PHS 812 Global Health

NATIONAL OPEN UNIVERSITY OF NIGERIA
FACULTY OF HEALTH SCIENCES

DEPARTMENT OF PUBLIC HEALTH
COURSE CODE: PHS 812
COURSE TITLE: GLOBAL HEALTH

PHS 812
COURSE
GUIDE
PHS 812
GLOBAL HEALTH
Course Developers: Dr. Elizabeth O. Oloruntoba &

Dr. Oyewale M. Morakinyo
University of Ibadan, Nigeria
Course Editor: Dr Olufemi O. Aluko

Department of Community Health,
Obafemi Awolowo University, Nigeria.
Programme Leader: Prof Grace Okoli-Nnabuenyi.
Programme Coordinator: Dr Gloria O. Anetor.
NATIONAL OPEN UNIVERSITY OF NIGERIA
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National Open University of Nigeria,

University Village,
91 Cadastral Zone, Nnamdi Azikiwe Express way,
Jabi, Abuja
e-mail: [email protected]
URL: www.nou.edu.ng
Published by
National Open University of Nigeria
Printed:
ISBN:
All Rights Reserved
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CONTENTS PAGE
Introduction……………………………………………. iv
What you will Learn in this Course…………………… iv
Course Aim……………………………………………. iv
Course Objectives…………………………………….. iv
Working through this Course…………………………. v
Course Materials………………………………………. v
Study Units……………………………………………. v
Text Books and References…………………………… viii
Assessment……………………………………………. ix
Tutor-Marked Assignment……………………………. ix
Final Examination and Grading………………………. ix
Summary………………………………………………. ix
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INTRODUCTION
This course, PHS 812 Global Health, is a two-credit unit course. There is a recent quest
for knowledge on global health challenges among which are many emerging and re-
emerging communicable diseases; not to mention the alarming increase in the mortality
arising from non-communicable diseases such as cancer, stroke, motor accidents and
injuries. All these necessitate the expansion of knowledge in Global Health; a course that
will address the factors contributing to the health of individuals and communities. Global
health was described by Koplan et al. (2009) as “an area for training, study, research, and
practice that places a priority on improving health and achieving equity and equality in
health for all people worldwide”. Global health emphasizes “transnational health issues,
determinants, and solutions; it involves many disciplines within and beyond the health
sciences and promotes interdisciplinary collaboration, and is a synthesis of population-
based prevention with individual-level clinical care” Koplan et al. (2009). This description
emphasizes the multidisciplinary nature of the course. The course will combine different
teaching methods: lectures, self-study, assessment and a practicum. This course guide,
therefore, tells you what to expect from studying this course material.
WHAT YOU WILL LEARN IN THIS COURSE

The Global health course will expose you to an overview of various issues, such as:
• globalization and health
• global burden of disease
• challenges in healthcare delivery
• social determinants of health
• healthcare financing
• leadership and management in global health
• global health and diseases including gender issues, and
• monitoring and evaluation of health services.
COURSE AIM
The aim of this course is to provide a good understanding of global health for sound
management and administration of healthcare services.
COURSE OBJECTIVES
After going through this course, you should be able to:
• define and describe the concept of global health
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• describe the social determinants of health

• describe the challenges of healthcare financing across countries
• explain the concept of financial management
• describe the effect of politics and policies on global health
• use case studies to describe the effect of climate change on the spread of diseases
• describe how to address global health disparities
• describe health-related targets and sustainable development
• illustrate the concepts of health services monitoring and evaluation
WORKING THROUGH THIS COURSE

In preparing this course, several thematic concepts were considered to ensure that students
with basic knowledge of global health are able to understand the contents. Nevertheless,
the listed textbooks and references will provide additional learning support to the students.
COURSE MATERIALS
This course comprises five modules subdivided into study units. Each of the units was
arranged into:
i. A course guide
ii. Study units
STUDY MODULES
• globalization and health
• global burden of disease
• challenges in healthcare delivery
• social determinants of health
• healthcare financing
• leadership and management in global health
• global health and diseases including gender issues, and
• monitoring and evaluation of health services.
Five study modules are broken down into 23 Units. The Units comprised of in each of the
study modules are listed below:
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Module 1 Concepts in Globalization and Health

Unit 1 Fundamentals of global health
Unit 2 Social determinants of health
Unit 3 Introduction to global healthcare delivery
Unit 4 Essential skills in global health
Unit 5 Interdisciplinary topics in global health
Module 2 Global Health Economics

Unit 1 Introduction to health economics
Unit 2 Financial management and control
Unit 3 Financing and delivery of healthcare services in developing countries
Unit 4 Economic demography and global health
Unit 5 Health policy and economics
Module 3 Leadership and Political Economy of Health Sector Reform

Unit 1 Health services administration
Unit 2 Health sector reform: a worldwide perspective
Unit 3 Leadership and management in global health
Unit 4 Global health politics and policy
Unit 5 The political economy of global health
Module 4 Global Health and Diseases

Unit 1 Case studies in tropical diseases
Unit 2 Gender and Health
Unit 3 Climate change, social justice, and health
Unit 4 Addressing global health disparities
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Module 5 Health Services Monitoring and Evaluation

Unit 1: Introduction to quality management for monitoring and evaluation
Unit 2: Programme monitoring and evaluation methods
Unit 3: Health systems strengthening
Unit 4: Global health in Nigeria; practicum
Module 1
In Unit 1, you will learn about the fundamentals of global health. The unit also discusses
the health indicators and explains the burden of disease. In Unit 2, you will be taken through
the social determinants of health. In Unit 3, you will be introduced to global healthcare
delivery. In Unit 4, you will learn about the essential skills needed in global health, while,
in Unit 5, you will learn about the major interdisciplinary topics in global health.
Module 2
In Unit 1, you will be introduced to health economics, its economic evaluation and types
of economic evaluation. In Unit 2, you will learn about financial management and control.
Unit 3 introduces you to the financing and delivery of healthcare services in developing
countries. In Unit 4, you will learn about economic demography and global health, while,
in Unit 5, you will learn about the importance of health policy and economics.
Module 3
In Unit 1, you will be taken through the various health services administration. In Unit 2,
you will be introduced to a global perspective of the health sector reform. Unit 3 introduces
you to leadership and management in global health. In Unit 4, you will learn about the
importance of global health politics and policy, while, in Unit 5, you will learn about the
political economy of global health.
Module 4
In Unit 1, you will be taken through case studies in tropical diseases, beginning with
learning about what tropical diseases are while in Unit 2, you will be introduced to gender
and health, in the context of global health and diseases. In Unit 3, you will learn about
climate change, social justice, and health, while, in Unit 4, you will learn how to address
global health disparities.
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Module 5
In Unit 1, you will be taken through basic concepts in M&E as well as quality management for
M&E. In Unit 2, you will be introduced to thematic monitoring and evaluation methods. In unit 3,
you will be introduced to the challenges of health systems and how they can be strengthened.
Finally, in Unit 4, you will be introduced to the practicum in Global Health in Nigeria and how it
will be graded.
TEXTBOOKS AND REFERENCES

The following are a list of textbooks, journals and website addresses that can be consulted
for further reading:
Birn, Anne-Emanuelle, Pilley, Yogan, and Holtz, Timothy H. (2017). Textbook of Global
Health, Fourth Edition, Oxford University Press, New York ISBN: 9780199392285,
712pp
Cornelis van Mosseveld, Patricia Hernández-Pe˜na, Daniel Arán, Veneta Cherilova, Awad
Mataria (2016). How to ensure quality of health accounts. Journal of Health Policy
120 (2016) 544–551
Jacobsen, Kathryn H. (2018). Introduction to Global Health, Third Edition; Jones &
Bartlett Learning, ISBN-13: 9781284123890, 450pp.
http://www.jblearning.com/catalog/9781284123890/
Koplan, J. P., Bond, T. C., Merson, M. H., Reddy, K. S., Rodriguez, M. H., Sewankambo,
N. K., & Wasserheit, J. N. (2009). Towards a common definition of global health. The
Lancet, 373(9679): 1993-1995. DOI: 10.1016/S0140-6736 (09) 60332-9
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60332-9/fulltext
Kristen Jogerst, Brian Callender, Virginia Adams, Jessica Evert, Elise Fields, Thomas Hall,
Jody Olsen, Virginia Rowthorn, Sharon Rudy, Jiabin Shen, Lisa Simon, Herica
Torres, Anvar Velji, and Lynda L. Wilson (2015). Identifying Interprofessional
Global Health Competencies for 21st-Century Health Professionals. Annals of Global
Health, 81(2): 239 -247.
The United Nations 2030 Agenda: 17 Sustainable Development Goals to Transform Our
World. http://afa.at/globalview/2015-2.pdf
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World health statistics 2017: Monitoring Health for the Sustainable Development Goals.
Geneva: World Health Organization; 2017. License: CC BY-NC-SA 3.0 IGO.
WHO (2007). Everybody business: strengthening health systems to improve health
outcomes: WHO’s framework for action.
http://www.who.int/healthsystems/strategy/everybodys_business.pdf
(Accessed Dec. 2017)
ASSESSMENT
There are two components of the assessment for this course. They are the tutor-marked
assignment and the final examination.
TUTOR-MARKED ASSIGNMENT
The Tutor-Marked Assignment (TMA) is the continuous assessment component of the
course. It accounts for 30 per cent of the total score. The TMAs will be given to you by
your facilitator, and you will return it after you have done the assignment.
FINAL EXAMINATION AND GRADING

The examination concludes the assessment for the course. It constitutes 70 per cent of the
whole course. You will be informed of the time of the examination.
SUMMARY
This course intends to provide you with knowledge about the factors contributing to the
health of individuals and communities. It is our hope that the materials will be of immense
benefit to you all.
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MAIN
COURSE
CONTENTS PAGE
Module 1 Concepts in Globalization and

Health................ 1
Unit 1 Fundamentals of global

health…………………………... 1
Unit 2 Social determinants of
health………………………….... 14
Unit 3 Introduction to global healthcare
delivery………… 18
Unit 4 Essential skills in global health…... 22
Unit 5 Interdisciplinary topics in global health 25
Module 2 Global Health Economics....................... 30
Unit 1 Introduction to health economics.......... 30

Unit 2 Financial management and control........... 36
Unit 3 Financing and delivery of healthcare in
developing countries................................ 44
Unit 4 Economic demography and global
health…………………………………… 51
Unit 5 Health policy and economics 57
Leadership and Political Economy of 63

Module 3 Health Sector Reform.............................
Unit 1 Health services administration........................ 63
Unit 2 Health sector reform: a worldwide 74

perspective.................................
Unit 3 Leadership and management in global
health...................... 85
Global health politics and policy.............. 92

Unit 4
Unit 5 The political economy of global health.......... 99
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MAIN
COURSE
CONTENTS PAGE
Module 4 Global Health and Diseases................ 105
Unit 1 Case studies in tropical diseases…….. 105

Unit 2 Gender and health………………….... 120
Unit 3 Climate change, social justice, and
health………… 127
Unit 4 Addressing global health disparities... 134
Module 5 Health Services Monitoring and 140

Evaluation
Unit 1 Introduction to quality management for 140

monitoring and evaluation
Unit 2 Programme monitoring and evaluation methods 154
Unit 3 Health systems strengthening 162
Unit 4 Global health in Nigeria: practicum 169
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MODULE 1: CONCEPTS IN GLOBALIZATION AND HEALTH

Unit 1 Fundamentals of global health
Unit 2 Social determinants of health
Unit 3 Introduction to global healthcare delivery
Unit 4 Essential skills in global health
Unit 5 Interdisciplinary topics in global health
UNIT 1 FUNDAMENTALS OF GLOBAL HEALTH

CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Global Health Governance
3.2 Health Indicators and Burden of Disease
3.3 Mixed-Method Approaches in Global Health Research
3.4 Ethics in Global Health Research
4.0 Conclusion
5.0 Summary
6.0 Tutor-Marked Assignment
7.0 References/Further reading
1.0 INTRODUCTION
Globalization has aided improved healthcare in the 21st Century, but it has also ushered in
new challenges, and new ways economically disadvantaged people can be exploited.
Globalization is instrumental in shaping legal rules, ethical rules, policies and guidelines
which affect health. Furthermore, research has linked globalization to disease proliferation,
with an emphasis on global health governance being instrumental in promoting the best
global practice in public health. In this unit, you will learn about the relationship between
globalization and health as well as health indicators and the burden of disease. Also, at the
end of this unit, you should have a good understanding of the concept of mixed-method
approaches to the conduct of research and ethics governing the conduct of research in
global health.
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2.0 OBJECTIVES
At the end of this unit, you will be able to:
• Explain the effects of globalization on health governance

• Define health governance and global health governance
• Discuss the importance of health indicators, list their groups with examples
• Define mixed-method approaches and discuss design methods it utilizes
• Discuss elements of ethics as it relates to global health research
3.0 MAIN CONTENT
The interrelationships among globalization, disease and global health governance cannot
be overemphasized. In order to provide a clear understanding of the concept of global
health governance, the term “health governance” has to be appropriately defined. Health
governance refers to strategies through which the health of a population is promoted and
protected, and it can exist at the local, national, regional, international or global levels.
Globalization has four major effects on health governance:
1. Increased globalization has brought about, or aggravated, transborder human health

risks, the origin and impact of which transcend national borders
2. A unique effect of globalization on health governance is the steady increase in the
number, and influence of, non-state actors
3. Globalization, in its current form, more often than not, worsens existing
environmental, political and socio-economic problems.
4. Globalization is partly responsible for the decrease in the ability of national
governments to deal with challenges related to global health
According to literature, Global Health Governance (GHG) can be defined as strategies

through which local, national and international public and private entities strive to manage,
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regulate and mitigate disease on a global scale. In this regard, the need for global health
governance arises due to the fact that health determinants are increasingly being
destabilized by globalizing forces, not within the scope of the health sector. Some of these
forces include climate or environmental change, criminal activities and conflict, as well as
investment and trade. Therefore, to ensure human health is given a higher priority in public
health policies, GHG has increasingly garnered popularity as a vital concept in
international debates. According to research, there is a relationship between global health
and the global system of disease; one which has not been adequately addressed. By and
large, the global system of disease is often characterized by health indicators and disease
burden.
3.2 Health Indicators and Burden of Disease
In general, health indicators can be defined as directly or indirectly measurable health

phenomena related to individuals or members of a defined population at the local, sub-
regional, regional, continental or global scale, which can be used to report and expantiate
upon the quality and quantity of their health over time. According to literature, global
health indicators which measure health phenomena, directly and indirectly, can also be
referred to as proximal and distal indicators, respectively. The World Health Organization
(WHO) grouped health indicators into four major groups, each of which belongs to the
communicable or non-communicable diseases subdomain. The four health indicators
groups are those relating to; health status, risk factors, service coverage and health systems.
Figure 1.1 to 1.4 provide more subdomains information of these groups.
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Figure 1.1: Health status indicators (World Health Organization, 2015)
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Figure 1.2: Risk factors indicators (World Health Organization, 2015)
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Figure 1.3: Service coverage indicators (World Health Organization, 2015)

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Figure 1.4: Health systems indicators (World Health Organization, 2015)
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In a research to determine the deadliest infectious disease over the last 25 years, it was
discovered that as of 2015, lower respiratory infection (pneumonia) was the most fatal
disease, causing over 700 thousand child deaths in 2015. It was further reported that
diarrheal diseases, malaria, HIV/AIDS and measles, were the four other leading cause of
child deaths in that same year. However, while it is important to note that the deaths caused
by these diseases are on a steady decline, Deloitte reported that by 2020, the three leading
causes of death (cardiovascular diseases, cancer and respiratory diseases) will account for
about 50 percent of the global healthcare expenditure, with an aging population which is
projected to see an eight percent increase. They further stated that an estimate of 36.9
million people is currently affected by HIV/AIDS, and about 70 percent of them reside in
Sub-Sahara Africa.
Apart from health indicators, health can also be measured in terms of the incidence,
prevalence, occurrence, disease burden. The proportion of the population that has a disease
at a point in time (prevalence) and the rate of occurrence of new disease during a period of
time (incidence) are closely related. The ubiquitous way through which the burden of
disease can be measured is by estimating the years ’lost’ as a result of poor health. This
loss is referred to as “Disability Adjusted Life Years (DALYs)”, and is the addition of years
of “potential life lost as a result of premature mortality and the years of productive life lost
due to disability”. Therefore, methods of global health research leading to accurate
estimations of DALYs is important, as DALYs are really useful in determining life
expectancy. This is due to the fact that it considers the global distribution of diseases and
associated harm estimates. Ideally, one DALY can be equated to one year of ‘healthy’ life
lost to one or more diseases.
3.3 Mixed-Method Approaches in Global Health Research
In the past, public health has followed a predominantly quantitative, epidemiological

approach to mapping out health problems and determining their impact with regards to
geographical location, time and characteristics of the individual, in addition to determining
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the root causes of these health problems, perhaps through the problem tree analysis, as one
of the analytical tools. However, since the 20th Century, the qualitative approach has been
adopted in order to better understand the social phenomenon that predicts human
behaviour. In this regard, the qualitative approach seeks to cultivate a more in-depth
understanding of the root causes of human behaviour or decision making through research
structured around in-depth interviews, key informant interviews, focus group discussions,
case studies, unstructured interviews and ethnographic observation of behaviour patterns
and possible modifiers. Nowadays, the quantitative approach which is based on deductive
logic is usually combined with the qualitative approach which is based on inductive logic,
to reach realistic conclusions; since reality cannot be fully expressed by a single approach.
The mixed-method approach to global health research, therefore, refers to a holistic
approach, or a mash-up between qualitative and quantitative methods, which draws on the
strengths of both approaches in order to provide answers to complex research questions.
Mixed-methods utilize various study designs, based on the type of research questions, and
this can be:
• An exploratory, or explanatory sequential mixed-method research. Here, results

achieved by the use of one tool, from either the quantitative or qualitative approach,
are used as input to further explore the determinants or explain the root causes of
findings or observations made in the study population.
• A convergent or concurrent mixed-method research. Here, from the onset of the
research, quantitative and qualitative approaches are selected to propose an answer
to the posed research question
• Embedded mixed-method research. Here, quantitative and qualitative approaches
are nested one in the other, in order to provide new research insights
• A multi-phase mixed-method research. Here, one quantitative, qualitative or mixed-
method research is conducted independently and is designed in such a way that each
independent research approach is a build-up on a previous approach, in order to
design and test a health prevention measure
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When it comes to research, however, it is important to be able to distinguish what is right

from what is wrong, and this is where ethics comes in.
3.4 Ethics in Global Health Research
Ethics, in general, seeks to determine why an action is right or wrong while ethics in
global health research seeks to apply ethical principles to health and its related
disciplines. Research ethics govern the standards of conduct for scientific researchers.
It is important to adhere to ethical principles in order to protect the dignity, rights and
welfare of research participants. As such, all research involving human beings should
be reviewed by an ethics committee to ensure that the appropriate ethical standards are
being upheld. Discussion of the ethical principles of beneficence, justice and autonomy
are central to ethical review.
There are various theories of ethics which help to tackle the problem of delineating right
from wrong, and these theories can further be divided into consequentialist and non-
consequentialist theories. Consequentialism dictates that only the result of any action can
determine if it is right or wrong. Two prominent examples of the consequentialist theory
are utilitarianism and egoism.
• Utilitarianism is a concept in which an action is deemed right if the greatest number

of people reap the highest benefit from its outcome.
• Egoism is on the other side of the utilitarianism spectrum and is individual-centric
in that it deems an action to be right if it results in the greatest good for the most
important person
On the other hand, non-consequentialism puts forward the idea that the consequences of a
decision are not the most important, in reality. One of the most important non-
consequentialist theories is Kantian ethics which deems that even though the consequences
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of an action may be good, the action itself might be wrong. Kantian ethics proposes that
individuals be “treated as ends, and not means to an end”.
4.0 Conclusion
In this unit, it has been explained that globalization affects health governance through
increased transborder health risks, a steady increase in the number and influence of non-
state actors, worsening of existing environmental, political and socio-economic problems
as well as being partly responsible for national governments inability to appropriately deal
with those challenges related to global health.
Furthermore, we learnt that global health governance is a set of defined strategies through
which local, national and international public and private entities strive to manage, regulate
and mitigate disease on a global scale. Also, we learnt that health indicators can be grouped
into; health status, risk factors, service coverage and health systems domains.
In addition, we learnt that mixed-method approaches to global health research is a mash-

up between qualitative and quantitative methods to global health research, and draws on
the strength of both approaches in order to provide answers to complex research questions.
We learnt that mixed-methods utilize design methods based on sequential, convergent or
concurrent, embedded and multi-phase mixed-method research.
Lastly, we learnt about ethics and delineating right from wrong using the consequentialist
and non-consequentialist theories of ethics. Here, we talked about utilitarianism, egoism
and Kantian ethics.
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5.0 Summary
In this unit, we learnt that:
• globalization affects health governance by increasing transborder health risks,

number and influence of non-state actors, worsening existing problems and being
partly responsible for the government’s inability to deal with global health
challenges
• global health governance is a set of defined strategies through which local, national
and international public and private entities strive to manage, regulate and mitigate
disease on a global scale
• mixed-method approaches to global health research is a mash-up between
quantitative and qualitative approaches to global health research
• Consequentialist and non-consequentialist theories of ethics are used to delineate
right from wrong
1. Give a concise definition of health governance and global health governance
2. List and discuss the various ways through which globalization affect health
governance.
3. Define health indicators, list the groups they can be divided into and give two main
examples from each group
4. Define mixed-method approaches to global health research and discuss all the
design methods it uses
5. How would you define ethics in global health research? Please give the theories of
ethics and consider one example under each category.
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Definition of Wellness (2017), “Health Indicator”, available at

http://definitionofwellness.com/wellness-dictionary/health-indicator/.
Deloitte (2017), Global health care sector outlook.
Dodgson, R., Lee, K., Drager, N. and Organization, W.H. (2002), “Global health
governance. A conceptual review”.
Harris, D.M. (2011), Ethics in health services and policy: A global approach, J-B public
health/health services text, Vol. 43, Jossey-Bass, San Francisco.
Kaur, M. (2016), “Application of Mixed Method Approach in Public Health Research”,
Indian journal of community medicine official publication of Indian Association of
Preventive & Social Medicine, Vol. 41 No. 2, pp. 93–97.
Kay, A. and Williams, O.D. (2009), Global health governance: Crisis, institutions and
political economy, International political economy series, Palgrave Macmillan,
Basingstoke.
Labonté, R. (2015), “Globalization and Health”, in Wright, J.D. (Ed.), International
encyclopedia of the social & behavioral sciences, 2. ed., Elsevier, Amsterdam, pp.
198–205.
Larson, C. and Mercer, A. (2004), “Global health indicators. An overview”, CMAJ
Canadian Medical Association journal = journal de l'Association medicale
canadienne, Vol. 171 No. 10, pp. 1199–1200.
Ortiz-Ospina, E. and Roser, M. (2017), “Global Health”, available at:
https://ourworldindata.org/health-meta/.
World Health Organization (2015), Global Reference List of 100 Core Health Indicators.
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UNIT 2 SOCIAL DETERMINANTS OF HEALTH

CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 The framework of Social Determinants of Health
4.0 Conclusion
1.0 INTRODUCTION
In the last unit, we learnt about health governance and global health governance; and
discussed how globalization affects health governance. In addition, mixed-method
approaches can be used in global health research, while ethics govern the delineation of
right and wrong from the protection of the public health perspective. In this unit, we shall
examine the social determinants of health. Also, we will learn how the social determinants
of health are grouped and what determinants are considered in each group.
2.0 OBJECTIVES
• define social determinants of health

• list the five social determinants of health groups and their sub-divisions
3.0 MAIN CONTENT
3.1 Framework of Social Determinants of Health
Almost everyone is impacted by the social determinants of health, and as such, this makes
them very important. Social determinants of health are the “conditions in the environments
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in which people are born, live, learn, work, play, worship, and age that affect a wide range
of health, functioning, and quality-of-life outcomes and risks”. Furthermore, using a
“place-based” framework, Social Determinants of Health (SDOH) can be divided into five
major parts, and these are presented in Figure 5. Sub-divisions of these five parts are
presented in Table 1.
Figure 1.5: Social determinants of health (Healthy People, 2017)
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Table 1.1: Social determinants of health and their sub-divisions (Healthy People, 2017;
Heiman and Artiga, 2015)
S/N Social determinants of health (SDOH) Sub-division
• Employment
• Income
1 Economic stability • Debt
• Support
• Poverty
• Early childhood education and
development
2 Education • Enrolment in higher education
• Vocational training
• Language and literacy
• Civic participation
3 Social and community context • Discrimination
• Engagement in the community
• Social connection
• Access to foods that support
healthy eating patterns
4 Neighbourhood and built environment • Safety
• Environmental conditions
• Quality of housing
• Transportation
• Access to healthcare
5 Health and healthcare • Access to primary care
• Health literacy
• Quality of healthcare
Health impact assessments are increasingly being carried out to address the social
determinants of health as well as strategies which seek to close health gaps and provide
health services to more people.
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4.0 Conclusion
Health is greatly affected by the existing conditions of an area, and these conditions,
referred to as social determinants of health (SDOH), contribute to the quality-of-life
outcomes, functioning and overall health of people in an area. The SDOH can be divided
into five broad groups, consisting of; economic stability, education, social and community
context, neighbourhood and built environment as well as health and healthcare. In addition,
careful assessment of SDOH is used to close health gaps and provide health services to
more people. Considering all these, the importance of social determinants to the overall
health cannot be overstated.
1. Define the social determinants of health.
2. List the major divisions of social determinants of health and give two examples from
each group.
Healthy People (2017), “Social Determinants of Health”, available at:

https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-
health (accessed 30 November 2017).
Heiman, H.J. and Artiga, S. (2015), “Beyond Health Care: The Role of Social
Determinants in Promoting Health and Health Equity”, available at:
https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-
social-determinants-in-promoting-health-and-health-equity/ (accessed 30 November
2017).
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UNIT 3 INTRODUCTION TO GLOBAL HEALTHCARE DELIVERY

CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Global Health and Healthcare Delivery
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
In the last unit, we defined the social determinants of health and looked at its major
subdivisions. In this unit, you will be introduced to global healthcare delivery. As we will
see, global healthcare delivery is the backbone of healthcare delivery services to resource
deficit areas around the world. Also, we will learn about strategies through which global
healthcare delivery problems can be alleviated.
2.0 OBJECTIVES
• define global healthcare and global healthcare delivery

• list top issues in healthcare
• discuss implementation bottleneck as it relates to healthcare delivery
• discuss the strategies for tackling problems posed by improper implementation
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3.0 MAIN CONTENT
3.1 Global Health and Healthcare Delivery
First and foremost, to have a good grasp of the importance of global healthcare delivery, it
is important to understand what global healthcare means. According to literature, global
healthcare is the subvention or supply of health services to resource-deficit areas
worldwide, which are provided with no or inadequate health services. In their report on the
global healthcare sector outlook, Deloitte projected that the global healthcare expenditure
ouldreach 8.7 trillion U.S. dollars by 2020. Besides, the percentage of Gross Domestic
Product (GDP) spent on healthcare was projected to increase to 10.5 percent in 2020, a 0.1
percent increase from 2015. Hence, low-income and emerging countries are expected to
drive this growth. Some of the top issues in healthcare are healthcare delivery, operations,
cost, innovation and regulatory compliance.
Global healthcare delivery can be defined as the conveyance of health services to people
with diseases for which a proven treatment is available. In addition, it refers to the
conscious effort to provide high-quality health services to areas previously considered too
remote or poor to utilize them. Health policies, equity and justice also play a large role in
expanding the reach of health services.
Research suggests that one of the greatest problems being experienced by the global health
community is an “implementation bottleneck”. An implementation bottleneck means there
exists a lack of appropriate delivery or implementation methods for the healthcare
resources injected into global health. In essence, availability of interventional health
services is not the primary constraint, but the delivery of these services to areas where they
are needed the most; mostly in developing countries. One of the evident reasons for this
breakdown in health services provision when it comes to delivery is the lack of appropriate
infrastructure in areas where global healthcare services are most needed. Three strategies
have been identified as having the potential to alleviate the problem posed by the
implementation bottleneck and these are:
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• Implementation research. This refers to studying successful implementation models

using the methods of global health research and building new healthcare delivery
system around them
• The synergy between health systems and Global Health Initiatives (GHIs). This
entails the close monitoring of GHIs and existing health systems to ensure health
services delivery is cost-effective and efficient
• Learning from successful business models. By doing this, those in charge of global
health delivery programming can understudy management strategies used by
companies in the private sector to successfully implement their delivery
4.0 Conclusion
Lack of adequate infrastructure for appropriate implementation of healthcare delivery, in

areas where health services are needed the most, is a problem that still has to be tackled in
low-income and emerging countries of the world today. By and large, to address the
implementation bottlenecks, it is paramount to understudy successful healthcare delivery
systems and implement these in context-specific remote areas lacking appropriate
healthcare.
5.0 Summary
• global healthcare delivery systems are important

• global healthcare delivery is the conveyance of health services to people battling
with diseases for which a proven treatment is available
• problems related to global healthcare delivery can be alleviated by using
implementation research, understudying the synergy between health systems and
global health initiatives in addition to learning from successful business models
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1. Define global healthcare
2. Define global healthcare delivery
3. What do we mean by “implementation bottleneck”
4. What is the greatest challenge faced by healthcare delivery in low-income and

emerging countries and contexts
5. Discuss strategies through which problems posed by the implementation bottleneck

can be solved
Deloitte (2017), Global healthcare sector outlook.

Kim, J.Y., Farmer, P. and Porter, M.E. (2013), “Redefining global health-care delivery”,
The Lancet, Vol. 382 No. 9897, pp. 1060–1069.
Unite for Sight (2015), “The Science of Global Health Delivery”, available at:
http://www.uniteforsight.org/global-health-university/global-health-delivery (accessed
30 November 2017).
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UNIT 4 ESSENTIAL SKILLS IN GLOBAL HEALTH

CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Core Competencies of Global Health
4.0 Conclusion
1.0 INTRODUCTION
In the last unit, we learnt about the global healthcare delivery and implementation strategies
which can be used to tackle problems being faced by the global healthcare delivery
systems. In this unit, we will learn about the core skills and competencies required by
healthcare professionals. By and large, it is important to have the right skills in order to be
able to adequately deliver health services.
2.0 OBJECTIVES
• discuss what essential skills connotes in global health

• determine which skills areas are a must-have for health services professionals
3.0 MAIN CONTENT
3.1 Core Competencies of Global Health
The essential skills in global health are a set of primary skills which professionals should
possess before indulging in the “practice, education and research of public health”.
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Furthermore, these essential skills serve as a framework to improve health practitioners

professionally and better serve their communities. In essence, these core competencies or
essential skills are needed by health professionals for the adequate and appropriate delivery
of healthcare services. The core competencies are divided into eight skill areas which
address different sections of global health. These eight essential skill areas are:
1. analytical skills
2. programme planning or policy development skills
3. management and financial planning skills
4. systematic thinking and leadership skills
5. public health sciences skills
6. cultural awareness or competency skills
7. communication skills
8. community health, oriented skills
4.0 Conclusion
Delivery of health services should be carried out by professionals who have the skills
required to successfully administer health care. A healthcare professional is required to be
able to analyze a situation to determine the best course of action, in addition to being able
to communicate the requirements of standard healthcare procedures to the affected parties.
In all, there are eight major skill areas which are a must-have for healthcare professionals
looking to deliver health services.
1. What do “essential skills” mean in the context of global health?
2. List the skill areas which are a must-have for healthcare professionals
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Council on Linkages (2014), “Core Competencies for Public Health Professionals”,

available at
http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Healt
h_Professionals_2014June.pdf (accessed 28 November 2017).
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UNIT 5 INTERDISCIPLINARY TOPICS IN GLOBAL HEALTH

CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Global Health and Climate Change
3.2 Global Health and Sustainable Development
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
In the last unit, we learnt about the essential skills that healthcare professionals must have
as part of the requirements to deliver health services. In this unit, we will look at
interdisciplinary topics which fall under the global health umbrella. Although there are
many interdisciplinary topics under global health, only the relationship between health,
climate change and sustainable development will be discussed in this unit.
2.0 OBJECTIVES
• Understand what is climate change and its impact on global health

• Understand the relationship between the social determinants of health and climate
change
• Understand sustainable development in the context of global health, and list the
Sustainable Development Goals which are trying to solve the global health crisis
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3.0 MAIN CONTENT
3.1 Global Health and Climate Change
According to the literature, the climate controls the ever-changing ecosystem as well as the
likelihood of disease outbreaks. The relationship between climate change and global health
is of paramount importance, even more so with global warming and the steady
environmental degradation being experienced around the world today. The tropical regions
of developing countries feel the most impact of climate change. According to the World
Health Organization, the global climate is being affected by human activities which release
carbon dioxide and other greenhouse gases into the atmosphere. The effect of this can be
seen in increased natural disasters and changes in precipitation patterns, which have also been
neither spatially nor temporally uniform. But how does climate change relate to global health?
The effects of climate change tend to be drastically negative, and this, in turn, affects the
social determinants of health. Some of these effects could include, but are not limited to:
• Excessive heat-related illnesses

• Air-, vector- and waterborne diseases
• Exposure to environmental toxins
• Amplification of cardiovascular and respiratory diseases
• Melting of the air glaziers and associated ecological transformations
• Increase in natural disasters and inconsistent rainfall patterns
Children and elderly people are the most vulnerable to health risks associated with climate
change. Also, people in developing areas as well as areas with inadequate health
infrastructures are prone to the consequences of climate change and ill-equipped to either
adapt or cope with its outcomes.
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3.2 Global Health and Sustainable Development
According to literature, sustainable development can be defined as any development

activity which provides for the needs of the present generation without jeopardizing the
ability of future generations to also develop and provide for themselves. The race is on to
build better health systems in order to be able to achieve the Sustainable Development
Goals (SDGs) as laid out in the 2030 Agenda for Sustainable Development launched at the
end of 2015. SDG 3 has 13 specific health targets and aims to “Ensure healthy lives and
promote well-being for people of all ages”. In addition to this, Table 2 presents other SDGs
with health-related targets.
Table 1.2: Sustainable Development Goals and their health-related targets
SDG No Goal
SDG 2 “End hunger, achieve food security and improved nutrition and promote
sustainable agriculture”
SDG 6 “Ensure availability and sustainable management of water and sanitation for
all”
SDG 7 “Ensure access to affordable, reliable, sustainable and modern energy for
all”
SDG 8 “Promote sustained, inclusive and sustainable economic growth, full and
productive employment and decent work for all”
SDG 11 “Make cities and human settlements inclusive, safe, resilient and
sustainable”
SDG 12 “Ensure sustainable consumption and production patterns”
SDG 13 “Take urgent action to combat climate change and its impacts”
Source: World Health Organization (2017b)
As the impact of climate change and environmental degradation becomes more profound,
governments are scrambling to sustainably take precedence in striving to achieve economic
development. Sustainable development and global health can be ensured if environmental
and health conditions in developed and developing countries are made top priorities.
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Besides, special attention should be paid to the aforementioned SDGs and efforts should
be intensified in order to achieve them on a global scale.
4.0 Conclusion
Climate change and sustainability are two topics of great importance in the world today,
given the drastic degeneration of the environment. An increase in the emission of
greenhouse and other ozone layer depleting gases due to increased globalization and
industrialization, and unchecked waste emission, is leading to an increase in global
warming. Consequentially, the social determinants of health are affected negatively,
leading to an increase in diseases and natural disasters. In all of this, children and the elderly
remains the most vulnerable to health risks associated with climate change.
This is where sustainability comes in. Sustainable development seeks out ways to provide
for present needs in a sustainable way, which does not affect the ability for future needs to
be met. A number of Sustainable Development Goals (SDGs) have been set out to achieve
this. Furthermore, among the SDGs, careful and successful implementation of SDG 3,
which aims to “Ensure healthy lives and promote well-being for all at all ages”, promises
to have an overall positive effect on global health.
5.0 Summary
• Climate change causes an increase in natural disasters, changes in precipitation or

rainfall patterns, affects the social determinants of health and causes a proliferation
of diseases
• Children and the elderly are the most affected by climate change
• Sustainable development seeks to ensure the future generation can provide for
themselves by providing for the needs of the present generation in a sustainable way
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• SDG 3 has 13 specific health targets which seek to “Ensure healthy lives and
promote well-being for all at all ages”
1. What are the negative effects of climate change on the social determinants of health?
2. What is the major cause of climate change and how does this come about?
3. Which groups of people are the most affected by climate change?
4. What do we mean by sustainable development?
5. Which of the Sustainable Development Goals specifically targets health?
6. List the goals of four other SDGs which have health-related targets
Comrie, A. (2007), “Climate Change and Human Health”, Geography Compass, Vol. 1
No. 3, pp. 325–339.
Luber, G. and Prudent, N. (2009), “Climate change and human health”, Transactions of
the American Clinical and Climatological Association, Vol. 120, pp. 113–117.
NIEHS (2017), “Global Environmental Health and Sustainable Development”, available
at https://www.niehs.nih.gov/health/topics/population/global/index.cfm (accessed 30
November 2017).
World Health Organization (2017a), “Climate change and health”, available at
http://www.who.int/mediacentre/factsheets/fs266/en/ (accessed 30 November 2017).
World Health Organization (2017b), Monitoring health for the SDGs: Sustainable
development goals, World health statistics, Vol. 2017, World Health Organization,
Geneva.
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MODULE 2 GLOBAL HEALTH ECONOMICS
Unit 1 Introduction to health economics

Unit 2 Financial management and control
Unit 3 Financing and delivery of healthcare in developing countries
Unit 4 Economic demography and global health
Unit 5 Health policy and economics
UNIT 1 INTRODUCTION TO HEALTH ECONOMICS
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Definition and Scope of Health Economics
3.2 Concept of Economic Evaluation in Health Economics
3.3 Types of Economic Evaluation in Health Economics
4.0 Conclusion
5.0 Summary
7.0 References/Further Reading
1.0 INTRODUCTION
Economists are concerned with the allocation of scarce resources between competing
demands. They are concerned with making the best choices and in particular, making the
best use of existing resources and growth in the volume of available resources. The
discipline of health economics emerged, as a result of economists’ involvement in solving
healthcare challenges. Some of these challenges being tackled in health economics include
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improvement of patient survival, quality of life and fairness in access to services, among
other concerns.
2.0 OBJECTIVES
At the end of this Unit, you will be able to:
• understand the scope of health economics

• explain the concept of economic evaluation in health economics
3.0 MAIN CONTENT
3.1 Definition and Scope of Health Economics
Health economics is the study of how scarce resources are allocated among alternative uses
for the care of sickness and the promotion, maintenance and improvement of health,
including the study of how health care and health-related services, their costs and benefits,
and health itself are distributed among individuals and groups in the society. It can broadly,
be defined as the application of the theories, concepts and techniques of economics to the
health sector.
It is concerned with matters involving the allocation of resources between various health
promoting activities, the quantity of resources used in health services delivery; the
organization and funding of health service delivery institutions, the efficiency with which
resources are allocated and used for health purposes, and the effects of preventive, curative
and rehabilitative health services on individuals and the society.
As presented in Figure 2.1, the scope of health economics can be divided into eight distinct
topics:
1. What influences health? (other than healthcare)
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2. What is health, and what is its value?

3. The demand for healthcare
4. The supply of healthcare
5. Micro-economic evaluation at treatment level
6. Market equilibrium
7. Evaluation at the whole system level
8. Planning, budgeting, and monitoring mechanisms.
Fig 2.1: The framework of health economics

Source: LSHTM, 1998
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Although all of these eight elements offer useful insights into the delivery of healthcare, it
is an economic evaluation that provides the bulk of health economists’ work and is of most
relevance to healthcare administrators and practitioners.
3.2 Concept of Economic Evaluation in Health Economics
The concept of economic evaluation emphasizes efficiency in health care choices. It relates
the benefits of alternative interventions to the resources incurred in their production. There
are three principles that are pertinent in health economic analysis. They are;
Opportunity cost: Health economists stress the importance of value. When budgets are
finite, resources invested in one area will be at the expense of a loss of opportunity in
another and resources should be valued in terms of this lost opportunity (the opportunity
cost).
Perspective: The viewpoint of the analysis of an economic problem is important. This will
dictate which costs and benefits are important. The perspective of the patient, health
authority and society may differ. Different perspectives will give different answers when
deciding between treatment options and decision-makers must be clear on the preferred
viewpoints.
Marginal analysis: The relationship between resources invested in an intervention and the
accrued benefits is usually not directly proportional. In healthcare decision-making, it is
important to consider how increments in benefit change with increment in resource
allocation. This is known as a marginal analysis.
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3.3 Types of Economic Evaluation in Health Economics
Cost minimization analysis: In a cost-minimization analysis, the consequences of two or

more interventions being compared are equivalent. The analysis, therefore, focuses on
costs alone, and the cheapest option is chosen.
Cost-effectiveness analysis: Cost-effectiveness analysis is the most common type of

analysis and is used to compare drugs or programmes which have a common health
outcome (for example, reduction in blood pressure, life-years saved). Results are usually
presented in the form of a ratio (for example, costs per life-year gained).
Cost-utility analysis: A cost-utility analysis can be used to assess costs and benefits of
interventions where there is no single outcome of interest and is useful comparing different
programmes across different treatment areas. The most frequently used measure is the
Quality Adjusted Life Year (QALY). Benefits are measured based on the impact on length
and quality of life to produce an overall index of health gain. A healthy state is valued
between 0 (worst health) and 1 (best health) combined with the length of time in that state.
Cost-benefit analysis: In a Cost-benefit Analysis, attempts are made to value all the costs
and consequences of intervention in monetary terms. If the costs are less than the benefits,
then the intervention is acceptable.
4.0 CONCLUSION
Health economics aims at allocating scarce resources in healthcare. This can be carried
out effectively by using the tools of economic evaluation so that the best results are
achieved and health sector goals are achieved with minimal investments.
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5.0 SUMMARY
In this unit, we have learnt that:
• Health economics is the study of how scarce resources are allocated among
alternative uses for the care of sickness and the promotion, maintenance and
improvement of health. It alsoincludes the study of how health care and health-
related services, their costs and benefits, and health itself are distributed among
individuals and groups in society.
• The scope of health economics can be divided into eight distinct component topics
• The concept of economic evaluation emphasizes efficiency in health care choices.
• There are three principles that are germane in health economic analysis, namely;
opportunity cost, perspective and marginal analysis.
6.0 TUTOR-MARKED ASSIGNMENT

1. Define health economics
2. Enumerate the health economics component topics
3. Explain the three principles of health economic analysis
4. List and discuss the economic evaluation methods
7.0 REFERENCES/FURTHER READING
LSHTM (1998). Health Economics and its Contribution to Health Planning, Chapter 1: In
LSHTM; 1998, Health Economics for Developing Countries: A Survival Kit 134 pages
http://helid.digicollection.org/en/d/Jh0197e/4.html
Kernick, D.P. (2008). Introduction to health economics for the medical practitioner. British
Medical Journal. Volume 79, Issue 929. http://dx.doi.org/10.1136/pmj.79.929.147
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Phelps, C.E. (2003), Health Economics (3rd ed.), Boston: Addison Wesley, ISBN 0-321-
06898 X Description and 2nd Ed.
Sekhar, R.H. and Chandra, N.N. (2007). Health and health economics: a conceptual
framework. Munich Personal RePEc Archive. Pg 1 - 9.
Rout, Himanshu Sekhar and Nayak, Narayan Chandra (2007), Health and Health Economics: A
Conceptual Framework, In Himansu Sekhar Rout and Prasant Panda (eds.), Health
Economics in India, New Century Publications, New Delhi, 13–29
Wolfe, B. (2008). Health economics. The New Palgrave Dictionary of Economics, 2nd
Edition. Abstract & TOC.
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UNIT 2 FINANCIAL MANAGEMENT AND CONTROL
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
4.1 The concept of Financial Management and Control
4.2 The Pillars of a Financial Management and Control Framework
4.2.1 Performance Information
4.2.2 Risk Management
4.2.3 Control Systems
4.2.4 Ethics, ethical practices and values
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Every organization makes use of funds for their activities. How money is handled will
determine whether an organization will be able to carry out its functions and activities as
well as achieve its set goals. Therefore, sound financial management and controls are
required, and this can only be achieved if sound financial management principles and
techniques are applied.
2.0 OBJECTIVES
• understand Financial Management and Control Frameworks

• explain the pillars of Financial Management and Control
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3.0 MAIN CONTENT
3.1 Concept of Financial Management and Control
Financial management refers to the efficient and effective management of money (funds)
in a way that enables an organization to accomplish it set objectives. It is the specialized
function directly associated with the top management. Financial management and control
are the basis of programme management and its framework should be the major source of
guidance for planners, administrators, managers and their financial advisers in the efficient,
effective and appropriate use of allocated resources.
According to planning technocrats, the purpose of a governmental or

departmental/agency’s financial management and control framework is: “to facilitates and
define the boundary lines for the planning, use and accounting of resources.” These
“boundary lines’ establishes a financial management and control framework through the
resource management cycle (from planning to external reporting) within the rules, values,
and performance expectations of the organization’s stakeholders.
The resource management cycle has the following components;
• Resource Planning: This involves estimating financial consequences and risk of

strategic objectives and alternatives.
• Resource Acquisition: Forecasting and acquiring resources in order to carry out
business processes.
• Resource Allocation: Allocating the resources and setting budgets for activities in
the business process.
• Managing: Using the acquired resources to carry out activities and deliver services
to clients.
• Monitoring/Controlling: Ensuring efficient, effective and appropriate use of
resources in light of the latest information (reallocating where needed).
• External Reporting: Providing accurate, relevant and timely information on the
use of resources to stakeholders.
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A successful financial management and control framework is present when an organization

has the capacity to; adequately navigate through the resource management cycle, establish
boundary lines that clearly delineate the limits within which all decisions and transactions
must be made towards establishing and exercising clear accountabilities for managing
resources and staying within the boundary lines as well as demonstrating integrity through
shared organizational values and beliefs.
3.2 The Pillars of a Financial Management and Control Framework
Financial Management and Control are premised on four important pillars, which can be
summarized as follows:
1. Performance Information (Linking financial and non-financial information)

2. Risk Management
3. Control Systems
4. Ethics, ethical practices and values
3.2.1 Performance Information (Linking financial and non-financial information)
This pillar is designed to associate resources with results. This objective can be difficult to
achieve if there’s poor management of the factors that cause costs (i.e. activities that
consume resources). When the factors that cause costs are understood and managed, it is
much easier to achieve sound resource management. Factors that cause the costs of
activities (resources consumed) may include many things, such as the volume of client
demand; service standards (e.g., accuracy and timeliness); the type of clients and the
complexity of the governing rules and systems. This is the non-financial information that
needs to be connected with the financial information in order to map resources with results.
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A good cost management structure within the financial management and control
framework will provide clear cost policies and principles, costing methodologies, and an
activity dictionary that reveals the work inputs to achieve results. It will also have a costing
module in its financial management and control system to link expenditures to activities,
and the resulting activity costs to be assigned to performance targets and other cost objects,
such as clients and services.
A good cost management framework not only enables the linking of resources to results
for accountability purposes, but also provides better information for planning, alternative
service delivery analysis, pricing of services, and other critical decisions. This technique,
however, seems difficult to practice in public sector management. This can be associated
with the fact that an expenditure culture is embedded in the system.
3.2.2 Risk Management
This second pillar is clearly related to financial management and control, particularly to
control. This is because control is a function of risk. Controls are instituted solely to guard
against undesirable and unpredictable events. Certain policies are established to debar the
likelihood of private workers, and civil servants from engaging in wrong financial acts,
such as misappropriating or overspending funds. Financial management controls are costly
with far-reaching effects, and this is why they should be subjected to risk management
techniques before implementation.
Financial management and control also use risk management to help in the analysis of
decisions such as how to minimize the risk of adverse financial consequences.
Furthermore, risk management exists also to alleviate the risk of opportunities being
missed. This involves anticipating new technologies or new legislative provisions to ensure
organizational readiness to take advantage of opportunities as soon as they are available or
take effect.
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3.2.3 Control Systems
Financial management control systems reflect mandatory controls such as those required
for expenditures and revenues under certain policies and those arising from risk
management techniques where at the discretion of the management. Decisions are made
on what areas of management and accountability need protective or facilitative control
measures. Protective controls serve to protect public funds from being spent recklessly and
irresponsibly and public assets from loss, theft, and damage. Facilitative controls are
controls that enable the achievement of programme objectives. For better understanding,
protective controls are input-oriented while facilitative controls are output-oriented.
Protective control systems are epitomized by financial, appropriation and commitment

accounting systems as well as inventory and asset systems. Due to their costly nature, these
systems should be efficient. Facilitative control systems are epitomized by financial
planning and forecasting systems and integrated financial and non-financial performance
systems. They alert administrators of the need to revise plans and take actions to correct
identified problems or to take advantage of newly identified opportunities.
3.2.4 Ethics, ethical practices, and values
Ethics for public service delivery usually means doing what is right rather than what is
expedient or personally beneficial. Majority of civil servants instinctively do the right
thing. However, in some circumstances, the right course of action for certain transactions
or dealings might not be in accordance with the natural instinct of an average financial
expert, so ethical principles have to be communicated to ensure that the right actions are
taken. This pillar is probably the most important from the perspective of control because a
lack of ethics and values can seriously weaken most control frameworks, whereas strong
shared values and ethics make controls not only stronger but unnecessary in many cases;
thus, creating the opportunity to reduce costs and increase innovation.
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4.0 CONCLUSION
Good financial management aids in the efficient and effective management of funds and
enables an organization to prudently accomplish set objectives. These have been shown to
involve linking financial and non-financial data, risk management, instituting control
systems and communicating ethical values and principles to financial and non-financial
experts in ensuring, in particular, the integrity of healthcare service delivery.
5.0 SUMMARY
• Financial management refers to the efficient and effective management of money

(funds) in a way that enables an organization to accomplish it set objectives.
• Financial management and control is the basis of government management and its
framework should be the major source of guidance for administrators, managers and
their financial advisers in the efficient, effective and proper use of public resources.
• Financial management and control sits on four pillars; Performance Information,
Risk Management, Control Systems and Ethics, ethical practices and values.
• A good cost management framework not only enables the linking of resources to
results for accountability purposes, but also provides better information for
planning, alternative service delivery analysis, pricing of services, and other critical
decisions.
• Financial management and control also use risk management to help in the analysis
of decisions such as how to minimize the risk of adverse financial consequences.
• Protective controls serve to protect public funds from being spent recklessly and
irresponsibly and public assets from loss, theft and damage. Facilitative controls are
controls that enable the achievement of programme objectives.
• Ethics for public servants usually means doing what is right rather than what is
expedient or personally beneficial.
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1. Explain the resource management cycle
2. Mention the pillars of financial management and control
3. Explain the importance of financial management and control in global health service
delivery
Ehrenworth, S. (2004). Why is government so difficult (reluctant) to change? Optimum

