation: standard errors, variance, confidence intervals;
• hypothesis testing;
• introduction to epidemiology;
• indices and concentration curves;
• diagnostic tests;
• standardization;
• regression analysis and modelling;
• discrete choice models;
• distribution equity - concentration curves.
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
37
Microeconomics for the health se
Aims to enable students to apply the theory and principles of microeconomics to health and health care.
The main objective is to develop skills in applying the microeconomic tool kit to analyse country situ
ations with a view to informing health-care planning and policy. This includes analysis of the demand,
production and cost functions of specific health-care services and the economics of health insurance
contracts.
Topics include:
• definition, scope and role of microeconomics in the health sector:
• market for health care and the public sector;
• individual and household demand for health and health care;
• household-level analysis: the medical poverty trap and related issues;
• need, agency theory and supplier-induced demand;
• taxation, health and health care;
• models of the market for medical goods and pharmaceuticals;
• health-care production and cost functions;
• efficiency in health-care provision;
• health insurance contracts and incentive effects;
• sustainable community health financing.
Macroeconomics, health am
Introduces students to the influence of macroeconomics and macroeconomic policy on health and health
care. Topics include the importance of economic growth and development for health; different approaches
to financing health services; and the impact of the public-private mix on health-care financing and delivery.
In recognition of the external political influences on domestic health policy, the module also introduces
students to the key ideological movements that have proved to be especially influential on developing
country health systems, including structural adjustment programmes, globalization and health-sector
reforms. While large portions of the module are theoretical and descriptive, practical tools for evaluating
economic and health-sector reforms (such as NHA) and financing and benefit incidence are covered.
Topics include:
• economic growth and health;
• macroeconomic policies and ideologies;
• structural adjustment programmes;
• globalization and health;
• health-sector reform and decentralization;
• public-private mix;
• health-care financing;
• NHA;
• financing and benefit incidence.
Aims to provide students with the technical skills required to write research proposals and to undertake
research projects requiring quantitative methods. It also aims to enable students to cooperate as a group
for protocol development.
Topics include:
° research protocol; ethics;
• literature review - defining the question;
° overview of study design;
c population and sampling; sample size calculation;
» mcasmement: questionnaires; validity and reliability;
• data management and analysis;
reporting, presentation and writing up.
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
39|
APPENDIX D
ZU?® LKWO
C IEPNet)
(liiv|!>•<- .rtrihy/):
HEPNei was initiated in early 2000 with the broad intention to develop and provide relevant in-depth
i;nder>i.injing and technical expertise in health-economics and health-policy analysis in the sub-Saharan
': ■ ic.in
; region. It was to focus particularly on informing health-sector reforms. HEPNet is unique
.gion, focusing specifically on health-economics issues and particularly on supporting healthrihicv J; . iopment. It involves health ministries, research institutes and academic institutions in con. nbuting •. liaboratively to health-sector development within five countries: South Africa, Uganda, the
United Republic of Tanzania, Zambia and Zimbabwe. The rationale for this membership was that the
feasibility and sustainability of a capacity-building initiative such as this can be promoted by starting
small. However, it was envisaged that the network would be expanded to include additional countries
over time.
1'he initial institutional members of HEPNet were the health policy, planning and/or financing unit of
the respective ministries of health; HEU at the University of Cape Town and the CHP at the Univer
sity of the Witwatersrand in South Africa; MUIPH in Uganda; the National Institute for Medical Re
search (NIMR) and Muhimbili University College of Health Sciences at the University of Dar es Salaam
(M UCHS) in the United Republic of Tanzania; DoE-UNZA in Zambia; and the Blair Research Institute
and Department of Community Medicine, University of Zimbabwe. HEPNet has been coordinated by
HEU and the CHP since it was initiated.
The goal of HEPNet is to contribute to health-sector development in the SSA region. Its objectives are
to:
•
undertake networking activities between member institutions and with international organizations
active within the region;
•
strengthen, promote and increase the scope of capacity building in health economics and policy;
•
strengthen, promote and increase the scope of health economics and policy research.
These objectives are achieved through the following strategies.
•
Information dissemination (including sharing of research findings, policy development and imple
mentation experiences; as well as information on courses, conferences and other relevant events).
•
Interaction with international organizations active within the region (including promoting the use of
regional expertise for providing technical assistance to ministries of health and other organizations).
•
Holding regular meetings, including thematic workshops at which ideas on key policy-development
and implementation issues can be shared in a critical way.
•
Promoting the use of existing (and developing additional) formal training programmes, particularly
at postgraduate level, and relevant short courses in the region.
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
APPENDIX D
•
•
•
Increasing opportunities for in-service training.
Sharing resources for training, particularly training materials and expertise.
Supporting research activities that address country-policy priorities (e.g. promoting the development
of appropriate research methods, collaborative research projects).
The key activities since HEPNet was founded are summarized below.
Networking activities
• Circulating policy and research reports.