Online, Vol. 34, Issue 3, Oct 2004. Accessed 02/02/2018.
McCrindell, J.Q. (2005). A Framework for Financial Management and Control. Financial
Management Institute of Canada Journal., Pp 11 – 39.
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UNIT 3 FINANCING AND DELIVERY OF HEALTHCARE IN

DEVELOPING COUNTRIES
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Healthcare Financing
3.2 Sources of Healthcare Financing
3.3 Financial Constraints of Healthcare Delivery in Developing Countries
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
It has been popularly said that “Health is wealth”. The productivity of a population will be
sub-optimal if it is unhealthy. The health sector in any country has been recognized as the
engine room for growth and development because health is the basis for job productivity,
the capacity to learn in school, and the capability to grow intellectually, physically and
emotionally. Access to healthcare services on a sustainable basis in any country is an
important obligation of government and the fundamental right of the citizens, through
direct participation in the health delivery system and good legislature on health.
2.0 OBJECTIVES
• understand healthcare financing

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• understand the relationship between financing and healthcare delivery

• explain the financial constraints of healthcare delivery in developing countries
3.0 MAIN CONTENT
3.1 Healthcare Financing
Healthcare financing can be defined as the mobilization of funds for healthcare service
delivery. Healthcare financing involves acquiring and using funds and resources to carry
out activities developed by the government to sustain the health of her population. These
activities include the provision of medical and related services aimed at maintaining sound
health through disease prevention and control and clinical (curative) treatments.
Concisely, the concept of healthcare financing deals with the quantity and quality of
resources that the country spends on healthcare for her population. The amount of these
resources is proportional to the country’s total national income. The proportion of resources
allocated for healthcare in a country can be said to be indicative of the value placed on
healthcare in relation to other competitive demand categories of goods and services.
In some quarters, it has been inferred that the characteristics of healthcare financing can be
used to describe the structure and the behaviour of different stakeholders and the quality of
health outcomes. The relationship between healthcare financing and the provisioning of
health services can thus be referred to as complex, intertwined and inseparable.
3.2 Sources of Healthcare Financing
Healthcare can be funded either publicly or privately such as through taxation or insurance,
(also known as single-payer systems), or voluntary private health insurance respectively.
Some common sources of funding for healthcare financing include the following;
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Out-of-pocket payments: Out-of-pocket payments (OOPs) are defined as direct

payments made by individuals to health care providers at the time of service use. This
excludes any prepayment for health services, for example, in the form of taxes or
specific insurance premiums or contributions. Out-of-pocket payments are part of the
health financing landscape in all countries relying on user fees and co-payments to
mobilize revenue, rationalize the use of health services, contain health system costs or
improve health system efficiency and service quality. This is the most common method
of healthcare financing in developing countries.
Tax-based revenue: The health financing system, where government revenues are drawn
from tax deductions across all levels and sectors as the primary source of funding for
healthcare expenditure is referred to as tax-based systems. The burden of healthcare
funding is mainly shared over a larger population than in other systems.
Donor funding: Governments of many developing countries usually cannot bear the
burden of healthcare financing for their populations alone due to declining economies. As
such, donor countries such as the United States of America through the United States
Agency for International Development (USAID) and international organizations such as
World Health Organization (WHO) and United Nations Children’s Emergency Fund
(UNICEF) among others give financial assistance to developing countries to support their
socio-economic growth and health development usually in the form of loans and/or aid
grants. The donor countries gives about 0.7% of their gross national product as Official
Development Assistance (ODA) to developing countries.
Social health insurance: Social Health Insurance (SHI) is a form of financing and
managing health care based on risk pooling. SHI pools both the health risks of the people
on the one hand, and the contributions of individuals, households, enterprises, and the
government on the other. Thus, it protects people against financial and health burden and
is a relatively fair method of financing health care.
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Community-based health insurance: The community-based health insurance is a scheme

which has a prepayment mechanism with pooling of health risks and of funds taking place
at the level of the community or a group of people who share common characteristics (such
as geographical or occupational). It is designed to provide financial protection from the
cost of seeking health care. It has three main components; prepayment for health services
by community members, community control, and voluntary membership
Private health insurance: The private health insurance is directly and voluntarily funded
by prepayment by the insured members. Private health insurance has historically been
characterized as voluntary, for-profit commercial healthcare coverage. Private health
insurance is playing an increasing role in both high- and low-income countries; however,
the distinctions between private and public health insurance are poorly understood by
researchers and policy-makers.
3.3 Financial Constraints of Healthcare Delivery in Developing Countries
Healthcare financing in the developing world is greatly dependent on out-of-pocket or user-

charge payments. Regrettably, there’s limited access to money in households for out-of-
pocket financing in many poor countries due to economic challenges and this becomes a
binding constraint on health care use. Risk pooling and cross-subsidization, possible with
pre-payments systems, break the dependency of health care utilization on current income.
Financing healthcare through out-of-pocket payments makes healthcare delivery prices a

significant determinant of demand. These prices are usually substantial, and there is strong
empirical support for the suggestion that the poor are more price-sensitive than the rich.
These expensive user charges tend to skew healthcare access towards the rich than the poor
unless effective mechanisms are implemented to shield the poor from these charges.
Furthermore, informal charges are sometimes introduced in many public health care
systems, and they also increase healthcare costs substantially.
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Besides charges paid to the healthcare service providers, travel costs, waiting time and
predetermined earnings are important costs of accessing healthcare in the developing
world. In rural areas, the distances to healthcare facilities and the poor condition of roads,
mean that time, effort and cost needed to arrive at the point of healthcare delivery can be
substantial. There is evidence supporting the expected negative impact of these constraints
on health care utilization in developing countries.
4.0 CONCLUSION
In this unit, we have looked at what healthcare financing entails, the importance and
relationship between funds and healthcare service delivery, the common models of
healthcare financing and financial constraints to healthcare service delivery in developing
countries. Developing countries have dwindling economies which affect the allocation of
resources to healthcare, thus making out-of-pocket payments the main source of healthcare
financing individuals and households. Increased healthcare costs coupled with low wages
have reduced access to healthcare in developing countries.
5.0 SUMMARY
• Healthcare financing can be defined as the mobilization of funds for healthcare

service delivery.
• Healthcare can be funded either publicly or privately.
• Some common sources of funding for healthcare financing include Out-of-Pocket

payments, Private health Insurance, Community-based Insurance etc.
• Healthcare financing in the developing world is greatly dependent on out-of-pocket

or user-charge payments.
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1. What is healthcare financing?
2. Mention five sources of healthcare financing
3. Explain the financial constraints of healthcare delivery in developing countries
Metiboba, S. (2012). Contemporary Issues in Health Sociology (A revised and enlarged

edition): Owerri, Banter Multimedia Network.
Mladoysky, P. & Mossialos, E. (2008). A Conceptual Framework for Community-Based
Health Insurance in Low-Income Countries: Social Capital and Economic
Development. World Development, 36 (4):590 - 607.
Neelam Sekhri & William Savedoff (2005). Private health insurance: implications for
developing countries. Bulletin. Press Release World Health Organization. Volume
83, Number 2, February 2005, 81-160
O'Donnell. O. (2007). Access to health care in developing countries: breaking down
demand side barriers. Cad. Saúde Pública vol.23 no.12 Rio de Janeiro. Dec. 2007
http://dx.doi.org/10.1590/S0102-311X2007001200003
Oyefabi, AO., Aliyu, AA. & Idris, A. (2014). Sources of Healthcare Financing among
Patients at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Journal
of Medicine in the Tropics, 16(1):27-31.
Popoola, O. E. I., Omolola O. and Oginni, M. O. (2015). Financing Health Systems in
Nigeria: Current Trends and Prospects. International Journal of Health Sciences &
Research Vol.5; Issue: 2; pp. 343 – 353. (www.ijhsr.org).
Rao, S.K., Salvaraju, S., Nagpal, S. & Sakthivel, S. (2005). Health Financing in India.
Available online:www.whoindia.org/:/. Commission on Macroeconomics and Health
Finance
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Riman, H.B. & Akpan, E.S. (2015). Healthcare Financing and Health outcomes in Nigeria:
A State Level Study using Multivariate Analysis. International Journal of Humanities
and Social Science, 2(15): 296-309.
Uzochukwu, B.S.U., Ughasoro, M.D., Etiaba, E., Okwuosa, C., Envuladu, E. and
Onwujekwe, O.E. (2015).. Health care financing in Nigeria: Implications for
achieving universal health coverage. Nigerian Journal of Clinical Practice.2 015 Jul-
Aug 18 (4):437-44. doi: 10.4103/1119-3077.154196.
World Health Organization (2018). Health financing policy. Geneva. Accessed
29/01/2018.
World Health Organization (2018). Out-of-pocket payments, user fees and catastrophic
expenditure. http://www.who.int/health_financing/topics/financial-protection/out of pocket-
payments/en/. Accessed 29/01/2018
World Health Organization (2003). Social Health Insurance. Report of a Regional Expert
Group Meeting New Delhi, India, 13-15 March 2003. Accessed 29/01/2018
World Health Organization (2018). Characteristics of Community-Based Insurance
http://www.who.int/health_financing/topics/community-based-health-insurance/key
characteristics/en/. Accessed 29/01/2018.
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UNIT 4 ECONOMIC DEMOGRAPHY AND GLOBAL HEALTH
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Definition of Terms
3.2 Health and Demography
3.3 Economic Growth and Health
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Studies have shown that high levels of population health are associated with higher national
income. This is expected as higher population incomes promote better health through
improved nutrition, improved access to safe water and sanitation, and increased ability to
purchase more and better‐quality health care. The dynamics of this relationship will be
further studied in this unit.
2.0 OBJECTIVES
• define important terms

• understand the relationship between demography and health
• understand the relationship between economics and health
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3.0 MAIN CONTENT
3.1 Definition of Terms
Demography is the study of vital statistics in human populations, including size, growth,
density, skewness and distribution.
Demographic economics: it is the application of economic analysis to demography. It is
also known as population economics.
Global health: it is the health of populations in the global perspective. It has been defined
as the area of study, research and practice that places a priority on improving health and
achieving equity in health for all people worldwide. The focus is often placed on problems
that exceed national borders or have a global political and economic impact. Thus, global
health is about worldwide health improvement, reduction of disparities and protection
against global threats that disregard national borders. Measures of global health include
Disability-adjusted life years, Quality-adjusted life years and mortality rate.
Disability-Adjusted Life Years (DALYs): The DALYs is a summary measure that

combines the impact of illness, disability, and mortality by measuring the time lived with
disability and the time lost due to premature mortality. One DALY can be thought of as
one lost year of "healthy" life. The DALYs for a disease is the sum of the years of life lost
due to premature mortality and the years lost due to disability for incident cases of the
health condition.
Quality-Adjusted Life Years (QALYs): QALYs combined the expected survival with
expected quality of life into a single number: if an additional year of a healthy life is worth
a value of one (year), then a year of less healthy life is worth less than one (year). QALY
calculations are based on measurements of the value that individuals place on expected
years of survival.
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3.2 Health and Demography
An upgrade in health status and reduced mortality rates can consequently lower fertility
and mortality rates. Population growth is the difference between birth and mortality rates
(excluding migration) and the global population explosion in the last century can be
attributed to improvements in health and dropping mortality rates. In developing countries,
progress in health, especially maternal and child health interventions tend to reduce infant
and child mortality rates, resulting initially to a surge in the number of children. Reduced
infant mortality, increased numbers of surviving children and rising wages for women can
also reduce desired fertility leading to smaller cohorts of children in future generations.
Improved access to family planning can also help couples match more closely their fertility
desires and realizations. However, recent health interventions have been targeted at the
elderly, reducing old‐age mortality and increasing the lifespan.
Theoretically, a sudden increase in the population reduces income per capita by putting
pressure on scarce resources and by reducing the capital-labour ratio. These theories imply
that population declines stimulate economic growth in per capita terms. However, these
theories seem not to apply to modern populations where only slight associations can be
inferred between overall population growth and economic growth. This was evident in the
last century in which population explosion and substantial rises in income levels were
observed.
High birth and low death rates both generate population growth, but seem to have quite
different effects on economic growth. This may be because, while both forces increase
population numbers, they affect the age structure quite differently. The effect of changing
age structure due to increased birth rate (baby boom) has significant effects as these
children (baby boomers) grow up and enter the workforce and then as they later retire. As
long as the baby boomers are of working age, economic growth may be spurred by a surplus
known as “demographic dividend” provided that the baby boom generation can be
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productively employed. The demographic dividend increases the potential labour supply
but its effect on economic growth depends on the policy environment.
3.3 Economic Growth and Health
Increased income levels result in increased health expenditure, as it is a function of income.

On average, it has been proved that increased health expenditure leads to improvements in
health. Moreover, wealthier persons are more likely to spend a more substantial proportion
of their disposable income on better quality nutrition, hence, positively impacting their
health status. In theory, health is a determinant of human capital and labour productivity.
Therefore, health expenditures as investments in health should result in higher income
levels.
The effect of health on individual productivity implies a relationship between population

health and total output. In 2003, Shastry and Weil standardized a production function
model of total output using microeconomic estimates of the return to health. They assumed
a stable relationship between average height (income levels) and adult survival rates so that
when adult survival rates improve, it can be inferred that there will be a rise in population
heights.
4.0 CONCLUSION
Demographics have a direct effect on the economic status of populations as a large working
population ensures productivity and increased income. This, in turn, improves the health
of populations through improved healthcare provision and access.
5.0 SUMMARY
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• Demography is the study of human populations, including size, growth, density,

distribution, and vital statistics.
• Demographic economics is the application of economic analysis to demography. It
is also known as population economics.
• Global health is the health of populations in a global perspective.
• The DALYs is a summary measure that combines the impact of illness, disability,
and mortality by measuring the time lived with disability and the time lost due to
premature mortality.
• QALYs combine expected survival with the expected quality of life into a single
number
• a sudden increase in the population reduces income per capita by putting pressure
on scarce resources and by reducing the capital-labour ratio.
• The effect of health on individual productivity implies a relationship between
population health and total output.
1. Define demographic economics and global health
2. Explain economic growth and health
3. Explain the meaning of the two terms; DALYs and QALYs
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Bloom, D.E. and Canning, D. (2008). Population Health and Economic Growth.
Commission for Growth and Development. Working Paper No 24.
Etches, V., Frank, J., Di Ruggiero, E. and Manuel, D. (2006). Measuring population health:
a review of indicators. Annual Review of Public Health. 27: 29-55
doi:10.1146/annurev.publhealth.27.021405.102141
Kelley, A.C. and Schmidt, R.M. (2008). The New Palgrave Dictionary of Economics: 655.
doi:10.1057/9780230226203.0428
Lee, R. 2003. The Demographic Transition: Three Centuries of Fundamental Change.
Journal of Economic Perspectives 17(4): 167–90.
Martin, S., Rice, N. and Smith, P.C. (2008). Further evidence on the link between
healthcare spending and health outcomes in England. London: The Health
Foundation.
Odrakiewicz, D. (2012). The Connection Between Health and Economic Growth: Policy
Implications Re-examined. Global Management Journal. ISSN 2080-2951.
Shastry, G. K. and D. N. Weil. 2003. How Much of Cross‐Country Income Variation Is
Explained by Health? Journal of the European Economic Association 1: 387–96.
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UNIT 5 HEALTH POLICY AND ECONOMICS
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Concept of Health Policy
3.2 Relationship between Health Policy and Economics
3.3 Health Policies in Nigeria
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Most political discourses surround personal healthcare policies, especially those that seek
to reform healthcare delivery, and they are usually approached from an economic
perspective. This often includes how to maximize the efficiency of healthcare delivery and
minimize costs. To achieve this, enabling environment should be created through
government statements, initiate sound policies and implement them through appropriate
legislations that allow for effective healthcare delivery.
2.0 OBJECTIVES
• understand the concept of health policy

• identify health policies in Nigeria
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3.0 MAIN CONTENT
3.1 Concept of Health Policy
According to the World Health Organization, health policy can be defined as the
"decisions, plans, and actions that are undertaken to achieve specific healthcare goals
within a society. The World Health Organization, states that health policy can achieve the
following aims; define a vision for the future, outline priorities and the expected roles of
different groups and build consensus and informs people.
Health policies are used to focus on the financing of healthcare services in order to spread
the economic risks and burdens of ill health. Health policy may involve issues regarding
financing and delivery of healthcare, access to care, quality of care and health equity. There
are many categories of health policies such as; global health policy, public health policy,
mental health policy, health care services policy, insurance policy, personal healthcare
policy and pharmaceutical policy, among others.
Health policy and its implementation is complex. Health policy should be understood as
more than a national law that supports a programme or intervention. Operational policies
are the rules, regulations, guidelines and administrative norms that governments use to
translate national laws and policies into programmes and services. The policy process
encompasses decisions made at a national or decentralized level (including funding
decisions) that affect whether and how services are delivered. Thus, attention must be paid
to policies at multiple levels of the health system and over time to ensure sustainable scale-
up. A supportive policy environment will facilitate the scale-up of health interventions.
3.2 Relationship between Health Policy and Economics
The interaction between health and the economy provides direction for investments in
health and the design of health financing policies. Just as growth, income, investment and
employment are a function of the performance and quality of the economic system, its
regulatory frameworks, trade policies, social capital and labour markets; so, health
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conditions (mortality, morbidity, disability) depend not just on standards of living, but on
the actual performance of health systems themselves.
Health performance and economic performance are interlinked. Wealthier countries have
healthier populations. It is common knowledge that poverty directly impacts life
expectancy. National income has a direct effect on the development of health systems,
through insurance coverage and public spending. The relationship between health policy
and economics can be shown in efficient fiscal systems practised in some countries which
have led to increases in taxes on certain health-threatening substances such as tobacco.
These tax increases could be used to reinforce other public health policies like rule-based
restrictions on smoking in public places.
Policymakers often run into a dilemma in trying to strike a balance between increasing
funding for healthcare and cutting funding from other important areas of the economy. The
challenge is to harmonize health and economic policies to improve health outcomes, as
well as to minimize any negative impacts of compromises made while promoting support
where necessary.
3.3 Health Policies in Nigeria
The following are some of the existing health policies in Nigeria;
National Health Policy (2005): It encourages the participation of communities and

households in community-based financing programmes for primary healthcare services as
well as public-private partnerships and collaborations for the growth and development of
healthcare financing alternatives across all operational levels.
National Health Financing Policy (2006): It was designed to advance equity and access
to quality and affordable health care and to ensure a high level of efficiency and
accountability in the system through developing a fair and sustainable financing system.
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National Strategic Health Development Plan (2010): The aim of the policy is to ensure
that adequate and sustainable funds are available and allocated for accessible, affordable,
efficient, and equitable health care provision and consumption at local, state and federal
levels.
4.0 CONCLUSION
Health policies provide direction and focus for healthcare delivery. It can be an important
tool for governments in backing and ensuring financial investments in healthcare and
enforcing public health initiatives. However, oftentimes policymakers have to make
decisions on providing the necessary resources for healthcare while trying to minimize
impacts on other areas of the economy.
5.0 SUMMARY
• Health policies are the "decisions, plans, and actions that are undertaken to achieve
specific healthcare goals within a society.
• Health policy may involve issues regarding financing and delivery of healthcare,
access to care, quality of care and health equity.
• Health policies are used to focus on the financing of healthcare services in order to
spread the economic risks and burdens of ill health.
• The interaction between health and the economy provides direction for investments
in health and the design of health financing policies
• Health performance and economic performance are interlinked.
• Existing health policies in Nigeria include; National Health Policy, National Health
Financing Policy and National Strategic Health Development Plan.
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1. What is health policy?
2. Summarize the relationship between health policy and economics
3. List the health policies in Nigeria
Brown, T. M.; Cueto, M.; Fee, E. (2006). "The World Health Organization and the
Transition from "International" to "Global" Public Health". American Journal of
Public Health. 96 (1): 62–72. doi:10.2105/AJPH.2004.050831.
Cross, H, N Jewell and Karen Hardee. (2001). Reforming Operational Policies: A Pathway
to Improving Reproductive Health Programs POLICY Occasional Paper. No. 7.
Washington DC: The Futures Group International, POLICY Project
FMOH. National Health Financing Policy. Abuja, Nigeria: Federal Ministry of Health;
2006. Accessed 29/01/2018.
FMOH. Revised National Health Policy. Abuja, Nigeria: Federal Ministry of Health;
(2005). Accessed 29/01/2018.
FMOH. The National Strategic Health Development Plan (National Health Plan) (2010-
2015). Abuja, Nigeria: Federal Ministry of Health; 2010. Accessed 29/01/2018.
Hardee, K., Ashford, L., Rottach, E. Jolivet, R. and Kiesel, R. (2011). The Policy
Dimensions of Scaling Up Health Initiatives. Washington, DC: Futures Group, Health
Policy Project
Kereiakes, D. J.; Willerson, J. T. (2004). "US Health Care: Entitlement or Privilege?"
Circulation 109 (12): 1460 1462. doi: 10.1161/01. CIR.0000124795. 36864.78.
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OECD Observer (2004). Health and the economy: A vital relationship. OECD Observer
No 243, May 2004. Accessed 01/02/2018.
World Health Organization (2018). Health and Human Rights. Geneva. Accessed
29/01/2018
World Health Organization (2018). Health Policy. Accessed 29/01/2018.
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MODULE 3 LEADERSHIP AND POLITICAL ECONOMY OF HEALTH

SECTOR REFORM
Unit 1 Health services administration
Unit 2 Health sector reform: a worldwide perspective
Unit 3 Leadership and management in global health
Unit 4 Global health politics and policy
Unit 5 The political economy of global health
UNIT 1 Health Services Administration/Delivery

CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.1 Definition and concept
3.2 Healthcare delivery in Nigeria
3.3 Major challenges of Healthcare delivery in Nigeria
4.0 Conclusion
5.0 Summary
7.0 References/Further Readings
1.0 INTRODUCTION
Good service delivery is a vital element of any health system. Service delivery is a
fundamental input to population health status, along with other factors, including social
determinants of health. The precise organization and content of health services will differ
from one country to another. The need for improvement in the delivery of health services
can be pictured as the gap between what available funds and technologies could achieve
and what they do achieve in specific countries, districts, and communities.
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2.0 OBJECTIVES
At the end of this unit, you will able to:
• understand the concept of health service administration/delivery

• challenges of Healthcare delivery in Nigeria
3.0 MAIN CONTENT
3.1 Definition and Concept

The Healthcare industry is one of the largest industries in the service sector, the provision
of healthcare services is a critical aspect of service delivery for any nation’s economy to
survive and for people therein to prosper.
Health service delivery systems that are safe, accessible, high quality, people-centred, and
integrated are critical for moving towards universal health coverage. Service delivery
systems are responsible for providing health services for patients, persons, families,
communities, and populations in general, and not only care for patients. While patient-
centred care is commonly understood as focusing on the individual seeking care (the
patient), people-centred care encompasses these clinical encounters and also includes
attention to the health of people in their communities and their crucial role in shaping health
policy and health services.
People-centred and integrated health services are critical for reaching universal health
coverage. People-centred care is care that is focused and organized around the health needs
and expectations of people and communities, rather than on diseases. Whereas patient-
centred care is commonly understood as focusing on the individual seeking care (the
patient), people-centred care encompasses these clinical encounters and also includes
attention to the health of people in their communities and their crucial role in shaping health
policy and health services.
Integrated health services encompass the management and delivery of quality and safe
health services so that people receive a continuum of health promotion, disease prevention,
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diagnosis, treatment, disease management, rehabilitation and palliative care services,

through the different levels and sites of care within the health system, and according to
their needs throughout the life course. The WHO is supporting countries in implementing
people-centred and integrated health services by way of developing policy options, reform
strategies, evidence-based guidelines and best practices that can be tailored to various
country settings.
Service delivery systems should also consider the whole spectrum of care from promotion
and prevention to diagnostics, rehabilitation and palliative care, as well as all levels of care
including self-care, home care, community care, primary care, long-term care, hospital
care, to provide integrated health services throughout the life course. World Health
Organization is supporting countries in moving towards universal health coverage through
improving the efficiency and effectiveness of their health service delivery systems.
Good service delivery is a vital element of any health system. Service delivery is a
fundamental input to population health status, along with other factors, including social
determinants of health. The precise organization and content of health services will differ
from one country to another. The need for improvement in the delivery of health services
can be pictured as the gap between what available funds and technologies could achieve
and what they do achieve in specific countries, districts, and communities. Low-
performance levels for health care–delivery systems as a whole means that performance
indicator averages are below what could be attained and is being attained by other,
comparable systems. In many low- and middle-income countries, the overall level of health
service–delivery performance is not what it could be.
The delivery of services is the immediate output of all the inputs into the delivery system.
The organisation of this delivery determines, to a large extent if the inputs lead to the
desired output: access to quality care. Delivery of health services is produced at the
interface with the population. The most atomized product of this is the interaction between
a single health provider and patient. However, from the perspective of a (national or local)
HS perspective, it comprises the total of services in a specified area. The word ‘health
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service’ can refer both to the organisation that supplies care and to the specific product
which is delivered.
When we talk about health services, we mean all services that have as a primary purpose
the improvement of health. The term includes general health care and services that are
aimed at specific health problems; disease control interventions and services responsive to
the suffering of individuals; preventive and curative services; personal health services and
population-based activities. There are many other terms with a different focus, for instance,
on the level of care or the package of services. Examples of other terms are ‘health care’,
‘primary health care’, ‘essential services’ or ‘priority interventions’ services. We will use
‘service’ as a generic term, which can refer to all of the above. Health services are thus
very diverse in nature. Besides, these services are delivered to the population via multiple
modes and channels. Health services include all services dealing with the diagnosis and
treatment of a disease condition, or the promotion, maintenance and health restoration.
Some concepts that have frequently been used to measure health services remain extremely
relevant and are part of the key characteristics. For example, access, availability,
utilization, and coverage have often been used interchangeably to reveal whether people
are receiving the services they need. Access is a broad term with varied dimensions: the
comprehensive measurement of access requires a systematic assessment of the physical,
economic, and socio-psychological aspects of people’s ability to make use of health
services. Availability is an aspect of comprehensiveness and refers to the physical presence
or delivery of services that meet a minimum standard. Utilization is often defined as the
quantity of health care services used. Coverage of interventions is defined as the proportion
of people who receive a specific intervention or service among those who need it.
A routine facility reporting system often referred to as a Health Management Information

System (HMIS), is generally used to monitor and compare service delivery. Service data
are generated at the facility level and include key outputs from routine reporting on the
services and care offered and the treatments administered. Reporting may include
supervisory or clinic-reported data on medicine stock-outs in a defined reference period
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(e.g. during the last month), functioning of outreach services and availability of health
workers. Because the data are routinely collected (often monthly or quarterly), it provides
information on a continuous basis for time and seasonal trend analyses.
Strengthening service delivery is crucial to the achievement of the health-related

Millennium Development Goals (MDGs), which include the delivery of interventions to
reduce child mortality, maternal mortality and the burden of HIV/AIDS, tuberculosis, and
malaria. Service provision or delivery is an immediate output of the inputs into the health
system, such as the health workforce, the logistics of procurement, supplies, and financing.
Increased inputs should lead to improved service delivery and enhanced access to services.
Ensuring the availability of health services that meet a minimum quality standard and
securing access to them are key functions of a health system.
Sufficient funding and efficient technology are necessary conditions for achieving health
gains, but experience in many countries confirms that they are not sufficient. Effective and
efficient service delivery is the point at which the potential of the health system to improve
lives meets the opportunity to realize health gains. Health service–delivery performance
means to access and use by those in need; adequate quality of care to produce health
benefits; efficient use of scarce resources; and organizations that can learn, adapt, and
improve for the future. All too often, potential benefits are not realized because service
delivery underperforms.
The World Health Organization judges the performance of a health system against four
goals; health, responsiveness, fair financing and financial risk protection. Responsiveness
has however remained a key issue of concern among the four goals. It is defined as the
degree to which a health system is able to meet the expectations of patients and their
families in areas not directly related to healthcare delivery. These areas include:
• The ability of healthcare workers to show respect for the patients irrespective of
their status, background or colour.
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• Patients are getting prompt attention (i.e. immediate attention during emergencies
and reasonable waiting times for non-emergencies).
• Access to amenities of adequate quality and to hospitals/clinics that are clean,
spacious and serve quality food.
• Autonomy of people to take part in making choices about their health.
• The ability of patients to choose either a provider or the flexibility to pick which
individual or organization that should deliver their care.
Deliberate efforts have been made by the Federal Government of Nigeria to initiate and
sustain health sector reforms over the past years. The reform of this sector is predicated
upon the fact that it is characterized by poor quality and inefficiencies in the provision of
public sector health services, resulting in poor health outcomes and poor performances in
the basic health indicators.
3.2 Healthcare Delivery in Nigeria
The tertiary level of healthcare in Nigeria is the domain of the Federal Government,
secondary or intermediate care level is being administered by the state governments and
the primary health care, that is the lowest governmental level of health care under the
jurisdiction of the local government areas.
The tertiary level that the responsibility rests with the Federal Ministry of Health headed
by the Minister of Health is the highest level of healthcare and it provides a mutually
supportive referral system to the secondary care level. It provides specialist and
rehabilitative, while the secondary level provides mutually supportive referral system to
the primary health care level that provides at least the essential elements of primary health
care that are delivered at the first point of contact between individuals and the health care
system. Health service delivery structures are also largely tiered, and federal and state
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parastatal and agencies have been created to implement programmes and manage services
across different levels.
The primary health care system is a grass-roots approach meant to address the main health
problems in the community, by providing preventive, curative and rehabilitative services
(Olise, 2012). As defined in the Alma Ata declaration, primary health care is the “essential
care based on practical, scientifically sound and socially acceptable methods and
technology, made universally accessible to individuals and families in the community
through their full participation, and at a cost that the community and country can afford to
maintain at every stage of their development in the spirit of self-reliance and self-
determination” (WHO, 2012). In Nigeria, primary healthcare was adopted in the National
Health Policy of 1988 (FMOH, 2004) as the cornerstone of the Nigerian health system as
part of efforts to improve equity in access and utilization of basic health services
(Aigbiremolen et al., 2014). Since then, primary health care in Nigeria has evolved through
various stages of development. In 2005, primary health care facilities were found to make
up over 85% of health care facilities in Nigeria (FMOH, 2010).
The general understanding is that while policy development remains the responsibility of
the Federal Government for those health issues that have national impact and cross-border
implications, State Governments may choose to respond to these national directions in the
context of local priorities they have established. They also develop their policy documents
to which state budgets respond. Responsibility for service delivery is also shared among
the three tiers of government.
Again, the general understanding is that the Federal Government is responsible for tertiary
care and training of selected health professionals, state governments for secondary care and
supervisory oversight of local government health units which are, in turn, responsible for
the provision of primary care service delivery activities and its integration community-
based outreach and support activities. While the organization of the health sector seems
well-coordinated, the practical workings of the systems are not as seamless as depicted.
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There is often a duplication and confusion of roles and responsibilities among the different
tiers of government - the weakness in coordinating and tracking performance and
benchmarking.
The tiered health service delivery system in Nigeria has, over the years, been plagued by
sundry factors including inadequate funding and management, disconnect between health
policy initiatives, reforms, and programmes of different regimes and weak institutional and
human capacity building.
3.3 Major Challenges of Healthcare Delivery in Nigeria
With a teeming population of over 180 million people, Nigeria has continued to grapple
with the challenge of creating an efficient healthcare delivery system. Healthcare services
in Nigeria have been and are still very poor. With the poor quality of governance in Nigeria,
the delivery of services in the public health sector has notably continually been constrained.
Arguably, some incremental efforts have been made in terms of policy formulation and
programme execution; such efforts have not significantly translated into concrete
improvement and enhancement of public service delivery in the health sector.
Two plausible explanations for the poor performance are the decline in governance and
near absence of quality culture. There is, therefore, a growing recognition and acceptance
by governments that they do not need to dominate the provision of services. They only
need, as a matter of exigency, to provide the enabling environment and play their roles in
an increasingly complex governance environment. As a consequence, the current focus on
governance as the totality of institutional structures within a political community as distinct
from government that is the state’s instrument for formulating and implementing public
health sector policy and regulations helped to strengthen the case for institutional capacity
and diversity for the efficient and effective delivery of public services in the developing
world like Nigeria.
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The absence of an adequate and effective management regime in the Nigeria health care
delivery system contributes to the weakness in health management capacities at all levels
of public and private health institutions. Such a weakness creates a high propensity for
error in the implementation of health care policies. Feedback from healthcare receivers has
shown that many healthcare workers have come short of the various indicators of
responsiveness. Nigeria falls short of several indicators of frequent occurrences of
disrespect towards patients during treatments and unduly long waiting times for non-
emergency treatment among others. The lack of basic hospital amenities, the prevalence of
small clinic spaces and non-compliance with the required basic water supply within 500m,
basic sanitation conveniences, hand-hygiene and hand-washing standards continue to
contribute to the declining quality of healthcare in Nigeria.
A world health report which specifically focused on the overall performance of health
systems around the world ranked Nigeria 177 out of a total of 191 countries, on its degree
of responsiveness to healthcare needs. The 2011 world health statistics show that Nigeria
had only four doctors and 16 nurses per 10,000 people. This means that one doctor attends
to 2500 patients and one nurse to 155 patients. The major challenges faced by the Nigerian
health sector include inadequate facilities, inadequate training for doctors, inadequate
funds, incessant strikes by healthcare workers, the erratic electricity supply, flooding the
market by fake and adulterated drugs, and emigration of experienced health professionals
and less than five percent of the national budget focused on health. All of these realities
and more are caused by poor institutional arrangements, defective functional relationships,
and management mechanism as a result of the absence of formal planning, clear objectives
or a realistic appraisal of available resources in many aspects of healthcare delivery in the
country.
One of the limitations to the full achievement of a universal healthcare delivery system is
the limited coverage of Nigerians under Social Health Insurance. The National Health
Insurance Scheme (NHIS) in Nigeria was established under Act 35 of the 1999 Constitution
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by the Federal Government of Nigeria to improve the health of all Nigerians at an

affordable cost through various prepayment systems. Through this scheme, universal
coverage for all Nigerians is targeted at an affordable cost.
By its structure, it aims to provide social health insurance in Nigeria on a contributory basis
where health care services of contributors and their dependents are made from a common
pool of fixed, regular amounts made by the contributors. However, the coverage of the
National Health Insurance Scheme is still below 5%. Some of the reasons for this can be
attributed to ignorance, weak governance, funding etc. Most people covered that make up
this 5 percent are workers in paid employment where a direct deduction from their wages
(their contribution) is made into the pool. The larger uncovered population is mostly the
unemployed who live in rural areas. There are people in paid employment who are yet to
key into this plan for lack of proper machinery that seeks to enforce the provisions of the
act setting up the scheme.
4.0 CONCLUSION
Health services are the most visible functions of any health system, both to users and the
general public. Effective health service delivery in any country is engendering an
acceptable programme that will assist the country to provide health care to populations
having insufficient or no access to health services.
5.0 SUMMARY
In this unit, we have learned that:
• Health service delivery systems that are safe, accessible, high quality, people-
centred, and integrated are critical for moving towards universal health coverage.
• The organizational structure of the Nigerian healthcare system suffers from a lack
of specificity and ambiguities in the definition of roles and responsibilities of the
three tiers of the system.
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1. Explain the role of health service delivery systems in the attainment of universal
health coverage.
2. Discuss the possible ways of solving the myriad of challenges facing the Nigerian
healthcare system.

Aigbiremolen, A.O., Alenoghena, I., Eboreime, E. and Abejegah, C. (2014). Primary
Health Care in Nigeria: From Conceptualization to Implementation. Journal of
Medical and Applied Biosciences. 6(2): 35-43.
Berman, P., Pallas, S., Smith, A.L., Curry, L. and Bradley, E.H. 2011. Improving the
Delivery of Health Services: A guide to choosing strategies. Pp 1-78.
CIUCI Consulting. Nigeria’s Healthcare delivery: The missing links.
Federal Ministry of Health (FMOH), Nigeria. Revised National Health Policy. In. Abuja:
Federal Ministry of Health; 2004.
Federal Ministry of Health (FMOH), Nigeria. National Strategic Health Care Development
Plan 2010-2015.
Olise P. (2012): Primary Health Care for Sustainable Development. 2nd ed. Abuja: Ozege
Publications. Pg. 17.
Oyibo, E.E. (2010), “Organization and Management of Health Services in Nigeria: The
State of the Art” Lagos: Amfhop Books.
World Health Organization. 2008. Service Delivery. Toolkit on monitoring health systems
strengthening.
World Health Organization (2012). Declaration of Alma Ata’, Report on the International
Conference on Primary Health Care, World Health Organisation, September 1978.
Available Online at http://www.who.int.
World Health Organization. 2017. Health services.
http://www.who.int/topics/health_services/en/. Accessed 19/12/17.
World Health Organization. 2017. Health systems service delivery.
http://www.who.int/healthsystems/topics/delivery/en/. Accessed 19/12/17.
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UNIT 2 HEALTH SECTOR REFORM: A WORLDWIDE PERSPECTIVE
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.2 Principles of health reform processes
3.3 Health Sector Reform in Nigeria
3.4 PHC Under One Roof in Nigeria
3.5 Issues in Health Sector Reform
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Health is wealth, and according to the WHO constitution adopted in 1948, health is defined
as a state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity. It is an essential carrier for economic growth and development.
Good health is a critical input into poverty reduction, economic development at the scale
of whole societies. In every country, the health sector is vital to both social and economic
development. Health is central to sustainable development and wellbeing. High quality and
affordable healthcare delivery, both at primary and tertiary levels, is a necessary condition
for the development of human capital.
2.0 OBJECTIVES

• understand what is health sector reform
• understand the issues affecting health sector reform
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3.0 MAIN CONTENT
3.1 Definition
Health sector reform implies more than just an improvement in health or health care. Health
Sector Reform (HSR) is a sustained process of fundamental change in policies, regulation,
financing, provision of health services, re-organization, management and institutional
arrangements, which is led by government and designed to improve the performance of the
health system for the better health status of the population. Health sector reform is aimed
at improving the functioning and performance of the health sector and, ultimately, the
health status of the population. It deals with equity, efficiency, quality, financing, and
sustainability in the provision of health care, and also in defining the priorities, refining the
policies and reforming the institutions through which policies are implemented.
Health sector reform is not only a health-related but also a development issue as health care
systems account for nine percent of global production and a significant portion of global
empowerment. Health sector reform implementation varies across different countries and
regions of the world, indeed states within a country. This is because of differences in
values, goals and priorities.
3.2 Principles of health reform processes
The three main principles of health reform processes are equity, efficiency and quality.
Equity
Equity refers to fairness. Equity in health is a major topic of discussion and literature. There
are two types of equity namely; vertical equity and horizontal equity. The equitable
distribution of health care among people of different levels of income is usually called
vertical equity (care should be available as a function of need, not income), while
distribution among people with the same health condition or need is called horizontal
equity (equal need should entail equal treatment). The underlying assumptions are that
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unequal health outcomes are unjust, that health services should be provided (or guaranteed)
socially, and that the distribution of costs and benefits should somehow be related to health
and wealth status.
Efficiency
Efficiency is a standard declared objective of reform in the public sector most especially
in the health sector. Many reform processes are led by the economic national authorities,
and are focused on public budget reduction, on changing the relative weight of fixed and
variable government expenditure, and on producing better services with the same (or
fewer) resources.
Quality
Technical quality refers to the impact of the health services on the health conditions of a
particular population. Technical quality is an important dimension of the providers'
performance. Sociocultural quality measures the degree of acceptability of services and
responsiveness to users' expectations.
3.3 Health Sector Reform in Nigeria
The Federal Ministry of Health has the responsibility to develop policies, strategies,
guidelines, plans, and programmes that provide direction for the national healthcare
delivery system. The Federal Ministry of Health is the main provider of tertiary healthcare
services and various other health intervention programmes aimed at promoting, protecting
and preventing ill health of Nigerians. In Nigeria, the health sector reform was initiated
and adopted in 2004 by the Obasanjo administration as a result of the prevailing poor health
status of the population.
The strategic focus of the 2004 HSR in Nigeria was as follows:
1. Improve the performance of the stewardship role of government
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2. Strengthen the national health system and improve its management
3. Improve availability of health resources and their management
4. Improve the access (including physical and financial) to quality health services
5. Reduce the disease burden attributable to priority health problems
6. Promote effective public-private partnership in health
7. Increase consumers’ awareness of their health rights and health obligations
Health reform actions by the Nigeria Government
The following health reform actions were undertaken by the Nigeria government
• National Strategic Health Development Plan (NSHDP):
This plan was developed by Jonathan’s administration in line with its Transformation
Agenda for the period 2010 to 2015 through a participatory approach. The major objective
of the program is to transform the health sector to enable it to better implement and institute
results-oriented programmes within the context of the millennium development goals
(MDGs) and national targets as enshrined in the National Vision 20:2020, and a new
national health plan.
The plan seeks to:
1. Reduce the morbidity and mortality rates due to communicable diseases to the barest
minimum
2. Reverse the increasing prevalence of non-communicable diseases
3. Meet global targets on the elimination and eradication of diseases
4. Significantly increase the life expectancy and quality of life of Nigerians
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• The Anti-Tobacco Bill of 2011:
The bill is a comprehensive law to regulate the manufacturing, advertising, distributing,

and consuming of tobacco products in the country by domesticating the WHO's Framework
Convention on Tobacco Control (FCTC). The bill aims to protect children from being
exposed to tobacco smoke as well as prohibiting every form of advertisement of tobacco
products which may encourage children to smoke including the sale of tobacco too, and
by, minors.
• The NAFDAC Act (Amendment) Bill 2013:
This is a bill that seeks to empower the agency to effectively carry out its functions. The
principal objective is to reduce the incidence and proliferation of drugs offences.
• The National Health Insurance Scheme Act (Amendment) Bill:
This bill is to ensure more effective implementation of health insurance policy that
enhances greater access to healthcare services by all Nigerians, as well as promote and
effectively regulate health insurance schemes in Nigeria.
• Save One Million Lives Initiative (SOML):
The SOML Initiative was launched in October 2012 to provide quality health care services
for the underserved through a public/private partnership. This approach does not only focus
on providing inputs but also focus on delivery and impact. The SOML Initiative also
demonstrates Nigeria’s commitment to the UN Commission on Life-Saving Commodities
for Women’s and Children’s Health goal to save the lives of 6 million women and children
globally by 2015.
• SURE-P Maternal and Child Health Programme:
The programme recruits and deploys nurses, midwives, and community health extension
workers to designated healthcare facilities across the country to reduce maternal, newborn,
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and child morbidity through expanded access to an integrated package of quality maternal
and child health services in underserved and hard to reach communities across Nigeria.
• Midwives Service Scheme (MSS):
This programme aims at reducing maternal mortality by providing access to qualified and
adequate birth attendants to the underserved, especially in the rural areas.
• Community-Based Social Health Insurance:
This scheme seeks to raise the coverage of health insurance by reaching out to the rural
communities as well as the underserved. Under this scheme, rural communities pay only
₦150 monthly as a premium to benefit from the National Health Insurance Scheme.
• Quality Improvement and Clinical Governance Programme:
This programme aims at improving the quality of care in primary, referral, and tertiary
facilities. The quality improvement and clinical governance agenda assess quality
improvement through three prime lenses: patient safety, clinical outcomes, and patient
experience.
Other Policy Actions include:
• Establishment of the Centre for Disease Control

• Introduction of new vaccines
• Modernization of the Federal Teaching Hospitals
• Private Sector Involvement in the Health Sector
• Nutrition
3.4 Primary Healthcare Under One Roof in Nigeria
Primary health care under one roof (PHCUOR), also called Integrated PHC Governance is
a PHC reform promoted by the Government of Nigeria. It was introduced in 2005, aimed
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at integrating PHC structures and programmes in states by the Primary Health Care
Development Agency or Board (SPHCDA/B) within the framework of a decentralized
health system. The PHCUOR policy is premised on the principle of “Three Ones”- i.e., one
management, one plan and one monitoring & evaluation system. The PHCUOR was
adopted by the National Council of Health in Nigeria, progress with implementation has
been slow with States making varying degrees of progress on each domain, with Jigawa
recording the highest proportion in compliance implementation (80%), while states, such
as Ebonyi and Akwa Ibom recorded 0% (NPHCDA, 2015).
The PHCUOR guidelines outlines specific steps and approaches involved in establishing a
functional SPHCDA/B and consists of nine specific domains
• Governance
• Legislation
• Minimum Service Package
• Repositioning
• Systems Development
• Operational Guidelines
• Human Resources
• Funding Sources
• Structure and Office Setup
The 2015 PHCUOR scorecard 3 assessment showed that 28 States in Nigeria now have
State Primary Health Care Development Agencies with 26 of them having a legal
establishment basis. However, majority of the States’ establishment laws, and the bills in
process do not conform with the national guidelines. Also, most States with SPHCDAs or
equivalent structures, struggles with institutional repositioning and human resource
management as staff are managed and paid by their parent MDAs. In addition, most States
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with SPHCDAs are yet to establish the Local Government Health Authorities (LGHAs),
which are expected to be the implementing arm of the SPHCDAs, while only 8 States have
collapsed the LGA health departments into LGHAs. The implementation of PHCUOR
requires huge financial resources, but with improved services focussed to the primary
beneficiaries in resident domains.
3.5 Issues in Health Sector Reform
• Institutional corruption:
Corruption in the health sector is a major challenge worldwide. Institutional corruption is

the deliberate effort of some individuals to make an institution ineffective by working at
cross purposes to its goals thereby eroding public trust in the institution. Institutional
corruption places an enormous burden on poor people who are mostly unable to pay for
healthcare services.
In every health institution, improving the health of the nation should be of great importance
to the workers and this can be achieved by ensuring that initiatives aimed at reforming the
health sector are supported without prejudice, personal glorification, and deceit. These
improvements would increase public trust in the health sector, ensure the effective use of
financial resources for health, and produce increased investment in the health of the people.
Lack of development of previous governments’ policies by new administrations also
affects the process of HSR in the country. The culture of continuity should be imbibed by
government administrations. Improvements in the health of individuals in a nation should
be made a national priority and treated with the utmost importance among decision makers.
Health care financing reforms
The most marked reform in the health sector involves, securing sustainable financing for
health care. In most countries, the focus is on the contents of reforms rather than on the
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processes and these always caused failure or delay in implementation. A worldwide study,
with external assistance to the health sector from 1972 to 1990 revealed that smaller and
poorer countries received more funds from external assistance in health sector per capita
than larger and richer countries.
The fundamental principle of financing reforms is that health care funds are raised by the
people according to their ability to pay, and not according to health need. It is also equally
important that funds are spent according to health priority need, and not according to the
ability to pay.
Resource generation
The quality, quantity, and balance of human resources for health are the main concerns in
the health care delivery system. In most countries, there are still shortages of health
personnel, despite all attempts to expand training institutions and their production
capacities. This scarcity of workers is one of the reasons for high maternal mortality and
low accessibility of essential obstetric care during pregnancy and childbirth. Lack of
balance in the deployment of workers between the rural and urban areas is also an issue in
health sector reform.
Reform in the provision of healthcare
Most countries in the world, developed different sets of health care packages to ensure
good health delivery system and these include mother-baby package, baby-friendly
hospitals, health-promoting hospitals, Integrated Management of Childhood Illnesses
(IMCI), Safe Motherhood Initiative (SMI), EPI-plus, and recently, Making Pregnancy
Safer with support and guidance. These essential health packages aimed at improving
healthcare and increasing efficiency by making the best use of contact between health
workers and concentrating on the needs of the individual rather than focusing on the single
disease.
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4.0 CONCLUSION
Health is an essential carrier for economic growth and development. High quality and
affordable healthcare delivery, both at primary and tertiary levels, is a necessary condition
for the development of human capital. Health sector reform is a sustained process of
fundamental change in policies, regulation, financing, provision of health services, re-
organization, management and institutional arrangements, which is led by government and
designed to improve the performance of the health system for the better health status of the
population.
5.0 SUMMARY

• The principles of health sector reform
• The multi-dimensional issues in the health sector reform

1. What is health sector reform?
2. Discuss the issues in the health sector reform
3. Discuss the health reform actions in Nigeria
7.0 REFERENCE/ FURTHER READING

Aga Khan Health Services. (2004). “Health Facility Committees: The Governance Issue.”
Policy Brief 4, Best Practices in Community-Based Health Initiatives, Community
Health Department, Aga Khan Health Services in Kenya, Nairobi.
Aitken, J.-M., and J. Kemp. (2003). “HIV/AIDS, Equity, and Health Sector Personnel in
Southern Africa. Equinet Discussion Paper 12, Network for Equity in Health in
Southern Africa, Harare, Zimbabwe
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Cassels A. Health Sector Reform: Key Issues in Less Developed Countries. Forum on
Health Sector Reform discussion paper no.1. Geneva: World Health Organization:
1995. (Document WHO/SHS/NHP/95.4).
Donabedian A. (1971). Social responsibility for personal health services: An examination
of basic values. Inquiry, 8(2):3-19.
Ewurum, Ngozi C, Mgbemena,O.O, Nwogwugwu, Uche, C and Kalu, Chris. U (2015).
Impact of Health Sector Reform on Nigeria’s Economic Development: An
Autoregressive Distributed Lag Model Journal of Economics and Sustainable
Development, 6(12), pp 194-206.
Lessig L. (2016). Institutional corruption. http://wiki.lessig.org/Institutional_Corruption
Michaud C. and C.J.L. Murray. (1994). Bulletin of World Health Organization.
NPHCDA. (2015). Primary Health Care Under One Roof Implementation Scorecard III
Report. 130 Pp.
Reissman D, Orris P, Lacey R, Hartman D. (1999). Downsizing, role demands, and job
stress. Journal of Occupational & Environmental Medicine, 41(4):289-293.
Rigoli Felix and Dussault Gilles (2003): The interface between health sector reform and
human resources in health. Human Resources for Health 1:9, http://www.human-
resources-health.com/content/1/1/9
Sach J D et al (2001). Macroeconomics and Health, investing in Health for Economic
Development. Report of the Commission on Macroeconomics and Health of the
World (WHO)
Saka M. J., Isiaka S. B., Akande T. M., Saka A. O., Agbana B. E. and Bako I. A. (2012):
Health-related policy reform in Nigeria: Empirical analysis of health policies
developed and implemented between 2001 to 2010 for improved sustainable health
and development. Journal of Public Administration and Policy Research Vol. 4(3),
pp. 50-55
Transparency International. Global Corruption Report. (2006).
http://www.transparency.org/
whatwedo/publication/global_corruption_report_2006_corruption_and_health
WHO. (2000). Health Sector Reform. Issues and opportunities
World Bank. World Development Report: making services work for poor people. 2004.
https://openknowledge.worldbank.org/ handle/10986/5986.
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UNIT 3 LEADERSHIP AND MANAGEMENT IN GLOBAL HEALTH
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Strong leadership and management competencies have long been identified as key
elements for encouraging health systems that are responsive to population needs. National
level management and leadership typically include setting policy and overseeing strategic
direction, managing resource allocation, and monitoring policy targets and outcomes. At
the end of this unit, you will be aware of the importance of good leadership and
management in global health as well as global health governance.
2.0 OBJECTIVES
• understand the concept of leadership and management in health