• Setting up an electronic mailing list. This is updated annually to ensure the inclusion of all staff
working in the areas of health-economics and health-policy analysis within HEPNet member institu
tions. The list has been used primarily for circulating information to members (e.u. calls for research
proposals, conference information, etc.). On occasion, it has been used for discussion of polio -relevant
issues.
• Newsletter: from one to three per year. The newsletter has mainly included a brier update from each
country; information on recent research findings; and dissemination of information on upcoming
conferences, courses and calls for research proposals etc.
• Meetings: at least two activities per year have provided opportunities for HEPNet members to meet.
• Thematic workshops: these were envisaged as relatively informal meetings focusing on facilitated dis
cussions. They serve as forums at which MoH officials and researchers from HEPNet institutions can
share insights on particular policy issues to promote cross-country interaction on experiences of policy
development and implementation, including research findings to strengthen these processes. Although
these have been limited, they are seen as a priority in future HEPnet activity.
• Consultant database: contains information on HEPNet members and their areas of expertise and
interest. Made available to international organizations to promote the use of regional expertise in
technical-support activities.
Capacity development through and for training activities
There has been substantial progress in capacity' development over the first five years of HEPNet. It is
recognized that this will be an ongoing and continuous process due to staff turnover in HEPNet institu
tions. Two of the most important remaining challenges are to promote the use of this capacity and staff
retention. Another key area of concern for future action is that capacity building has been relatively nar
rowly defined as training of individuals and there is a great need for institutional capacity development.
Key activities directed towards this objective include those listed below.
• Opportunities for staff from HEPNet institutions to attend postgraduate programmes. In particular,
the HEU has given priority to these institutions when allocating the four bursaries it manages for the
University of Cape Town Masters programme.
• Given the limited funding for formal training programmes, it has not been possible to use HEPNet
resources for postgraduate programmes, particularly at the PhD level, which tend to be quite expensive.
Instead, information was compiled and circulated to HEPNet members on sandwich PhD programmes
(i.e. research doctorates with time at an academic institution at the beginning and end of the PhD and
in-country data collection in the middle) and on funding opportunities for PhD training.
• Two TOT programmes have been conducted: one on generic training skills such as interactive facilita
tion, formal presentation, curriculum development and case-study preparation skills; one more focused
on health economics and policy content.
•
•
All HEPNet members were asked to share case studies. These were compiled with facilitators’ notes
onto a CD-ROM and distributed to all HEPNet institutions.
Each country was funded to provide an in-country short course so as to utilize and further develop
training skills. Some countries are now running these courses annually by charging cost-recovery
fees.
Research-related activities
Research activities were given less overall priority in the first five years of HEPNet. Key activities relating
to this objective include the following.
• A number of initiatives relating to skills development for research, including workshops on writing
skills, "Research to Policy” and quantitative skills.
• Funding attendance of up to 15 HEPNet members at each International Health Economics Association
(il 1F.A": conference. This is an important mechanism for enabling HEPNet members to present their
research findings to international audiences and be exposed to recent international health-economics
research developments.
• An emphasis on disseminating information on research-funding opportunities has increased opportu
nities for HEPNet members.
H EPNet evaluated its activities after the first five years of operation. It agreed to continue the above activi
ties and also resolved to:
• include more institutions within each of the existing HEPNet countries where relevant;
• gradually expand HEPNet to include additional countries (one in 2006, 2007 and 2008 respective
•
•
•
•
ly);
improve networking activities, e.g. by strengthening the newsletter content, enhancing in-country
networking and developing a web site;
give greater priority to thematic workshops;
support and facilitate institutional capacity strengthening;
support increased research activities (e.g. providing seed funding to enable a few HEPNet institutions
to collaborate on the preparation of a research proposal in order to promote intercountry collaborative
research).
STRENGTHENING HEALTH-ECONOMICS CAPABILITY IN AFRICA
43l
DOI: 10.2471/TDR,08.978-924-156362 8
Special Programme for Research & Training
in Tropical Diseases (TDR) sponsored by
UNICEF/UNDP/World Bank/WHO
TDR/World Health Organization
20, Avenue Appia
1211 Geneva 27
Switzerland
Fax: (+41) 22 791-4854
tdr@who.int
www.who.int/tdr
The Special Programi
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g&WO i©
collaboration cstablis
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DOI: 10.2471/TDR.08,978-924-156362 8
Special Programme for Research & Training
in Tropical Diseases (TDR) sponsored by
UNICEF/UNDP/World
Bank/WHO
TDR/World Health Organization
20, Avenue Appia
1211 Geneva 27
Switzerland
Fax: (+41) 22 791-4854
tdr@who.int
www.who.int/tdr
The Special Programme for Research and Training in Tro
pical Diseases (TDR) is a global programme of scientific
collaboration established in 1975. Its focus is research
into neglected diseases of the poor, with the goal of im
proving existing approaches and developing new ways to
prevent, diagnose, treat and control these diseases. TDR
ISBN 978 92 4 156362 8
9"789241 " 563628
is sponsored by the following organizations:
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vt*/ Organization
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