• understand the role of governance in global health
3.0 MAIN CONTENT

Many definitions of ‘leadership’ exist in the literature. In organisational psychology, it is
mostly defined as a group phenomenon (including the interaction between two or more
people) and an intentional social exertion of influence, which aims at attaining objectives
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by communication processes. While leadership and management are theoretically distinct,

in practice, they overlap. Management is a set of task-oriented processes of planning,
budgeting, organizing, staffing, controlling and problem-solving. Conversely, leadership
is viewed as a process of enabling others to work in a specific context. It involves the
creation of a vision and strategic direction for the organization, the communication of that
vision to staff and stakeholders, and inspiring, motivating and aligning actors and the
organization to the achievement of the vision.
Indeed, leadership has been cited as one of the key ingredients for healthcare reform in
low-income settings. Leadership, communication, and vision are valuable attributes for
health professionals who ascend to positions in which they design, implement and scale-
up health programmes and policies. However, the competencies that support these
attributes are rarely taught in standard medical or nursing curricula. The majority of health
leaders and managers in developing countries are trained health professionals (doctors,
nurses, clinical/medical officers and pharmacists) who rarely have any training or
experience prior to being offered a managerial position. New managers are often promoted
on account of clinical expertise: they may be ill-prepared for their new responsibilities and
may be expected to gain managerial capacities by learning on the job or through brief
training courses.
At the operational level, hospital, district and primary health care facility managers are
responsible for converting inputs and resources such as finance, staff, supplies, equipment,
and infrastructure into effective services that produce health results and are responsive to
population needs. As decision space is transferred to these operational levels, the perceived
need for leadership and management capacities has become more urgent.
Given the need to implement health policies in resource-poor and challenging contexts,
health leaders and managers require both managerial and leadership competencies. A
conceptualization of “managers who lead” provides a holistic approach to running health
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care programmes, organizations, or facilities, where strong leadership and managerial

practices strengthen organizational capacity and result in higher-quality services and
sustained improvements in health. Management and leadership are an important part of the
same job and are both necessary for success in simple and complex organizations.
The importance of management and leadership is also apparent in relation to the need to
scale up HIV/AIDS, child health, maternal health, tuberculosis and malaria services in
order to meet the health-related Sustainable Development Goals (SDGs). Despite increases
in development assistance for health, many low and middle-income countries may miss
these targets, and weaknesses in a general managerial capacity at all levels of the health
system have been cited as one of the contributory factors in failing to scale up effective
health services.
The 2014–15 Ebola outbreak in West Africa has demonstrated again the urgent need for
strong leadership and coordination when responding to global health emergencies. The
outbreak started in Guinea during December 2013, but cases soon began to spread to
neighbouring countries Liberia and Sierra Leone. Despite 25 previous outbreaks of Ebola
being successfully contained, this time, the disease spread from rural to urban locations
and crossed borders, becoming a global threat – an unprecedented situation. All actors in
the Ebola crisis appreciate that this has been a challenging response. Many agencies have
struggled to identify and establish their role in the process, and therefore meet the needs of
the people within this new landscape of a widespread, infectious, deadly disease in
developing countries. We must learn lessons from this unprecedented outbreak, which will
require a critical perspective.

In today’s world of changing health risks and opportunities, the capacity to influence health
determinants, status and outcomes cannot be assured through national actions alone
because of the intensification of cross-border and transborder flows of people, goods and
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services, and ideas. The need for more effective collective action by governments, business
and civil society to better manage these risks and opportunities is leading us to reassess the
rules and institutions that govern health policy and practice at the subnational, national,
regional and global levels.
In broad terms, governance can be defined as the actions and means adopted by a society
to promote collective action and deliver collective solutions in pursuit of common goals.
This a broad term that is encompassing of the many ways in which human beings, as
individuals and groups, organize themselves to achieve agreed objectives. Such
organization requires agreement on a range of matters including membership within the
co-operative relationship, obligations, and responsibilities of members, the making of
decisions, means of communication, resource mobilization and distribution, dispute
settlement, and formal or informal rules and procedures concerning all of these. Defined in
this way, governance pertains to highly varied sorts of collective behaviour ranging from
local community groups to transnational corporations, from labour unions to the United
Nations Security Council. Governance thus relates to both the public and private sphere of
human activity, and sometimes a hybrid or combination of the two. The ability of a society
to promote collective action and deliver solutions to agreed goals is a central aspect of
governance.
Health governance concerns the actions and means adopted by a society to organize itself
in the promotion and protection of the health of its population. The rules defining such
organization, and its functioning, can again be formal (e.g. Public Health Act, International
Health Regulations) or informal (e.g. Hippocratic oath) to prescribe and proscribe
behaviour. The governance mechanism, in turn, can be situated at the local/subnational
(e.g. district health authority), national (e.g. Ministry of Health), regional (e.g. Pan
American Health Organization), international (e.g. World Health Organization) and at the
global level. Furthermore, health governance can be public (e.g. National Health Service),
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private (e.g. International Federation of Pharmaceutical Manufacturers Association), or a

combination of the two (e.g. Malaria for Medicines Venture).
“Global health governance” refers to the use of formal and informal institutions, rules, and
processes by states, intergovernmental organizations, and non-state actors to deal with
challenges to health that require cross-border collective action to address effectively. To
improve social determinants of health requires policies that penetrate political, economic,
and social contexts, often down to the local, neighbourhood and household levels. There is
an acute need to broaden the public health agenda to take account of these globalizing
forces and to ensure that the protection and promotion of human health are placed higher
on other policy agendas. There is a widespread belief that the current system of
international health governance (IHG) does not sufficiently meet these needs and, indeed,
has a number of limitations and gaps. In light of these perceived shortcomings, the concept
of Global Health Governance (GHG) has become a subject of interest and debate in the
field of international health.
4.0 CONCLUSION
Leadership is more than a micro-organisational phenomenon. It goes beyond direct
relationships between leaders and subordinates; rather, it takes place at all levels of an
organisation. It can occur in indirect as well as direct forms. It includes the efforts of the
management to reach both short-term and long-term objectives. Health governance deals
with the actions and means embraced by a society to organize itself in the promotion and
protection of the health of its population.
5.0 SUMMARY
• Good leadership and management competencies have long been identified as critical
elements for encouraging health systems that are responsive to population needs.
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• Leadership is one of the key ingredients for healthcare reform in low-income

settings.
• Health governance entails the actions and activities used by a society to organize
itself in the promotion and protection of the health of its population.
1. Explain the roles of leaders and managers in health promotion and protection.
2. What is the role of good leadership and management in the reduction of global child
and maternal mortality?

Byleveld, S., Haynes, R., and Bhana, R. (2009). District management study: a review of
structures, competencies and training interventions to strengthen district management
in the national health system of South Africa. Durban: Health Systems Trust.
Daire, J., Gilson, L. and Susan Cleary. (2014). Developing leadership and management
competencies in low and middle-income country health systems: a review of the
literature. Working Paper 4, pp 1-12.
De Savigny, D. and Adam, T. (2009). Systems thinking for health systems strengthening.
Alliance for Health Policy and Systems Research, Geneva: World Health
Organization.
Dorros, G. L. (2006). Building management capacity to rapidly scale up health services
and outcomes. Geneva: World Health Organization.
Fidler, D.P. (2010). The Challenges of Global Health Governance. Working paper. Pp 1-
33.
Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y,
Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S, Scrimshaw
S, Sepulveda J, Serwadda D, Zurayk H. (2010). Health professionals for a new
century: transforming education to strengthen health systems in an interdependent
world. Lancet, 376:1923–58.
Kaluza, S., Hauke, A., Starren, A., Drupsteen, L. and Bell, N. (2012). Leadership and
Occupational Safety and Health (OSH): An Expert analysis. Leadership and
occupational safety and health: An expert analysis. Pp 1-61.
Kotter, J. P. (2001). What leaders really do. Harvard Business Review 79, 85-96.
McMichael A.J. and Beaglehole R. (2000). "The changing global context of public health",
The Lancet, 356: 495-99.
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OXFAM. (2015). Improving international governance for global health emergencies:

lessons from the Ebola crisis. www.oxfam.org
Senkubuge F, Modisenyane M, Bishaw T. (2014). Strengthening health systems by health
sector reforms. Global Health Action, 7:23568.
Vriesendorp, P., De La Peza, L., Perry, C.P., Seltzer, J.B., O'Neil, M., Reimann, S., Gaul,
N.M., Clark, M., Barraclough, A., Lemay, N., and Buxbaum, A. (2010). Health
Systems in Action: An handbook for leaders and managers. Cambridge:
Management Science for Health.
Waddington, C. (2007). Towards better leadership and management in health: report on an
international consultation on strengthening leadership and management in low-
income countries. Making Health Systems Work working paper series. Geneva: World
Health Organization.
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UNIT 4 GLOBAL HEALTH POLITICS AND POLICY

CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.1 What is Global Health Policy?
3.2 Health Policy Triangle
3.3 Global Health and Politics
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
The human race is presented with new and demanding problems such as global poverty,
lack of global development, climate change, human and national security, nuclear
proliferation, transborder infectious diseases, globalization of disease risk factors, and
global economic crisis. Traditional multifaceted policy models such as the global health
policy are strained to sufficiently tackle these global problems.
Generally, there is a growing interest in global health governance and global health in the
last decade; this is as a result of an increased interconnection between globalization and
public health. Closer attention is being paid to global health policy and its important place
in global politics with a plethora of social science publications being generated since the
turn of the millennium.
2.0 OBJECTIVES
• understand what is global health policy

• describe health policy triangle
• understand politics in global health policies
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3.0 MAIN CONTENT
3.1 What is Global Health Policy?
Global health refers to issues that directly or indirectly impact on the health of populations
and can transcend national boundaries. Solutions to global health issues often require
global cooperation and policy actions that are beyond the capacity of individual countries.
Global health policy was also defined as “the statement of goals, objectives, and means
that create the framework for global health activities” Global health policy incorporates
both policy content, the substance of policy comprising rules and guidelines, and policy
processes, the purposeful, deliberate actions, methods, and strategies that influence the
shape and impact of policy development and implementation.
Global health policy and its implementation are formed by a complex and dynamic set of
individuals, groups, and organizations that form global, interrelated networks of actors.
These networks have an impact on the health of populations. Understanding such policy
processes is a prerequisite for achieving global population health goals, such as universal
health coverage, and for tackling the social and economic determinants of health, where
causes and actions go beyond country borders.
Actors are considered important to the analysis of how policies are made and implemented.
Global and country policy actors include individuals and institutions, such as civil society
organizations, research institutions, the private sector and philanthropic organizations,
governments and programme managers, health workers, and community-based
organizations. Policy analysis in global health can help explain how power and the interests
and values of different global actors play an important role in shaping policies. Power and
politics, which are implicit in all fields of knowledge and activity, are made explicit and
thereby more transparent through policy analysis.
Health policy analysis is a growing field, occupied by policy practitioners, including

policy-makers and technical analysts, and by academic researchers and students.
Practitioners are primarily interested in using policy analysis prospectively to help shape
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future policies (analysis for policy), and in bringing evidence from the clinical sciences,
epidemiology, and economics to inform the content of health policies.
3.2 Health Policy Triangle
Health policy triangle provides a useful framework to identify key issues in health policy
and how they impact on the health systems, policies, and health of populations. The
framework can be used to move beyond a study of the content of policies to understand
how political, historical, and cultural contexts influence the direction and feasibility of
policy-making.
Context: Historical,
political, cultural,
economic, trans-national
Actors: Individuals,
organizations, and
networks that make
policy
Content: Technical Process: Priority setting, policy

content of policies formation, implementation and
evaluation
Figure 3.1: Health policy triangle

Walt and Gilson, 1994
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The triangle emphasizes the importance of identifying the actors or stakeholders and the
processes that lead to (or obstruct) health policy development and implementation. It is a
flexible framework that can complement different policy theories to help explain which
issues get on the policy agenda, and how these are formulated and implemented. The health
policy triangle can be used to illustrate some important contextual factors, actors, and
processes influencing the content of global health policy.
It is widely accepted that human beings require adequate health in order to maintain a
minimally decent life. It is also widely accepted that states and their citizens have duties of
justice to maintain health systems for the delivery of basic national health and the health
needs of its population. Nevertheless, at the global level, there is far less certainty about
what moral duties exist regarding the satisfaction of adequate health for those beyond
borders. Although there is almost unified agreement that there are vast inequalities in
global health and that more concerted efforts are needed to rectify these inequalities, there
is also widespread disagreement about how to deliver these systems globally and the ethical
principles that should underwrite such a system.
3.3 Global Health and Politics
The global health agenda has been dominating the current global health policy debate. It
has compelled countries to embrace strategies for tackling health inequalities in a wide
range of public health issues, such as communicable and non-communicable diseases,
essential medicines shortfalls, access to healthcare delivery services, and health systems
strengthening. In recent decades, the politics of global health has been narrowly debated.
On the contrary, global health governance has been the milestone in politics and political
processes to influence the shaping of population health goals worldwide.
Despite that several authors have developed theoretical frameworks for global health
governance, politics have been conceived as one driver rather than the core of a shared
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governance covenant worldwide. Nevertheless, and notwithstanding that current

theoretical effort has focused on seeking renewal in global health as a conceptual
framework, politics remain hindered by financing and policy initiatives. Thus, identifying
an ideology behind global health is also a global quest by itself.
Global politics has posed the social determinants of health as a cross-cutting paradigm to
understand population health. Nevertheless, as a social determinant of health, politics has
led to a misguided debate on what are global health’s ideological roots. Also, it has
contributed to a misleading global health advocacy debate that can be driven based on the
perceptions of two conflicting policy trends: one philanthropic-based and the other state-
based. Consequently, there has not been political will for a thorough and comprehensive
political debate from different world’s stakeholders for addressing gaps in the economic
model.
Global health will remain lacking in politics, while its challenges and principles undermine
the economic model as the political driver worldwide. Moreover, moving toward politics-
based global health would nudge High-Income Countries (HICs) to embrace a different
path for development where Low- and Middle-Income Countries (LMICs) would not be
part of their enrichment policies.
For policy diffusion of ideas, a lack of global health politics implies the capture of the
global policy agenda by HICs while LMICs development continues tied to the global
extracted economic model. Therefore, sharing global solutions shaped from LMICs’
backgrounds would still be seen as a threat by HICs.
4.0 CONCLUSION
The design of these policies tends to have two key considerations involved in their
formulation and which ultimately guide the practice of how issues are governed: an
ethical/moral dimension regarding the decision of “who gets what and why” and more
practical dimensions involving questions regarding “how, when, and where.”
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5.0 TUTOR- MARKED ASSIGNMENT
1. What is global health policy?
2. Described the health policy triangle
6.0 SUMMARY
Global health refers to issues that directly or indirectly impact on the health of populations
and can transcend national boundaries. Global health policy entails a statement of goals,
objectives, and means that create the framework for global health activities.
7.0 REFERENCES/FURTHER READINGS
Buse K, Mays N, Walt G. (2005). Making Health Policy. Maidenhead: Open University
Press.
Cassels A, Janovsky K. 1998. Better health in developing countries: are sector-wide
approaches the way of the future? Lancet 352(9142), 1777–9.
Frenk J, Gómez-Dantés O, Moon S. (2014). From sovereignty to solidarity: a renewed
concept of global health for an era of complex interdependence. Lancet, 383: 94–7.
Frenk J, Moon S. 2013. Governance challenges in global health. New England Journal of
Medicine, 368: 936–942.
Gilson L (ed.). (2012). Health Policy and Systems Research: A Methodology Reader.
Geneva: Alliance for Health Policy and Systems Research/WHO.
Jenkins WI. (1978). Policy Analysis: A Political and Organizational Perspective.
London: Martin Robertson.
Koplan JP, Bond TC, Merson MH et al. 2009. Towards a common definition of global
health. Lancet 373(9679), 1993–5.
Kruk M. (2013). Universal health coverage: a policy whose time has come. BMJ 347,
f6360.
Méndez CA. (2014). Global health politics: neither solidarity nor policy; Comment on
“Globalization and the diffusion of ideas: why we should acknowledge the roots of
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mainstream ideas in global health”. International Journal of Health Policy and

Management, 3: 103–105
Ng NY, Ruger JP. (2011). Global health governance at a crossroads. Glob Health
Governance, 2: 1–37.
Haffeld J. (2012). Facilitative governance: transforming global health through complexity
theory. Glob Public Health, 7: 452–64.
Ruger JP. (2012). Global health governance as shared health governance. Journal
Epidemiology of Community Health, 66: 653–61.
Smith RD, MacKellar L. (2007). Global public goods and the global health agenda:
problems, priorities and potential. Global Health 2007; 3: 9
Walt G, Gilson L. (1994). Reforming the health sector in developing countries: the
central role of policy analysis. Health Policy Plan 9(4), 353–70.
Wiley Blackwell (2014): The handbook of global health policy. Global policy
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UNIT 5 THE POLITICAL ECONOMY OF GLOBAL HEALTH
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.1 Definition and concept of the political economy of global health
3.2 Political economy analysis of Human resources
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
This course takes a social scientific approach to understand global health from a political
economy perspective. This course will examine the conditions which shape population
health and health service development within the wider macroeconomic and political
context. Students will learn to critically analyse the social, economic and political forces
that converge to create inequities in health both across and between countries.
2.0 OBJECTIVES
• analyse global health issues from a critical political economy perspective

• discuss the political economy analysis of human resources
3.0 MAIN CONTENT

‘Political economy’ originally developed in the 18th century as a form of moral philosophy
that examined the conditions that influenced the economic actions of states. It is today an
interdisciplinary field with diverse academic influences, ranging from Marxist analysis,
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public choice theorists, and social scientists concerned with development. Most recently,
it is also being mainstreamed into development agencies, as demonstrated by the range of
guidance documents produced on how to undertake an applied political economy analysis
for furthering organizational objectives (DFID, Worldbank).
The political economy provides concepts and methods for analyzing and influencing
difficult challenges to health reform, including collective action problems, corruption,
distributional issues, and patronage. It helps explain and manage different forms of power
and the networks through which they flow, including the production of knowledge and the
creation of legitimacy. Political economy analysis can help with understanding and change
the structure and allocation of power, for instance, through assessments of governance,
accountability, participation, and voice.
The political economy of health refers to a body of analysis and a perspective on health
policy which seeks to understand the conditions which shape population health and health
service development within the wider macroeconomic and political context. However, the
relationships between economic development and health development are complex and can
be analysed in terms of a range of different linkages:
• economic growth leads to increased resources for health

• health improvement contributes to economic growth
• people's health is exchanged for economic growth (mining 'accidents', unhealthy
environments) and the 'disease burden' associated with these is the price of
economic growth; raising questions
The dynamics of the global economy shape in various ways the health chances of people
all over the world. Creating environments which can deliver ‘health for all’ requires
knowingly and deliberately reshaping the global economy. Stories about the global
economy play a powerful role in the political debate including the debate over health care
and policy debates which shape the social determinants of health.
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The field of political economy of global health seeks to explain and influence the broader
forces that affect the distribution of health and resources for health within and across
populations globally. Studying the prioritization, design, adoption, and implementation of
health policies through a political economy lens allows us to draw inferences about the
motivations, incentives, policies, and dynamics that can lead to improvements in
population health. Political economy differs from more traditional perspectives in that it
seeks to better understand and analyze the contestation of interests, and engages core
concepts such as power, incentives, interest groups, ideas, and institutions. Weak
institutions contribute to profound problems of implementation, and thus improving the
performance of institutions is essential to improving health. Political economy can analyze
the incentives that affect institutions and identify ways to make them more responsive to
the health needs and desires of citizens.
To promote more political economy approaches among researchers and practitioners, the
meeting participants made the following recommendations: First, we recommend the
application of political economy concepts and methods in the design, adoption, and
implementation of health policies. For instance, we recommend more political economy
analysis to better understand and support the processes by which countries are making
progress toward Universal Health Coverage (UHC). Examining issues such as UHC using
a political economy approach offers a fuller understanding of policy processes and
outcomes, in particular explaining why some countries are making progress toward UHC
while others are not.
3.2 Political economy analysis of Human resources

The genesis of the human resources for health (HRH) crisis in African countries is complex
and context-specific, even if common factors are applicable across the region.
Underinvestment in the social sector, which accelerated in the 1980s and 1990s as part of
the International Monetary Fund (IMF) and World Bank structural adjustment
programmes, undermined the health sector. The health worker situation in developing
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countries has deteriorated to crisis levels due to a variety of factors, including political
instability and weak health systems, characterized by poor working conditions, while
further exacerbated by the migration of health workers to industrialized countries.
The rationale for a political economy analysis of HRH stems from a recognition that the
solution to the shortage of health workers across Africa involves more than a technical
response. The problem consists in how policy is made, how leaders are accountable, how
WHO and foreign donors encourage (or distort) health policy, and how development
objectives are prioritized in these countries. Fundamentally, this is a political process,
which presents constraints and opportunities for potentially effective technical solutions to
be adopted and implemented.
The lack of health workers in low-income countries has been recognized as a development
challenge since the 1970s, beginning with the Alma Ata Declaration or Health for All
campaign in 1978 and later nested in broader discussions of structural adjustment in the
1980s and 1990s. HRH rose to the top of the global health agenda through the publication
of the Joint Learning Initiative’s report in 2004 and the World Health Report in 2006, which
described the extent of the shortage of health workers in a number of countries.
Donor agencies responded by targeting increased production of health workers as a key

development objective. In 1978, the WHO set a target of one physician per 5000 people in
the Alma Ata Declaration/Health for All. In 2006, WHO adopted a threshold of 2.28 skilled
health workers per 1000 people; if a country falls below that prescribed threshold, WHO
refers to it as an HRH crisis country. According to WHO, there are 57 HRH crisis countries
as of 2011 and 37 in Sub-Saharan Africa. One of the major obstacles to HRH crisis
countries to raise their health worker density is the weak capacity of the government to
plan and coordinate effectively.
As HRH was emerging as a global issue in the first decade of the 2000s, nearly every HRH
crisis country in Africa wrote a strategic HRH plan to address its own health worker
shortage. Many national HRH plans suffered from similar problems: over-ambitious
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targets, disruptions (or even abandonment) due to leadership changes, little political
support, and weak resource mobilization.
Despite a global recognition of the gravity and urgency of health worker shortage in Africa,
little progress has been achieved to improve health worker coverage in many of the African
HRH crisis countries generally. Powerful political and institutional incentives push
stakeholders at the domestic and international levels not to invest in HRH. The status quo
of institutional arrangements needs to be changed for new policy choices to reach the top
of the agenda, and ideas have the power to be the earthquake to disrupt the previous rules
of the game. Good governance and some degree of bureaucratic capacity alone do not
ensure a successful HRH plan.
4.0 CONCLUSION
The political economy analysis in global health seeks to explain and change the structural
inequalities and related processes that characterize certain forms of globalization. The field
recognizes the role of social movements engaged with understanding and shaping public
health and builds on past efforts by the classical pioneers of political economy who sought
to improve the lives of those marginalized by structural forces in the industrial revolution.
5.0 SUMMARY
• A political economy approach offers a better understanding of policy processes and
outcomes, in particular explaining why some countries are making progress toward
universal health coverage while others are not.
• Political will, in the form of a long-term commitment to HRH, is essential to
mobilize internal and external resources.
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1. Explain the concept of political economy in global health
2. Discuss the role of health workers in the attainment of Sustainable Development
Goals (SDGs).

Bowser D, Sparkes S, Mitchell A, Bossert T, Bärnighausen T, Gedik G, Atun R. (2014).
Global Fund investments in human resources for health: innovation and missed
opportunities for health systems strengthening. Health Policy Plan, 29:986–97.
Bump, J.B. and Reich, M.R. (2015). Report from Bellagio: Advancing Political Economy
of Global Health to Understand and Influence the Drivers of Universal Health
Coverage. Health Systems & Reform, 1(1):20–21.
Chen L, Evans T, Anand S, Boufford J, Brown H, Chowhery M, Cueto M, Dare L, Dussault
G, Wlzinga G, Fee E, Habte D, Hanvoravongchai P, Jacobs M, Kurowski C, Michael
S, Pablos-Mendez A, Sewankamba N, Solimano G, Stillwell B, de Waal A,
Wibulpalprasert S. (2004). Human resources for health: overcoming the crisis.
Lancet, 364:1984–90.
Dussault, G and Franceschini, M. (2006). Not enough there, too many here: understanding
geographical imbalances in the distribution of the health workforce. Human
Resources and Health, 4:12.
George, A., Ng, C., Coelho, V.S., Okungu, V., Bennett, S. (2014). Exploring how political
economy analysis is understood by health policy and system researchers. SHaPeS:
social science approaches for research and engagement in health policy & systems
Health Systems Global Thematic Working Group, pp 1-16.
Mills E, Schabas W, Volmink J, Walker R, Ford N, Katabira E, Anema A, Joffres M, Cahn
P, Montaner J. (2008). Should active recruitment of health workers from sub-Saharan
Africa be viewed as a crime? Lancet, 371:685–8.
Mullan F. (2005). The metrics of the physician brain drain. New England Journal of
Medicine, 353:1801–8.
Windisch R, Wyss K, Prytherch K. (2009). A cross-country review of strategies of the
German development cooperation to strengthen human resources. Human Resources
and Health, 7.
World Health Organization. (2006). World Health Report 2006: working together for
health. Geneva: WHO.
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MODULE 4 GLOBAL HEALTH AND DISEASES

Unit 2 Gender and Health
Unit 3 Climate change, social justice, and health
Unit 4 Addressing global health disparities
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.1 Definition of Tropical Diseases
3.2 Neglected Tropical Diseases
3.3 Case studies of Tropical Diseases
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Tropical diseases include all diseases that occur mainly in the tropics. It often refers to
infectious diseases that thrive in hot, humid conditions, such as malaria, leishmaniasis,
schistosomiasis, onchocerciasis, lymphatic filariasis, Chagas disease, African
trypanosomiasis, and dengue. In recent times, tropical regions of the world were more
severely affected by infectious diseases in comparison to the temperate world. The main
reasons why infectious diseases thrive in the such areas is due to both environmental and
biological factors that support high levels of biodiversity of pathogens, vectors and hosts,
but also in social factors that undermine efforts to control these diseases.
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2.0 OBJECTIVES
• understand what are tropical and neglected tropical diseases

• understand the distribution and epidemiology of some tropical diseases
3.0 MAIN CONTENT

3.1 Definition
Tropical diseases are infectious diseases that increase in hot and humid weather conditions.
Some of these diseases are caused by protozoa, such as malaria, leishmaniasis, Chagas’
disease and sleeping sickness. Others are caused by worms, including schistosomiasis,
onchocerciasis and lymphatic filariasis. One is viral, dengue fever. The eight WHO tropical
diseases are transmitted to humans by various means, but always include a vector that is
generally a hematophagous insect. Schistosomiasis has no vector, but rather intermediary
hosts – snails – that release in water the infectious forms for humans.
The designation “tropical diseases” was not invented by the WHO and has been part of the
medical vocabulary since the 19th century. It arose at no particular date and was gradually
consolidated, as microorganisms came to be acknowledged as the causal factors of diseases
and had their transmission mechanisms elucidated. The colonial expansion of England,
France and other minor partners, including the United States, into the Caribbean and the
Pacific, unfolded a new world full of exploitable riches, but also of unknown or unwanted
diseases. Since most of the new colonies were located in the tropics, these curious and
exotic diseases were said to be “tropical” From the start, however, many scientists,
especially those from the tropics, disputed the “tropical diseases” designation, because it
implicitly denoted some sort of biogeographic curse or fate.
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3.2 Neglected Tropical Diseases
Neglected Tropical Diseases (NTDs) – is a diverse group of communicable diseases that

prevail in tropical and subtropical conditions in 149 countries – affect more than one billion
people and cost developing economies billions of dollars every year. NTDs are called
neglected because they have been largely wiped out in the developed world and persist
only in the poorest, most marginalized communities and conflict zones. They thrive in
places with unsafe water, poor sanitation, and limited access to basic health care.
Populations living in poverty, without adequate sanitation and in close contact with
infectious vectors and domestic animals and livestock are those worst affected.
Parasitic and bacterial diseases, known to be neglected, are among some of the most
common infections that affect an estimated 2.7 billion people who live on less than US$ 2
per day. The disparity between the haves and the have-nots has continued, and global
climate change – besides unleashing natural calamities – is also creating conditions for
diseases to thrive and for vectors to re-emerge in regions where they were previously
thought to have been eliminated. The resurgence of dengue fever over the past few years
is a testimony to this phenomenon.
Neglected tropical diseases kill an estimated 534 000 people worldwide every year. Their
impact on worker productivity adds up to billions of dollars lost annually and maintains
low-income countries in poverty. A WHO report on Social Determinants of Health found
that those living in poverty, even those inhabiting large affluent cities, remain the most
vulnerable and die younger. How much more severe must be the plight of millions, who
live in deprived rural communities where basic facilities are non-existent.
Many NTDs disproportionately affect women and children. Those living in remote areas
are most vulnerable to infections, and their biological and sociocultural consequences.
Deliberate global health responses are needed to promote interventions in the biological
and social contexts in which these diseases persist. Additional efforts are required to collect
epidemiological data that show the differential impact of these diseases according to a
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patient’s sex and age in order to better inform policies, and guide targeted interventions for
sustainable control.
Enormous progress has been made towards the control and elimination of several NTDs.
Never before have so many of these diseases been targeted for action with time-limited
goals, typically through the creation of public-private partnerships. This mobilization has
changed the health landscape dramatically. Provision of drugs free of charge is a striking
feature of such partnerships, with the release of additional resources for country-level
activities to make treatment more accessible to patients.
Figure 4.1: The 17 priority NTDs.

Source: Cotton (2015
3.3 Case studies of Tropical Diseases

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Malaria
Malaria is caused by Plasmodium parasites. The parasites are spread to people through
the bites of infected female Anopheles mosquitoes, called "malaria vectors." There are
five parasite species that cause malaria in humans, and two of these species –
Plasmodium. falciparum and P. vivax– pose the greatest threat. P. falciparum is the most
prevalent malaria parasite on the African continent. It is responsible for most malaria-
related deaths globally while P. vivax is the dominant malaria parasite in most countries
outside of sub-Saharan Africa.
According to the World Malaria Report, released in November 2017, there were 216
million cases of malaria in 2016, up from 211 million cases in 2015. The estimated
number of malaria deaths stood at 445 000 in 2016, a similar number to the previous
year (446 000). In 2016, nearly half of the world's population was at risk of malaria.
Most malaria cases and deaths occur in sub-Saharan Africa. However, the WHO regions
of South-East Asia, Eastern Mediterranean, Western Pacific, and the Americas are also
at risk. In 2016, 91 countries and areas had ongoing malaria transmission.
The WHO African Region continues to carry a disproportionately high share of the
global malaria burden. In 2016, the region was home to 90% of malaria cases and 91%
of malaria deaths. Some 15 countries – all in sub-Saharan Africa, except India –
accounted for 80% of the global malaria burden. In areas with high transmission of
malaria, children under 5 are particularly susceptible to infection, illness and death;
more than two thirds (70%) of all malaria deaths occur in this age group. The number
of under-5 malaria deaths has declined from 440 000 in 2010 to 285 000 in 2016.
However, malaria remains a major killer of children under five years old, taking the life
of a child every two minutes.
In most cases, malaria is transmitted through the bites of female Anopheles mosquitoes.
There are more than 400 different species of Anopheles mosquito; around 30 are malaria
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vectors of major importance. All of the important vector species bite between dusk and
dawn. The intensity of transmission depends on factors related to the parasite, the vector,
the human host, and the environment. Anopheles mosquitoes lay their eggs in water,
which hatch into larvae, eventually emerging as adult mosquitoes. The female
mosquitoes seek a blood meal to nurture their eggs. Each species of Anopheles mosquito
has its preferred aquatic habitat; for example, some prefer small, shallow collections of
freshwater, such as puddles and hoof prints, which are abundant during the rainy season
in tropical countries.
Transmission is more intense in places where the mosquito lifespan is longer (so that
the parasite has time to complete its development inside the mosquito) and where it
prefers to bite humans rather than other animals. The long lifespan and strong human-
biting habit of the African vector species is the main reason why nearly 90% of the
world's malaria cases are in Africa. The transmission also depends on climatic
conditions that may affect the number and survival of mosquitoes, such as rainfall
patterns, temperature and humidity. In many places, transmission is seasonal, with the
peak during and just after the rainy season. Malaria epidemics can occur when climate
and other conditions suddenly favour transmission in areas where people have little or
no immunity to malaria.
Vector control is the main way to prevent and reduce malaria transmission. If coverage
of vector control interventions within a specific area is high enough, then a measure of
protection will be conferred across the community. The WHO recommends protection
for all people at risk of malaria with effective malaria vector control. Two forms of
vector control – insecticide-treated mosquito nets and indoor residual spraying – are
effective in a wide range of circumstances.
Long-Lasting Insecticidal Nets (LLINs) are the preferred form of Insecticide-Treated

Mosquito Nets (ITNs) for public health programmes. In most settings, WHO
recommends LLIN coverage for all people at risk of malaria. The most cost-effective
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way to achieve this is by providing LLINs free, to ensure equal access for all. In parallel,
effective behaviour change communication strategies are required to ensure that all
people at risk of malaria sleep under a LLIN every night, and that the net is properly
maintained.
Indoor Residual Spraying (IRS) with insecticides is a powerful way to rapidly reduce
malaria transmission. Its potential is realized when at least 80% of houses in targeted
areas are sprayed. Indoor spraying is effective for 3–6 months, depending on the
insecticide formulation used and the type of surface on which it is sprayed. In some
settings, multiple spray rounds are needed to protect the population for the entire malaria
season.
Antimalarial medicines can also be used to prevent malaria. For travellers, malaria can
be prevented through chemoprophylaxis, which suppresses the blood stage of malaria
infections, thereby preventing malaria disease. For pregnant women living in moderate-
to-high transmission areas, WHO recommends intermittent preventive treatment with
sulfadoxine-pyrimethamine, at each scheduled antenatal visit after the first trimester.
Similarly, for infants living in high-transmission areas of Africa, three (3) doses of
intermittent preventive treatment with sulfadoxine-pyrimethamine are recommended,
delivered alongside routine vaccinations. In 2012, WHO recommended Seasonal
Malaria Chemoprevention as an additional malaria prevention strategy for areas of the
Sahel sub-region of Africa. The strategy involves the administration of monthly courses
of amodiaquine plus sulfadoxine-pyrimethamine to all children under five years of age
during the high transmission season.
Early diagnosis and treatment of malaria reduces disease and prevents deaths. It also
contributes to reducing malaria transmission. The best available treatment, particularly
for P. falciparum malaria, is Artemisinin-based Combination Therapy (ACT). The
WHO recommends that all cases of suspected malaria be confirmed using parasite-based
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diagnostic testing (either microscopy or rapid diagnostic test) before administering

treatment.
Schistosomiasis
Schistosomiasis is an acute and chronic parasitic disease caused by blood flukes

(trematode worms) of the genus Schistosoma. Estimates show that at least 206.5 million
people required preventive treatment in 2016. Preventive treatment, which should be
repeated over a number of years, will reduce and prevent morbidity. Schistosomiasis
transmission has been reported from 78 countries. However, preventive chemotherapy
for schistosomiasis, where people and communities are targeted for large-scale
treatment, is only required in 52 endemic countries with the moderate-to-high
transmission.
People become infected when larval forms of the parasite – released by freshwater snails
– penetrate the skin during contact with infested water. Transmission occurs when
people suffering from schistosomiasis contaminate freshwater sources with their excreta
containing parasite eggs, which hatch in water. In the body, the larvae develop into adult
schistosomes. Adult worms live in the blood vessels where the females release eggs.
Some of the eggs are passed out of the body in the faeces or urine to continue the
parasite’s lifecycle. Others become trapped in body tissues, causing immune reactions
and progressive damage to organs.
Schistosomiasis is prevalent in tropical and subtropical areas, especially in poor

communities without access to safe drinking water and adequate sanitation. It is
estimated that at least 92% of those requiring treatment for schistosomiasis live in
Africa. There are two major forms of schistosomiasis – intestinal and urogenital –
caused by five main species of blood fluke. Schistosomiasis mostly affects poor and
rural communities, mainly agricultural and fishing populations. Women doing domestic
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chores in infested water, such as washing clothes, are also at risk. Inadequate hygiene
and contact with infected water make children especially vulnerable to infection.
Migration to urban areas and population movements are introducing the disease to new
areas. Increasing population size and the corresponding needs for power and water often
result in development schemes, and environmental modifications facilitate transmission.
With the rise in eco-tourism and travel “off the beaten track”, increasing numbers of
tourists are contracting schistosomiasis. At times, tourists present severe acute infection
and unusual problems, including paralysis.
Symptoms of schistosomiasis are caused by the body’s reaction to the worms' eggs.
Intestinal schistosomiasis can result in abdominal pain, diarrhoea, and blood in the stool.
Liver enlargement is common in advanced cases and is frequently associated with an
accumulation of fluid in the peritoneal cavity and hypertension of the abdominal blood
vessels. In such cases, there may also be enlargement of the spleen.
Schistosomiasis is diagnosed through the detection of parasite eggs in stool or urine

specimens. Antibodies and/or antigens detected in blood or urine samples are also
indications of infection. For urogenital schistosomiasis, a filtration technique using
nylon, paper or polycarbonate filters is the standard diagnostic technique. Children with
S. haematobium almost always have microscopic blood in their urine which can be
detected by chemical reagent strips.
The eggs of intestinal schistosomiasis can be detected in faecal specimens through a

technique using methylene blue-stained cellophane soaked in glycerine or glass slides,
known as the Kato-Katz technique. For people living in non-endemic or low-
transmission areas, serological and immunological tests may be useful in showing
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exposure to infection and the need for a thorough examination, treatment and follow-
up.
The control of schistosomiasis is based on the large-scale treatment of at-risk population

groups, access to safe water, improved sanitation, hygiene education, and snail control.
The WHO strategy for schistosomiasis control focuses on reducing disease through
periodic, targeted treatment with praziquantel through the large-scale treatment
(preventive chemotherapy) of affected populations. It involves regular treatment of all
at-risk groups. In a few countries, where there is low transmission, the interruption of
the transmission of the disease should be aimed for.
Groups of people targeted for treatment are:
• School-aged children in endemic areas.
• Adults considered to be at risk in endemic areas, and people with occupations
involving contact with infested water, such as fishermen, farmers, irrigation
workers, and women whose domestic tasks bring them in contact with infested
water.
• Entire communities living in highly endemic areas.
Schistosomiasis control has been successfully implemented over the past 40 years in
several countries, including Brazil, Cambodia, China, Egypt, Mauritius, Islamic
Republic of Iran, Oman, Jordan and Saudi Arabia. There is evidence that
schistosomiasis transmission was interrupted in Morocco. In Burkina Faso, Niger,
Ghana, Sierra Leone, Rwanda and Yemen, it has been possible to scale up
schistosomiasis treatment to the national level and have an impact on the disease in a
few years. An assessment of the status of transmission is being made in several
countries.
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Soil-Transmitted Helminths
Soil-transmitted helminth infections are caused by different species of parasitic worms.

They are transmitted by eggs present in human faeces, which contaminate the soil in
areas where sanitation is poor. Approximately 1.5 billion people are infected with soil-
transmitted helminths worldwide. Infected children are nutritionally and physically
impaired.
Soil-transmitted helminth infections are among the most common infections worldwide
and affect the poorest and most deprived communities. They are transmitted by eggs
present in human faeces which in turn contaminate soil in areas where sanitation is poor.
The main species that infect people are the roundworm (Ascaris lumbricoides), the
whipworm (Trichuris trichiura) and hookworms (Necator americanus and Ancylostoma
duodenale).
More than 1.5 billion people, or 24% of the world’s population, are infected with soil-
transmitted helminth infections worldwide. Infections are widely distributed in tropical
and subtropical areas, with the greatest numbers occurring in sub-Saharan Africa, the
Americas, China and East Asia. Over 267 million preschool-age children and over 568
million school-age children live in areas where these parasites are intensively
transmitted and need treatment and preventive interventions.
Soil-transmitted helminths are transmitted by eggs that are passed in the faeces of
infected people. Adult worms live in the intestine where they produce thousands of eggs
each day. In areas that lack adequate sanitation, these eggs contaminate the soil. This
can happen in several ways:
• eggs that are attached to vegetables are ingested when the vegetables are not
carefully cooked, washed or peeled;
• eggs are ingested from contaminated water sources;
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• eggs are ingested by children who play in the contaminated soil and then put their
hands in their mouths without washing them.
In addition, hookworm eggs hatch in the soil, releasing larvae that mature into a form
that can actively penetrate the skin. People become infected with hookworm primarily
by walking barefooted on contaminated soil. There is no direct person-to-person
transmission, or infection from fresh faeces because eggs passed in faeces need about 3
weeks to mature in the soil before they become infective. Since these worms do not
multiply in the human host, re-infection occurs only as a result of contact with infective
stages in the environment.
Soil-transmitted helminths impair the nutritional status of the people they infect in
multiple ways.
• The worms feed on host tissues, including blood, which leads to a loss of iron
and protein.
• Hookworms in addition cause chronic intestinal blood loss that can result in
anaemia.
• The worms increase malabsorption of nutrients. In addition, roundworm may
possibly compete for vitamin A in the intestine.
• Some soil-transmitted helminths also cause loss of appetite and, therefore, a
reduction of nutritional intake and physical fitness. In particular, T. trichiura can
cause diarrhoea and dysentery.
Morbidity is related to the number of worms harboured. People with infections of light
intensity (few worms) usually do not suffer from the infection. Heavier infections can
cause a range of symptoms, including intestinal manifestations (diarrhoea and
abdominal pain), malnutrition, general malaise and weakness, and impaired growth and
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physical development. Infections of very high intensity can cause an intestinal

obstruction that should be treated surgically.
In 2001, delegates at the World Health Assembly unanimously endorsed a resolution

(WHA54.19) urging endemic countries to start seriously tackling worms, specifically
schistosomiasis and soil-transmitted helminths.
The strategy for control of soil-transmitted helminth infections is to control morbidity

through the periodic treatment of at-risk people living in endemic areas. People at risk
are:
• Pre-school children
• school-age children
• women of childbearing age (including pregnant women in the second and third
trimesters and breastfeeding women)
• adults in certain high-risk occupations such as tea-pickers or miners.
The WHO recommends periodic medicinal treatment (deworming) without a previous

individual diagnosis to all at-risk people living in endemic areas. Treatment should be
given once a year when the baseline prevalence of soil-transmitted helminth infections
in the community is over 20 percent, and twice a year when the prevalence of soil-
transmitted helminth infections in the community is over 50 percent. This intervention
reduces morbidity by reducing the worm burden.
In addition, health and hygiene education reduce transmission and reinfection by

encouraging healthy behaviours; and provision of adequate sanitation is also necessary
but not always possible in resource-poor settings. Periodical treatment aims to reduce
and maintain the intensity of infection and to protect infected at-risk populations from
morbidity.
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Deworming can be easily integrated with child health days or supplementation

programmes for preschool children or integrated with school health programmes. In
2016, over 385 million school-aged children were treated with anthelminthic medicines
in endemic countries, corresponding to 68 percent of all children at risk.
The global target is to eliminate morbidity due to soil-transmitted helminthiases in
children by 2020. This will be obtained by regularly treating at least 75 percent of the
children in endemic areas (an estimated 836 million in 2016).
4.0 CONCLUSION
Tropical diseases are diseases that occur mainly in the tropics. The infectious diseases that
thrive in hot, humid conditions and disproportionately afflict the “poor and outcast
populations” of the world. The NTDs are a group of 17 lesser-known chronic infections
which predominantly affect poor and disenfranchised communities. They are mostly
chronic infections that are often disfiguring and stigmatising and result in reduced
economic productivity. There are a number of NTDs that cause significant global morbidity
in children, including the three major soil-transmitted helminths (STH) infections
(ascariasis, trichuriasis and hookworm infection), schistosomiasis and trachoma. These
NTDs are currently being targeted for global control and elimination through mass drug
administration campaigns. They represent the most common NTDs and share significant
geographical overlap.
5.0 SUMMARY
• Many Tropical diseases disproportionately affect women and children.
• Those living in remote areas are most vulnerable to infections, and their biological
and sociocultural consequences.
• NTDs also provides an excellent example of the complex inter-relationships
between the different Sustainable Development Goals.
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1. What are tropical and neglected tropical diseases?
2. Discuss the epidemiology of two Tropical diseases
3. Discuss the role of vaccine in malaria prevention.

Camargo, E.P. (2008). Tropical Diseases. Estudos Avançados 22 pp 95-110.
Cotton, R. (2015). A student in Immunology, Harvard University. Neglected Tropical
Diseases: Challenges for the Post-2015 Development Era. Public Library of Science
(PLOS) Blogs: Student Blogs.
Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–
2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet
2017; 16; 390: 1151–1210
Nelson, J. (2016). Supporting research in Neglected Tropical Diseases. Lessons from
AbbVie’s Neglected Diseases Initiative. CR Initiative at the Harvard Kennedy
School, pp 1-36.
WHO (2009). Neglected tropical diseases, hidden successes, emerging opportunities, pp 1-
71.
WHO (2013). Sustaining the drive to overcome the global impact of Neglected Tropical
Diseases, pp 1-153.
WHO (2017). Tropical Disease. http://www.who.int/topics/tropical_diseases/en/.
Accessed 10/12/17.
WHO (2017). Malaria. http://www.who.int/mediacentre/factsheets/fs094/en/. Accessed
10/12/17.
WHO (2017). Neglected Tropical Disease.
http://www.who.int/neglected_diseases/diseases/en/. Accessed 10/12/17.
WHO (2017). Soil-transmitted Helminths.
http://www.who.int/mediacentre/factsheets/fs366/en/. Accessed 10/12/17.
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UNIT 2 GENDER AND HEALTH
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.2 Gender and Health
3.3 Gender Inequality
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Men and women are comparable in many ways. Nevertheless, there are important
biological and behavioural differences between them. These differences, as well as the
gender norms prevalent in any society, determine the health status of the people living in
it. A gender approach to health considers the critical roles that social and cultural factors
and powers relations between women and men play in promoting and protecting health.
Gender issues in health determine access to health care, use of the health care system and
the behavioural attitudes of medical personnel. At the end of this unit, you will be aware
of the role of gender in health outcomes.
2.0 OBJECTIVES
• Understand the concept of gender and sex

• Understand the role of gender in disease causation
• Know what gender inequality means
3.0 MAIN CONTENT
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Gender refers to “the array of socially constructed roles and relationships, personality traits,
attitudes, behaviours, values, relative power and influence that society ascribes to the two
sexes on a differential basis. Gender is relational—gender roles and characteristics do not
exist in isolation, but are defined in relation to one another and through the relationships
between women and men, girls and boys” (Health Canada, 2000; Vlassoff, 2007). Gender
is related to how we are perceived and expected to think and act like women and men
because of the way society is organised, not because of our biological differences.
However, sex is the genetic/physiological or biological characteristics of a person which
indicates whether one is female or male. Sex refers to biological differences, whereas
gender refers to social differences (Vlassoff, 2007).
Gender norms, roles and relations can influence health outcomes and affect the attainment
of mental, physical and social health and well-being. Gender has been shown to influence
how health policies are conceived and implemented, how biomedical and contraceptive
technologies are developed, and how the health system responds to male and female clients
(Vlassoff, 2002). By capturing the different experiences of men and women, gender can be
understood as dynamic and layered with a range of multiple, intersecting social
determinants that impact on health. The gender differences in the consequences of tropical
diseases include how illness is experienced, treatment-seeking behaviour, nature of
treatment, and care and support received from the family and care providers.
3.2 Gender and Health

Patterns of health and illness in women and men show marked differences. Most obviously,
women as a group tend to have longer expectancy than men in the same socio-economic
circumstances as themselves. Yet despite their longevity women in most communities
experience more illness and distress than men (US National Institutes of Health, 1992).
The details of this excess in female morbidity and the factors that fuels it varies in different
social groups, but the broad picture is one where women’s lives seem to be less healthy
than those of men (Macintyre, 1996).
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Concerning public health and gender issues, this mostly affects maternal and child health
issues where delays could occur due to delay in decision making. Also, it would certainly
affect other health outcomes too. Improving female literacy would be one of the greatest
investments a country could do to overcome this barrier.
We have seen that being ‘male’ or being ‘female’ has a major effect on an individual’s
health and well-being. The combination of their biological sex and the gendered nature of
their cultural, economic and social lives will put individuals at risk of developing some
health problems while protecting them from others.
Furthermore, the subsequent effect of these problems on the individuals concerned will
also be influenced by both their gender roles and their sex. The ‘natural’ course of a disease
may be different in women and men; women and men themselves often respond differently
to illness, while the wider society may respond differently to sick males and sick females.
Women and may also respond differently to treatment, have different access to health care
and be treated differently by health providers others.
Biological factors vary between the sexes and influence susceptibility and immunity to
tropical diseases. Gender roles and relations influence the degree of exposure to the
relevant vectors and also to access and control of the resources needed to protect women
and men from being infected.
Even when tropical diseases are shared by both sexes, they may have different
manifestations or natural histories in women and men or differ in the severity of their
consequences. For example, malaria is shared by women and men, with a tendency to be
slightly higher in males (Howson et al., 1996). However, biologically, women’s immunity
is compromised during pregnancy, making them more likely to become infected and
implying differential severity of the consequences. Malaria during pregnancy is an
important cause of maternal mortality, spontaneous abortions and stillbirths. Particularly
during pregnancy, malaria contributes significantly to the development of chronic anaemia.
Women engage in far more health-promoting behaviours than men and have healthier
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lifestyle patterns (Lonnquist et al., 1992). Being a woman may be the strongest predictor
of preventive and health-promoting behaviour.
On the other hand, some disease conditions are more prevalent in men. For instance, men
in the United States, on average, die nearly seven year younger than women and have
higher death rates for all 15 leading causes of death. Men's age-adjusted death rate for heart
disease, for example, is two times higher than women's, and men's cancer death rate is 112
times higher. The incidence of 7 out of 10 of the most common infectious diseases is higher
among men than women. Men are also more likely than women to suffer severe chronic
conditions and fatal diseases and to suffer them at an earlier age. Nearly three out of four
persons who die from heart attacks before age 65 are men.
Furthermore, Income, education, age, ethnicity, sexual orientation and place of residence
are all important determinants of health. When they intersect with gender inequality, they
can compound the experience of discrimination, health risks, and lack of access to
resources needed for health attainment.
3.3 Gender Inequality
Gender inequality is the notion that women and men are not equal. Gender inequality
refers to unequal treatment or perceptions of individuals wholly or partly due to
their gender. It arises from differences in gender roles. It stems from distinctions, whether
empirically grounded or socially constructed.
Promoting gender equality and empowering women is one of the Sustainable Development
Goals (SDGs). The SDGs explicitly recognize that gender equality and women’s
empowerment are not only human rights, but also play an influential role in promoting the
development and reducing poverty. When women have the same opportunities, access to
resources, and life choices as men, the benefits and opportunities extend far beyond women
themselves Gender in Nigeria. Allowing girls access to educational opportunities is one of
the proven ways of bridging the gender gap and improving health care. By empowering
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women and young girls through educational opportunities, they are able to become well-
versed in the safest health practices, learning the best ways to deal with common issues in
their communities. According to a 2011 report from the World Health
Organization, denying primary education to young girls has been shown to negatively
impact fertility rates, birth spacing, health literacy and healthy behaviours. Similar reports
have found that educating women in Africa and Latin America lowers their risk of HIV
infection.
Nigeria has a National Gender Policy that focuses on women empowerment while also
making a commitment to eliminate discriminatory practices that are harmful to women.
However, significant gender gaps in education, economic empowerment and political
participation remain in Nigeria. While progress towards parity in primary school education
has been made, there remains a significant wage and labour force participation gender gap.
Discriminatory laws and practices, violence against women and gender stereotypes hinder
greater progress towards gender equality. Nigeria has a particularly high maternal mortality
rate and women access to quality health care is limited, particularly in rural areas.
Nigeria has one of the highest rates of maternal mortality in the world. One Nigerian
woman dies in childbirth every ten minutes. Spending and implementation have not
matched policies. Nigeria spends only 6.5 percent of its budget on health care. Poor access
to safe childbirth services and lack of adequate and affordable emergency obstetric care are
the main reasons for high mortality. Only 36 percent of women deliver in a health facility
or in the presence of a qualified birth attendant.
4.0 CONCLUSION
Women and men are different as regards their biology, the roles and responsibilities that
society assigns to them and their position in the community. These factors have a great
influence on causes, consequences and management of diseases and ill-health and the
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efficacy of health promotion policies and programmes. This is confirmed by evidence on

male-female differences in cause-specific mortality and morbidity.
Gender inequality limits access to quality health services and contributes to avoidable
morbidity and mortality rates in women and men throughout the life-course. Developing
gender-responsive health programmes which are appropriately implemented is
beneficial for men, women, boys and girls. Addressing gender inequality improves
access to and benefits from health services.
5.0 SUMMARY
• men and women are different in their biological makeup.
• these differences contribute to differential health risks among men and women.
• taking actions to discourage gender inequality in health is one of the most direct and
potent ways to reduce health inequities.

1. Distinguish between gender and sex
2. Explain the roles of gender in disease causation.
3. Discuss the concept of gender inequality.
4. Discuss the possible ways by which the government and all stakeholders can ensure
gender equity in the distribution of resources in the health system.

American Heart Association, (1995). Heart and Stroke Facts: 1995 Statistical Supplement.
American Heart Association, Dallas: TX.
CEDAW. (2008). Concluding observations of the Committee on the Elimination of
Discrimination against Women: Nigeria, CEDAW/C/NGA/CO/6, CEDAW, New
York: NY.
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Center for Disease Control. (1997). Demographic differences in notifiable infectious

disease morbidity in the United States, 1992-1994. Morbidity and Mortality Weekly
Report, 46(28) pp. 637-641.
Department of Health and Human Services. (1996). Report of final mortality statistics,
(1994). Monthly Vital Statistics Report, 45(3, Supplement). Public Health Service,
Hyattsville: MD.
Gender in Nigeria Report. (2012). Improving the lives of Girls and women in Nigeria.
Issues, policies & action. 2nd Edition.
Health Canada (2000). “Health Canada’s gender-based analysis policy,” Ottawa, 14.
Howson, C., Harrison, P., Hotra, D., & Law, M. (1996). In Her Lifetime: female morbidity
and mortality in Sub-Sharan Africa, Washington DC: National Academy Press.
JICA. (2011). Country Gender Profile Nigeria Final Report,
(http://www.jica.go.jp/english/operations/thematic_issues/gender/background/pdf/e1
0nig.pdf.
Lonnquist, L.E., Weiss, G.L., & Larsen, D.L. (1992). “Health value and gender in
predicting health protective behaviour.” Women and Health, 19 (2/3) pp. 69-85.
Macintyre, S., Hunt, K., and Sweeting H. (1996). Gender differences in health: are things
really as simple as they seem? Soc Sci Med. 42(4):617-24.
Manderson, L., Jenkins, J., & Tanner, M. (1993). “Women and tropical diseases:
introduction.” Social Science & Medicine, 37(4) pp. 441-443.
McGregor, I.A. (1984). “Epidemiology of Malaria and Pregnancy.” American Journal of
Tropical Medicine and Hygiene, 33 pp. 17-525.
National Institutes of Health. (1992). Consensus Statement. Dec 7-9;10 (4):1-31.
Rathgeber, E., & Vlassoff, C. (1993). “Gender and tropical disease: a new research focus.”
Social Science & Medicine, 54(4) pp. 513-520.
Ratner, P.A., Bottor, J.L., Johnson, J.L., & Hayduk, L.A. (1994). “The interaction effects
of gender within the health promotion model.” Research in Nursing and Health, 17
pp. 341-350.
Vlassoff, C., & Garcia Moreno, C. (2002). Placing gender at the centre of health
programming: challenges and limitations. Social Science & Medicine, 54 pp. 1713-
1723.
Vlassoff, C. (2007). “Gender Differences in Determinants and Consequences of Health and
Illness.” Journal of Health Population and Nutrition, 25(1) pp. 47-61.
WHO (1998). “Gender and Health: Technical Paper.” pp 1-77.
World Economic Forum. (2011). The Global Gender Gap Report 2011,
http://www3.weforum.org/docs/WEF_GenderGap_Report_2011.pdf
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UNIT 3 CLIMATE CHANGE, SOCIAL JUSTICE, AND HEALTH
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.2 Climate change and health
3.3 Climate change and social justice
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Climate change refers to long-term statistical shifts of the weather, including changes in
the average weather condition or the distribution of weather conditions around the average
(i.e. extreme weather events). Despite many discussions on the causes of climate change,
there is a general recognition of an on-going global climate change and the non-minor role
of human activities during this process. Climate changes include alternations in one or
more climate variables including temperature, precipitation, wind, and sunshine. These
changes may impact the survival, reproduction, or distribution of disease pathogens and
hosts, as well as the availability and means of their transmission environment. The health
effects of such impacts tend to reveal as shifts in the geographic and seasonal patterns of
human infectious diseases, and as changes in their outbreak frequency and severity.
Climate change should be viewed fundamentally as an issue of global justice.
Understanding the complex interplay of climatic and socioeconomic trends is imperative
to protect human health and lessen the burden of diseases. At the end of this unit, you will
be aware of the link between climate change, social justice and health.
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2.0 OBJECTIVES
• understand the concept of climate change and global warming

• understand the link between climate change, social justice and health
3.0 MAIN CONTENT

Climate change is a global problem with grave implications: environmental, social,
economic, political, and for the distribution of goods. It represents one of the principal
challenges facing humanity in our day. Climate change is a current global concern and,
despite continuing controversy about its cause and the magnitude of its effects, it seems
likely that climate change will affect the incidence and prevalence of both indigenous and
imported infections in Europe. Climate restricts the range of infectious diseases, whereas
weather affects the timing and intensity of outbreaks. Climate change scenarios predict a
change distribution of infectious diseases with warming and changes in outbreaks
associated with weather extremes, such as flooding and droughts. Adverse health
consequences caused by climate change include heat-related disorders, vector-borne
diseases, waterborne and foodborne diseases, respiratory and allergic disorders,
malnutrition, violence, and mental health problems. Its worst impact will probably be felt
by developing countries in the coming decades.
3.2 Climate change and Health

A range of infectious diseases can be influenced by climatic conditions. The diseases that
are most sensitive to influence, by ambient climate conditions are those spread not by
person-to-person pathways but directly from the source: the water- and foodborne diseases
as well as vector-borne diseases (which involve insects or rodents within the pathogen’s
life cycle). The ranges of several key diseases or their vectors are already changing in
altitude due to warming. In addition, more intense and costly weather events create
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conditions conducive to outbreaks of infectious diseases, such as heavy rains leave insect
breeding sites, drive rodents from burrows, and contaminate clean water systems.
The largest health impacts of climate change worldwide seem to occur from vector-borne
infectious diseases. The incidence of mosquito-borne diseases, including malaria, dengue,
and viral encephalitides, are among those diseases most sensitive to climate. Climate
change would directly affect disease transmission by shifting the vector’s geographic range
and increasing reproductive and biting rates and by shortening the pathogen incubation
period. Climate-related increases in sea surface temperature and sea level can lead to a
higher incidence of waterborne infectious and toxin-related illnesses, such as cholera and
shellfish poisoning.
Water- and foodborne diseases are likely to become a greater public health problem as
climate change accelerates, due to elevated temperatures, increases in extreme rainfall and
flooding frequency, and an anticipated deterioration in water quality following wider
drought events. There is strong evidence that links the incidence of waterborne outbreaks
from pathogens such as Cryptosporidium, Escherichia coli 0157: H7,60 and
Campylobacter jejuni following heavy rainfall events. Storm events of more than 3 inches
of rainfall within 24 hours can overwhelm combined sewer systems and lead to an overflow
that contaminates recreational and drinking water sources. Climate change is anticipated
to increase the frequency of these events. Overall, there is growing evidence that climate-
driven changes in air and water temperatures, rainfall, humidity, and coastal salinity can
contribute to the risk for waterborne diseases in both marine and freshwater ecosystems. A
recent meta-analysis of 87 waterborne outbreaks occurring globally from 1910 to 2010
showed an association with heavy rainfall and flooding, with Vibrio and Leptospira spp.,
being the most often cited etiologic agents.
There are many ways in which climate change disproportionately affects women. In low-
income countries, women generally assume primary responsibility for gathering water,
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food, and fuel for their households. Climate change-induced droughts to make this work
much more difficult because water becomes less accessible, agricultural production
decreases, and wood used for fuel needs to be obtained from increasingly distant places.
As women face greater challenges in gathering water, they may develop increased risks of
injury and rape.
Women have higher rates of death than men from extreme weather events, such as
hurricanes and other storms. Pregnant women are especially susceptible to vector-borne
diseases, such as malaria and waterborne disease. Because of longstanding bias and
discrimination, in many countries, women have fewer resources to deal with damage and
loss from extreme weather events.
Like women, children are especially susceptible to vector-borne diseases, such as malaria,
and waterborne disease. Climate change adversely affects children in many ways.
According to the World Health Organization (WHO), 88 percent of the burden of disease
that can be attributed to climate change affects children younger than five years of age.
Shortages of water and food lead to increased occurrence of childhood malnutrition and
make it less likely that children will receive an adequate education. Besides, children are
more vulnerable than adults to extreme weather events and other disasters because they
have less physical strength and during the disasters, they may be separated from their
parents.
Extreme high air temperatures raise levels of ozone and other pollutants and contribute
directly to deaths from cardiovascular and respiratory disease, as can pollen or other
aeroallergens that worsen in heat, particularly among elderly people.
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3.3 Climate change and Social justice

The environmental and health consequences of climate change, which disproportionately
affect low-income countries and poor people in high-income countries, have profound
effects on human rights and social justice. These consequences threaten rights embodied
in the Universal Declaration of Human Rights, such as the right to security and the right to
a standard of living adequate for health and well-being, including food, clothing, housing,
medical care, and necessary social services. They threaten civil and political rights, such
as “the inherent right to life” and rights related to culture, religion, and language, as
embodied in the International Covenant on Civil and Political Rights. They threaten
economic, social, and cultural rights, as enshrined in the International Covenant on
Economic, Social, and Cultural Rights, including the following:
The rights of self-determination.

• The rights to freely determine one’s political status and freely pursue one’s
economic, social, and cultural development.
• The right “to the enjoyment of the highest attainable standard of physical and mental
health”.
• The right to education.
Climate change threatens the rights of women, as embodied in the Convention on the
Elimination of all Forms of Discrimination against Women, especially women living in
rural areas of developing countries, who are particularly vulnerable to the consequences of
climate change. National governments have a duty to ensure that all of these human rights
are promoted and protected.
These environmental and health consequences threaten civil and political rights and
economic, social, and cultural rights, including rights to life, access to safe food and water,
health, security, shelter, and culture. On a national or local level, those people who are most
vulnerable to the adverse environmental and health consequences of climate change
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include poor people, members of minority groups, women, children, older people, people
with chronic diseases and disabilities, those residing in areas with a high prevalence of
climate-related diseases, and workers exposed to extreme heat or increased weather
variability.
People in developing countries are more than 20 times as likely to be affected by climate-
related disasters as those in the developed world4. Small island states, coastal regions,
megacities, mountainous and Polar Regions are also particularly vulnerable.
4.0 CONCLUSION
The global climate crisis threatens most people and their human rights. The adverse
consequences of climate change will worsen. Addressing climate change is a health and
human rights priority, and action cannot be delayed. Adaptation and mitigation measures
to address climate change needed to protect human society must also be planned to protect
human rights, promote social justice, and to avoid creating new problems or exacerbating
existing problems for vulnerable populations.
5.0 SUMMARY

• climate change health risks are occurring today and pose serious and widespread
challenges for global health
• climate change has profound effects on human rights and social justice.

1. What is climate change?
2. Discuss the role of climate change in the increased prevalence of two vector-borne
diseases.
3. Discuss the role of climate change in social justice.
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Bezirtzoglou, C., Dekas, K. & Charvalos, E. (2011). Climate changes, environment and
infection: Facts, scenarios and growing awareness from the public health community
within Europe. Anaerobe, 17 pp. 337-340.
Levy, B.S. & Patz, J.A. (2015). Climate Change, Human Rights, and Social Justice. Annals
of Global Health, 81(3) pp. 310-322.
Wu, X., Lu, Y., Zhou, S., Chen, L. & Xu, B. (2015). Impact of climate change on human
infectious diseases: Empirical evidence and human adaptation. Environment
International, 86 pp 14-23.
Patz, J.A., Grabow, M.L. & Limaye, V.S. (2014). When It Rains, It Pours: Future Climate
Extremes and Health. Annals of Global Health, 80 pp. 332-344
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UNIT 4 ADDRESSING GLOBAL HEALTH DISPARITIES
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.1 Definition and concepts
3.2 Addressing Disparities in Health
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Health and healthcare disparities refer to differences in health and healthcare among
population groups. Disparities occur across many dimensions, including race/ethnicity,
socioeconomic status, age, location, gender, disability status, and sexual orientation. Health
disparities adversely affect groups of people who have systematically experienced greater
obstacles to health on the basis of their racial or ethnic group, religion, socioeconomic
status, gender, age, mental health, cognitive, sensory, or physical disability; sexual
orientation or gender identity; geographic location; or other characteristics historically
linked to discrimination or exclusion. At the end of this unit, you will be aware of what
health disparity means and the global efforts put in place to address it.
2.0 OBJECTIVES
• understand the concept of disparity in health

• understand the various measures and strategies put in place to combat disparity in
health
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3.0 MAIN CONTENT

Health disparity is defined as differences in health outcome between population groups due
to differences in “social, demographic, environmental and geographic attributes”. Further,
health disparity is described as the differences in the health outcomes of population groups
based on race, sex, education, social status, and geographic location. It is also referred to
as inequalities in health outcomes among population groups attributable to “social,
economic, and, or environmental disadvantage” based on race, religion, gender, sexual
orientation, geographical location, or socioeconomic status.
The terms “health disparities” and “health inequalities” (often used interchangeably), while
hardly household terms among the general public, have by now become familiar to many
health practitioners, program managers, and policy-makers as well as researchers in the
United States and other countries; “health equity” is a term rarely encountered in the United
States but more familiar to public health professionals elsewhere. There is little consensus
about what these terms mean, however, and the resulting lack of clarity is not merely of
academic concern. How one defines “health disparities” or “health equity” can have
important policy implications with practical consequences. It can determine not only which
measurements are monitored by national, state/provincial, and local governments and
international agencies, but also which activities will receive support from resources
allocated to address health disparities/inequalities and health equity.
Disparities have been documented for many decades and, despite overall improvements in
population health over time, many disparities have persisted and, in some cases, widened.
Moreover, the recent economic downturn has likely contributed to a further widening of
disparities. According to the WHO, “the social determinants of health are mostly
responsible for health inequities—the unfair and avoidable differences in health status seen
within and between countries”. The social determinants of health as well as race and
ethnicity, sex, sexual orientation, age, and disability all influence health. Identification and
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awareness of the differences among populations regarding health outcomes and health
determinants are essential steps towards reducing disparities in communities at greatest
risk.
Health disparities do not refer generically to all health differences, or even to all health
differences warranting focused attention. They are a specific subset of health differences
of particular relevance to social justice because they may arise from intentional or
unintentional discrimination or marginalization and, in any case, are likely to reinforce
social disadvantage and vulnerability. Disparities in health and its determinants are the
metric for assessing health equity, the principle underlying a commitment to reducing
disparities in health and its determinants; health equity is social justice in health.
Every person should be able to achieve his/her optimal health status, without distinction
based on race or ethnic group, skin colour, religion, language, or nationality;
socioeconomic resources or position; gender, sexual orientation, or gender identity; age;
physical, mental, or emotional disability or illness; geography; political or other affiliation;
or other characteristics that have been linked historically to discrimination or
marginalization (exclusion from social, economic, or political opportunities).
3.2 Addressing Disparities in Health

Reducing disparities in health will give everyone a chance to live a healthy life and improve
the quality of life of all. The challenges of knowing what to do - what actions to take - are
significant. For example, many health care providers are unaware of the fact that disparities
exist, or of their magnitude. Reducing health disparities is a major goal of public health.
Despite the persistence of disparities, progress is being made.
The different global strategy for the elimination of health disparities includes:
1. Ensure a strategic focus on communities at greatest risk.
2. Reduce disparities in access to quality health care.
3. Increase the capacity of the prevention workforce to identify and address disparities.
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4. Support research to identify effective strategies to eliminate health disparities.

5. Standardize and collect data to better identify and address disparities.
In ensuring that all Nigerians have access to affordable and quality healthcare, the National
Health Insurance Scheme (NHIS) was established under Act 35 of 1999. The scheme is a
social health insurance scheme aimed at providing universal coverage for all Nigerians.
This model ensured the introduction of Health Maintenance Organisations (HMOs) as
financial managers of the Scheme; it, however, did not take off until 2005. There are several
different programmes under the scheme aimed broadly at the formal and informal sectors.
However, present coverage under the scheme is very low at just 7.9 million. In Nigeria, the
WHO reported that private spending on health as a percentage of total health expenditure
was 63.3 percent. Of this 95.4 percent was from out-of-pocket payment, indicating that a
majority of Nigerians especially the poor have to pay for their healthcare, as they have no
insurance coverage and up to 70.2 percent were reported to be living on less than USD 1.00
per day.
Concerted efforts in recent times have been made to improve coverage under the scheme.
At the onset, the act establishing the NHIS made it optional, since it was a contributory
scheme, people simply opted out. Critics in the earlier years have linked the poor coverage
of the scheme to this and have repeatedly called for an amendment to the act to make it
mandatory. Also, the scheme started with an enrolment of federal government employees
while State employees and the informal sector were practically left out. Nine years after
the scheme was launched, it had only commenced in two States. Recently this was also
corrected with a mandate for all States of the federation to commence their own mandatory
schemes. To address the funding challenges a National Basic Health Care Provision Fund
was established under the National Health Act. Half (50 %) of this fund is meant for the
provision of a basic minimum package of care at primary and secondary levels of care for
the citizens under the NHIS. Provision for the poor and vulnerable was also included;
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however one must bear in mind that the NHIS is a contributory scheme and method of
accessing the scheme are not spelt out for the unemployed and the poor.
The mission of the NHIS-is to undertake a government-led comprehensive Health sector
Reform aimed at strengthening the National public and private Health System to enable it
to deliver effective, efficient, qualitative and affordable health services.
The objectives of the scheme are to:

• ensure that every Nigerian has access to good health care services
• protect families from the financial hardship of huge medical bills
• limit the rise in the cost of healthcare services
• ensure equitable distribution of healthcare costs among different income groups
• ensure a high standard of healthcare delivery to Nigerians
• ensure efficiency in healthcare services
• improve and harness private sector participation in the provision of healthcare
services
• ensure equitable distribution of health facilities within the federation
• ensure appropriate patronage of levels of healthcare
• ensure the availability of funds to the health sector for improved services.
4.0 CONCLUSION
Despite major advances in medicine and public health during the past few decades,
disparities in health and health care persist. Disparities exist when differences in health
outcomes or health determinants are observed between populations. Reducing health
disparities is of public health significance. Despite the persistence of disparities, progress
has been made in addressing the observed disparities.
5.0 SUMMARY
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• health disparities are preventable differences in the burden of disease, injury,

violence, or opportunities to achieve optimal health that are experienced by socially
disadvantaged populations
• health disparities are inequities that are directly related to the historical and current
unequal distribution of social, political, economic, and environmental resources
• strategies have been developed to reduce disparities in access to quality healthcare.

1. What is disparity in Healthcare?
2. Discuss the role of government and relevant stakeholders in addressing global health
disparities
3. Discuss the roles of the National Health Insurance Scheme in addressing health
disparity in Nigeria.

Adeniji, F.O. (2017). National Health Insurance Scheme in Nigeria; Progress towards
Universal Coverage. Asian Journal of Medicine and Health, 3(4): 1-2.
Braveman, P. (2006). Health disparities and health equity: Concepts and Measurement.
Annual Reviews in Public Health, 27 pp. 167-194.
Center for Disease Control and Prevention. (2011). Health disparities and inequalities
report—United States. MMWR. Morbidity and Mortality Weekly Reports. 60, 1–
116. Retrieved from
https://www.cdc.gov/mmwr/preview/mmwrhtml/su6001a2.htm?s_cid=su6001a2_W
Center for Disease Control and Prevention. (2013). CDC Health Disparities and
Inequalities Report — United States, 2013. Morbidity and Mortality Weekly Reports,
62(3) pp. 1-189.
Healthy People 2020. (2014). Disparities | Healthy People 2020. Retrieved July 7, 2015,
from http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf.
NHIS. National Health Insurance Scheme. Available at:
http://www.nhis.gov.ng/About%20us/#.WI4gn4WcFkA
Nwobilor, L.E. (2017). Health Disparity in Preventive Care among Nigerian Immigrants
in the United States. http://scholarworks.waldenu.edu/dissertations. Accessed
07/12/17.
Singh, G. and M. Siahpush. (2006). Widened socioeconomic inequalities in US life
expectancy 1980-2000. International Journal of Epidemiology. 35 pp. 969-979.
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MODULE 5: HEALTH SERVICES MONITORING AND EVALUATION

Unit 1: Introduction to quality management for monitoring and evaluation
Unit 2: Programme monitoring and evaluation methods
Unit 3: Health systems strengthening
Unit 4: Global health in Nigeria; practicum
UNIT 1 INTRODUCTION TO QUALITY MANAGEMENT FOR

MONITORING AND EVALUATION
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Definition of M& E
3.2 Basic Concepts in M&E
3.3 Quality Management for M&E
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
To understand the effects of health services, there is a need for monitoring and evaluation
of outcomes and impacts. According to Keeble (2010), Monitoring and Evaluation (M&E)
aim to, through studying results, determine how well the health services plans are being
achieved at various levels. It also seeks to determine if the health of the public is better as
a result of health interventions through programme level indicators.
In the planning and execution of health action plans, evaluation of health services is
important because it provides a breakdown of what worked, what did not work and the root
causes, in the case of failure. This serves to help improve future strategy to ensure
successful implementation of future health action plans and avoid the pitfalls of the
previous programmes.
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2.0 OBJECTIVES
• understand the meaning of monitoring and evaluation (M&E)

• describe the importance and basics of M&E
• differentiate between monitoring and evaluation
• describe the framework for M &E of public health programmes
• describe the Quality management of M&E
3.0 MAIN CONTENT

3.1: Definition of Monitoring & Evaluation
Monitoring and Evaluation (M&E) involves the collection, storage, analysis and
transformation of data into tactical information that can be used to make informed decisions
for programme management and improvement (sustainability), policy formulation and
advocacy. Monitoring and Evaluation show whether a service, or programme is
accomplishing its goals, perhaps as conceived in its logical framework, or other
frameworks, such as logic model. It identifies programme weaknesses and strengths, areas
of the programme that need revision, and those that meet or exceed expectations. Important
methods of improving the performance of those responsible for implementing health
services are by monitoring of progress and evaluation of results (Salama, 2010)
Development projects and programmes put together to improve the health of communities
cannot achieve their stated goals and objectives, except the planning stage is combined
with effective/strong monitoring and evaluation phases/components. These components
help in reducing the likelihood of having major cost overruns or time delays later. Good
planning ensures that emphasis is placed on important results, while monitoring and
evaluation aid learning from past successes and challenges to make an informed decision
so that current and future initiatives are better able to improve people’s lives and expand
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their choice (UNDP, 2009). A well-planned M&E requires about 5-10 percent of a project
budget
3.2: Basic concepts in Monitoring & Evaluation

3.2.1 What is Monitoring?
Monitoring of a programme or intervention project is an ongoing, continuous process

which requires data collection at multiple points throughout the programme cycle to
measure progress toward achieving programme objectives. Data collection from the
beginning of a project provides the baseline information which answers questions such as:
how well the programme has been implemented, variation from one
community/household/site to the other, and if the intended people benefit from the
programme. It also helps in deciding if intervention activities require an adjustment to
achieve desired outcomes. It can, therefore, be referred to as “process evaluation”.
Monitoring helps stakeholders to make informed decisions regarding the effectiveness of
programmes and the efficient use of resources (Frankel and Gage, 2007)
Monitoring can also be described as a:

• planning and management tool which provides the project management with regular
and continuous feedback that can be used to make decisions, manage the project
more successfully and plan for better project activities in the future.
• crucial part of the project management that will be carried out to observe the
progress of the project implementation and to ensure that inputs, activities, outputs
and external factors (such as the project assumptions) are proceeding according to
the plan.
• tool to identify problems which may occur during project implementation so that
corrective measure could be taken before the project is adversely affected
(International Center, Chiang University (2002).
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Figure 5.1 shows a graphic illustration of a programme monitoring over time. The indicator
used for monitoring (shown on the “Y" axis) could be an element of the program that needs
tracking, e.g. the cost of supplies, the number of times the staff provide certain information
to clients, number of people adopting new facility or the percentage of clients/people who
are pleased with the services they received.
Figure 5.1: Possible graphic illustration of programme monitoring

Source: USAID & Knowledge for Health, Global Health e-learning website
3.2.2 What is Evaluation?

Evaluation “is a rigorous and independent assessment of either completed or ongoing
activities to determine the extent to which they are achieving stated objectives and
contributing to decision making”. Like monitoring, evaluations can apply to many issues
such as an activity, project, programme, strategy, policy, topic, theme, sector or
organization (UNDP, 2009).
Evaluation measures how well programme activities have met the expected objectives and,
or the extent to which changes in outcomes can be attributed to the programme or
intervention. The difference in the outcome of interest between having, or not having, the
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programme/project or intervention is known as its "impact" and is commonly referred to

as "impact evaluation." Figure 5.2 shows the graphic representation of evaluation over time
Figure 5.2: Graphic representation of program impact

Source: USAID & Knowledge for Health, Global Health e-learning website
3.2.3 Importance of M&E in Health Programmes
Monitoring and Evaluation helps stakeholders’ to:

• make informed decisions regarding program operations and service delivery
based on objective evidence;
• ensure the effective and efficient use of resources;
• assess the extent to which the program is having or has had the desired impact,
in what areas it is effective, and where corrections need to be considered; and
• meet organizational reporting and other requirements and convince donors that their
investments have been worthwhile, or that alternative approaches should be
considered.
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3.2.4 Differences between Monitoring and Evaluation
Table 5.1: Significant differences between M&E

Monitoring Evaluation
Answers the question, what needs to Answers the question, have we achieved
happen now to reach the set goals? the set goals?
Tracks what is been done (primarily Determines if the desired results
inputs & outputs) to assess whether (outcomes & impact) are achieved
programmes are performing according to
plan (goals and objectives)
Assesses if things are being done right Assesses if the right things are being done
Ongoing from inception Done independently to provide managers
and staff with an objective assessment of
whether or not they are on track
Data collection at repeated intervals Data collection can be intermittent, at the
during programme implementation beginning of a programme (to provide a
baseline) or at the end of significant
milestones
Monitoring data provides regular Evaluation data can be used to assess the
feedback that measures change over time effectiveness, relevance and impact of
in any of the programme components achieving the programme’s goals
such as costs, personnel and programme
implementation
An unexpected change in monitoring Requires a comparison group to measure
data may trigger the need for a more if the observed changes in outcomes can
formal evaluation of activities be attributed to the programme
Progress indicators need to be closely Evaluation results need to be discussed,
monitored by a few people processed and interpreted by all
stakeholders
3.2.5 The Monitoring and Evaluation Plan
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A monitoring and evaluation (M&E) plan is a document that is usually developed at the
programme inception, before any monitoring and helps to track and assess the results of
the interventions throughout its life. The M&E plan consists typically of the same key
elements but may have different specific targets for each programme results. The M&E
plan consists of six major steps:
(i) Development of the programme goal and objectives;
(ii) Description of indicators (for tracking the progress and outcomes of the
Programme or intervention);
(iii) Data collection methods and data sources;
(iv) Define M&E roles and responsibilities with regards to who will collect data
for each indicator;
(v) Create analysis and reporting plan and
(vi) Plan for result dissemination.
Using these steps, the outline of the M&E plan is as shown below:
1. Introduction to the programme
• Programme goals and objectives:
• Logic model/Logical Framework/Theory of change
2. Indicators
• Table with data sources, collection timing, and staff member responsible
3. Roles and Responsibilities
• Description of each staff member’s role in M&E data collection, analysis,
and/or reporting
4. Reporting
• Analysis plan
• Reporting template table
5. Dissemination plan
• Description of how and when M&E data will be disseminated internally and
externally
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In order to ensure effective M&E of the programme/intervention, it is pertinent that the

M&E plan should be developed at the beginning when the interventions are being designed
(HealthCOMpass, 2012).
3.2.6 The Monitoring and Evaluation Logic Models

Logic models provide a streamlined linear interpretation of a project's planned use of
resources and its desired ends. They are tools that provide a diagrammatic representation
of inputs/ processes, outputs, outcomes and impact of a programme. Logic models consist
of five components:
1. Inputs: are resources, contributions, and investments that go into a programme;
2. Processes: are activities carried out to achieve the programme’s objectives;
3. Outputs: are immediate deliverables (measurable products of a programme) such
as services, events and products that reach the programme’s primary audience;
4. Outcomes: are the short-term and intermediate results (benefits) or changes related
to the programme’s intervention that is experienced by the primary audience
(clients, communities, or organization), e.g. change in behaviour or knowledge; or
improvement in health
5. Impacts: are the long-term effects of a programme, such as improved health status
(HealthCOMpass, 2015).
As shown in Fig 5.3, inputs (resources) used during processes (activities) produce
immediate intermediate results (outputs) which ultimately leads to longer-term/broader
results (outcomes) and impacts at population level. In a study focusing health services on
population health goals using a logic model, McEwan and Bigelow (1997) asserted that the
use of logic models facilitates overall governance of healthcare services by creating
performance-monitoring frameworks for both short-term and long-term outcome
objectives
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Input output outcome Impact
Activities People/Institution
Figure 5.3: Schematic representation of a Logic Model
Figure 5.4 presents a Logic model for a project designed to improve health providers’
knowledge, attitudes and practices (KAP); and to increase providers’ awareness of violence
against women as a public health problem and a violation of human rights.
Figure 5.4: Logical Framework for a Health Provider Training Programme

Source: UN Women (2012).
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INPUTS ACTIVITIES OUTPUTS OUTCOME IMPACT
• Human Distribution of IEC Increased community Reduced TB

resources IEC materials materials members knowledge morbidity
• Financial distributed on TB transmission, and mortality
resources among the treatment and
• IEC stakeholders support for TB
materials and clients
produced community
for the members
programme
Increased Increased Reduced TB
• Training Training of number of effectiveness and morbidity
guidelines laboratory staff laboratory efficiency in TB and mortality
and other key and other detection/
staff key staff management.
trained
Increased care and
Organisation of Number of support for TB
community families/ infected people Reduced
Health communities stigmatization
education sensitized on for TB
campaigns on TB and
care and care and
support for TB support for
infected
people
Figure 5.5: Logic model on the reduction of TB morbidity and mortality in
Lagos State
In addition, Karen Horsch’s presentation on the use of the logic model in assessing
improvement of the oral health of low-income children who received primary care in a
community health service provided an excellent example of the use of logic models for
programme planning and evaluation.
Use the link below to access the video on “Using Logic Models for Programme Planning
and Evaluation” by Karen Horsch:
http://slideplayer.com/slide/4351582/#.WlGz_qHVVhc.gmail
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3.3 Quality management for M&E
3.3.1 Introduction
The West Virginia Office of Technology (2012) described a quality management process
as a method (or set of procedures) by which the quality of deliverables and processes is
assured and controlled during the project. The process entails carrying out a variety of
appraisal techniques and implementing a set of corrective actions to address any
deficiencies and raise the quality levels within the project.
Accountability in programme reporting relies heavily on data quality. The M&E systems
produce data which are used to assess and document the progress of health programmes.
In many developing countries, such data have been found to be incomplete and inaccurate.
It is therefore imperative that data collected during these processes are certified to be of
high quality. This can be achieved by employing stringent and systematic data quality
assurance procedures, which utilise Data Quality Management (DQM) Plan and Routine
Data Quality Assessment (RDQA)
3.3.2 What Is Data Quality?

Data quality refers to the accuracy, value or worth of the information collected and
emphasizes the high standards required of data capture, verification, and analysis, such that
they would meet the requirements of an internal or external data quality audit.
3.3.3 Why is Data Quality Important?

Data quality is important because:
• Mistake should be prevented rather than detected
• Correcting data that has been wrongly recorded is difficult and expensive
• The quality of the data is largely determined by how well the interviews are
conducted and forms are completed
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• In the presence of errors, decisions based on the data is queried and may be
invalidated
4.0 Conclusion
This unit covered the concepts of monitoring and evaluation as an important component
of health projects. It helps stakeholders make informed decisions regarding programme
operations and service delivery.
5.0 Summary
• M&E should be an integral part of any health project right from the planning stage
• Monitoring is “process evaluation, while evaluation is “impact evaluation”
• A logic model is an excellent tool for programme planning and evaluation
• There should be a clear understanding of the purpose and scope of M&E as this will help
in deciding on the number of indicators to track and the budget levels
• Systematic data quality assurance procedures should be used to certify that data
collected during M&E are of high quality
• Data quality should be considered as an important component of monitoring and
evaluation
1. Why is M&E important?

2. What are the major differences between M&E?
3. What are M&E plans? What is there importance in health programmes?
4. List and describe the M&E components
5. Why is data quality important?
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Ayuso-Murillo D, de Andrés-Gimeno B, Noriega-Matanza C, López-Suárez RJ, Herrera-

Peco I. (2017). Quality management, a directive approach to patient safety, Enferm
Clin; 27 (4):251-255
Beverly J Nyberg (2016). Basix principles of M&E: Webinar series 8 76pp

https://cafo.org/wp-content/uploads/2016/08/Monitoring-Evaluation-Powerpoint-
Slides.pdf
Chiang Mai 50200, Thailand. UNODC Regional Training 11-16 November 2002
Frankel, N. and Gage, A. (2007). M&E Fundamentals: A self-guided minicourse USAID

and Measure Evaluation. 82pp
http://www.endvawnow.org/uploads/browser/files/M_E%20Fundamentals.pdf
HealthCOMpass (2012). How to Develop a Monitoring and Evaluation Plan

https://www.thehealthcompass.org/how-to-guides/how-develop-monitoring-and-
evaluation-plan
HealthCOMpass (2015). How to Develop a Logic Model

https://www.thehealthcompass.org/how-to-guides/how-develop-logic-model-0
International Center, Chiang Mai University (2002). Monitoring and evaluation for
Alternative development projects. International Center (IC), Chiang Mai University
Karen Horsch (nd). Using Logic Models for Program Planning and Evaluation”
http://slideplayer.com/slide/4351582/#.WlGz_qHVVhc.gmail
Keeble, G. (2010). Monitoring and Evaluation available at

https://www.spc.int/hpl/index.php?option=com_docman&task=doc_download&gi
d=48. (accessed 01 December, 2017)
McEwan Kimberley L. and Bigelow, Douglas A. (1997). Using a logic model to focus
health services on population health goals. The Canadian Journal of Program Evaluation,
Vol 12 (1): 167-174
https://www.k4health.org/sites/default/files/migrated_toolkit_files/11-2-167.pdf
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Measure Evaluation (2017). Data Quality for Monitoring and Evaluation Systems
Public Service Commission, South Africa (2008). Basic concepts in M&E 80pp
http://www.psc.gov.za/documents/docs/guidelines/PSC%206%20in%20one.pdf
Salama Rasha (2010). Monitoring and evaluation of health services.

https://www.slideshare.net/Raza_Ali/monitoring-and-evaluation-of-health-services
Siteresources.worldbank.org/INTGENDERTRANSPORT/Resources/mepres.ppt
Source: UN Women (2012). Monitoring and Evaluation Frameworks (3 parts)

http://www.endvawnow.org/en/articles/335-monitoring-and-evaluation-frameworks-3-
parts.html
UNDP (2009). Handbook on Planning, Monitoring and Evaluating for Development

Results
http://web.undp.org/evaluation/handbook/documents/english/pme-handbook.pdf
USAID & Knowledge for Health (K4Health), Global Health e-learning website.
Fundamentals of M & E.. https://www.globalhealthlearning.org/
West Virginia Office of Technology (2012). Project quality management process template
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UNIT 2: PROGRAMME MONITORING AND EVALUATION METHODS
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.1 M&E Tools and Approaches
3.2 Data Collection Methods
3.3 Factors affecting choice methods
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
There is presently an increasing interest among development partners and beneficiary
communities to include M&E in their development projects from the planning stage. This
is a sequel to the fact that M&E provides the opportunity of accessing the impact of
activities and decide if a different programme implementation method will provide better
output and outcomes. However, making a choice among different methods for a particular
health project may not be that easy. This module will, therefore, provide an insight into the
different types of methods to be used in data collection during M&E of development
programmes and the circumstances under which each can be used
2.0 OBJECTIVES
• List and describe different M&E tools, approaches and data collection methods
• State the purpose and use of each method
• State advantages and disadvantages of each method
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• Describe the factors affecting the selection of M&E tools and subsequent data
collection methods
3.0 MAIN CONTENT

3.1 M&E Tools, Approaches and data collection methods
It is important to ensure data collected during M&E will be used to check the progress of
a project and make the necessary improvements as the project proceeds.
Nine M&E tools/approaches compiled by the World Bank Operations Evaluation
Department include:
1. Performance Indicators.
Performance indicators measure inputs, processes,
Box 1: SMART INDICATORS
outputs, outcomes and impacts of a project. They are Specific: Is the indicator specific enough
therefore very useful in setting targets for project to measure progress towards the
results?
implementation and measuring the resulting progress Measurable: Is the indicator a reliable and
clear measure of results?
or achievement. However, SMART-G indicators that Attainable: Are the results in which the
indicator seeks to chart
will give a good picture of overall project progress realistic?
achievement can be developed only if the Relevant: Is the indicator relevant to the
intended outputs and
performance questions (e.g. question that will outcomes?
Time-bound: Are data available at
provide answer to the success or failure of a project); reasonable cost and effort?
Gender-sensitive: Programme and
the changes intended (e.g. presence of something achievements are viewed
through the gender lens to
absent before or type of access to a service or
ensure inclusive participation
product) and necessary information are first taken of all stakeholders and
beneficiaries and in results.
into consideration
There are three types of indicators that can be related to each performance question
• Input: describe what goes into a project, e.g. number of hours of training or amount
of money spent
• Output: describe project activities, e.g. a number of community workers trained etc.
• Impact indicators: measure the actual change in the target group or a situation
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2. The logical framework (Log-Frame) approach.

This approach identifies objectives and expected causal links and risks along the results
chain.
3. Theory-based evaluation
Provides a deeper understanding of the workings of a complex intervention. It helps
planning and management by identifying critical success factors
4. Formal surveys.
These are used to collect standardised information from a representative sample of people
or households. They are useful for understanding actual conditions and changes over time.
5. Rapid appraisal methods.

These are quick, cheap ways of providing decision-makers with views and feedback from
beneficiaries and stakeholders. They include interviews, focus group discussions and field
observations.
6. Participatory methods.
These allow stakeholders to be actively involved in decision-making. They generate a
sense of ownership of M&E results and recommendations. The method helps in building
local capacity.
7. Public expenditure tracking surveys.

These trace the flow of public funds and assess whether resources reach the intended
recipients. They can help diagnose service-delivery problems and improve accountability.
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8. Cost-benefit and cost-effectiveness analysis.

These tools assess whether the cost of an activity is justified by its impact. Cost-benefit
measures inputs and outputs in monetary terms, whereas cost-effectiveness looks at outputs
in non-monetary terms.
9. Impact evaluation.
This is the systematic identification of the effects of an intervention on households,
institutions and the environment, using some of the above methods. It can be used to gauge
the effectiveness of activities in reaching the poor.
Data Collection Methods for M&E projects

The wide variety of data collection methods can be grouped into two:
• Quantitative methods: produce data that are stated I represented as numbers)
• Qualitative methods: “gather information by asking people to explain what they
observe, do, believe or feel” It reflects a change in attitude, quality, etc.) They are
not easily represented in numerical form
The advantages, disadvantages and limitations of quantitative and qualitative data

collection methods are shown in Table 5.2, while Table 5.3 lists the common qualitative
and qualitative data collection methods for use in result chain,
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Table 5.2: Advantages, Disadvantages and Limitations of Quantitative and Qualitative

methods
Source: Angela Orlando with critical inputs from Tawfiq El-Zabri and Ed Mallorie (2013)
Table 5.3: Common Qualitative and Qualitative Data Collection Methods for use in a
Result chain
Source:
Case Study of IFAD Projects in Asia
IFAD’s results-based management framework and the logical framework approach
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Apart from survey/questionnaire, other quantitative tools include:

• Registries
• Activity logs;
• Administrative records;
• Patient/client charts;
• Registration forms;
• Case studies;
• Attendance sheets
The qualitative methods include:

• Field observation visits
• Stakeholder meetings
• Interviews
• Group discussions, focus group discussions
• Case studies
• Stories of change
• Action research
• Citizen report cards
• Most significant change
• Diaries
• Participatory video
• Timelines
• Spider diagrams
Of all the quantitative methods, the use of questionnaire survey is the most common, while
Focus Group Discussion and Key Informant Interviews are the most common qualitative
methods. It is imperative to note that the questionnaire can use both open and close-ended
questions to collect information such as the opinion of the respondent about useful project
services
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3. 3 Factors determining the choice of methods may include (World Bank, 2004):
• the purpose for which M&E is intended,
• main stakeholders who have an interest in M&E findings,
• how quickly the information is needed
• cost
5.0 Conclusion
This unit has described the different tools/approaches for data collection. Emphasis was
also placed on the different methods under the two major groups of data collection.
However, it is imperative to note that it is always better to use mixed data collection
methods that are participatory.
5.0 Summary
In this unit, we have learnt the:
• different types of M&E tools/approaches
• different data collection methods
• advantages, disadvantages and limitations of different data collection methods
• factors affecting the selection M&E tools and subsequent data collection methods
1. Describe the tools/approaches for data collection

2. What are the differences between the qualitative and quantitative types of data
collection?
3. What are the factors determining the choice of data collection methods?
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7.0 REFERENCES
Angela Orlando, Tawfig El-Zabri and Ed Maiiote (2013). Qualitative and Quantitative
Methods in Monitoring and Evaluation: Measuring Change: Experiences from IFAD-
Funded Projects in Asia Draft Feb. 8, 2013
https://asia.ifad.org/documents/627927/5b84ef3b-0a61-4bc8-9a2f-48e9fc188340
Umhlaba Development Services (2017). Introduction to Monitoring and Evaluation Using

the Logical Framework Approach. European Commission Civil Society Fund in
Ethiopia
UNDP (20019). Handbook on Planning, Monitoring and Evaluating For Development

Results
World Bank Operations Evaluation Department, 2002, Monitoring and Evaluation: Some
Tools, Methods and Approaches, The World Bank, Washington, D.C
http://www.gsdrc.org/document-library/monitoring-and-evaluation-some-tools-
methods-and-approaches/
World Bank (2004). Monitoring & Evaluation: Some Tools, Methods & Approaches
http://lnweb90.worldbank.org/oed/oeddoclib.nsf/24cc3bb1f94ae11c85256808006a004
6/a5efbb5d776b67d285256b1e0079c9a3/$FILE/MandE_tools_methods_approaches.p
df
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UNIT 3: HEALTH SYSTEMS STRENGTHENING
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.1 What is health system strengthening?
3.2 What are the challenges of health systems?
3.3 WHO building blocks for health system strengthening
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
A thriving and strong health system ensures that people and institutions, both public and
private, effectively undertake core functions to improve health care delivery and health
outcomes. The module is designed to improve students’ understanding of the processes
involved in health systems strengthening as well as recognize the principal inputs in the
whole process. The module offers the opportunity to acquire up-to-date knowledge about
health systems and the right skills set for evidence-based planning, management, and
financing for quality improvement. The outcome of this module will help the students to
build on their own experiences and understanding of health systems strengthening to
develop proposals about how these systems can be strengthened - and who might or might
not benefit. These improvements can be targeted at any combination of the regional,
national, district, and community level.
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2.0 OBJECTIVES
• Define and explain the meaning of Health System Strengthening (HSS)
• Describe the challenges of health systems globally, as well as at regional, national,
district, and community levels
• List and describe the six building blocks of HSS
3.0 MAIN CONTENTS
3.1 What is Health System Strengthening?

A "health system" is described as all the organizations, institutions, resources, and people
whose primary purpose is to improve health. The health system, therefore, delivers
preventive, promotive, curative and rehabilitative interventions through a combination of
public health actions and the pyramid of healthcare facilities that provide personal health
care - by both State and non-State actors” (WHO, 2010).
Health System Strengthening is described as:

(i) the process of identifying and implementing the changes in policy and practice in a
country’s health system, so that the country can respond better to its health and
health system challenges;
(ii) any array of initiatives and strategies that improves one or more of the functions of
the health system and that leads to better health through improvements in access,
coverage, quality, or efficiency
In many developing countries, health outcomes are at an unacceptably low, while inequities
in health status is a global problem. The Sustainable Development Goal (SDG) Target 3.8,
which seeks to achieve universal health coverage (UHC) focuses on ensuring that health
services at the reach of everyone without any hindrance. According to WHO (2017), ‘the
health-related targets of the SDGs cannot be achieved without making substantial progress
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on UHC’ UHC has been found to be inextricably linked with health system strengthening
which will provide an impetus for delivering effective and affordable services to prevent
ill health and to provide health promotion, prevention, treatment, rehabilitation and
palliation services”
3.2 What are the challenges of health systems?

All health economies around the globe seem to be facing similar challenges some of which
can be attributed to new inventions in consumer technology. Global challenges that may
likely affect the effectiveness of health care systems in the nearest future include:
• rising costs,
• changing demographics,
• filling resource gap,
• easy access,
• focus on quality and healthcare becoming customer driver
Note: Check full details in:

CGI, (2014). Healthcare Challenges and Trends: The Patient at the Heart of Care.
White Paper, 6pp.
https://www.cgi.com/sites/default/files/white-papers/cgi-health-challenges-white-
paper.pdf
The situation is worse in many developing countries where the health systems are
characterized by inadequate health resources and associated brain drain, lack of access to
basic health care especially in the rural areas and among internally displaced people (IDPs)
among others In Nigeria, the Health system is plagued by inadequate funding (<5% of total
budgetary expenditure as against minimum of 15% recommended WHO) and inequitable
distribution of health care resources between urban and rural areas among others
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Note: For more information, check:
1) WHO (2017). Malaria campaign saving young lives in Nigeria: Interview with
Dr Pedro Alonso, Director of the WHO Global Malaria Programme
http://www.who.int/malaria/news/2017/emergency-borno-state/en/
2) WHO (2017) One year after Nigeria emergency declaration.
http://www.who.int/features/2017/nigeria-declaration-photos/en/
3.3 WHO building blocks for health system strengthening

Health system building blocks are described as the analytical framework used by WHO to
describe health systems, disaggregating them into 6 core components. A health system will
be deemed to have performed efficiently if there are sustained health outcomes through
continuous improvement of the six inter-related HSS functions. Figure 5.5 shows the WHO
health systems framework detailing the six building blocks of a health system, aims and
desirable attributes.
1. Service delivery: An excellent service delivery is not only a vital element of a
health system but also a fundamental input to population health status.
Strengthening of service delivery is crucial to achieving the health-related SDGs
(see Fig 5.6).
2. Health workforce: this refers to a group of people responsible for providing health
services with the intent to improve the health of the populace. This group of people
includes clinical, managerial and support staff. Experience has shown that there is
always a shortage of health workers in many rural areas of developing nations.
3. Health information systems (HIS): a sound and reliable HIS is the bedrock of a
sustainable health system. It provides information that enables decision-makers at
all levels of the health system to identify problems and needs, makes evidence-
based decisions on health policy and allocates scarce resources in the most
desirable way. The health information system has four key functions:
• data generation,
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• compilation,
• analysis and synthesis, and
• communication and use.
4. Access to essential medicines: It is imperative that a functional health system
should provide adequate access to essential medical products, vaccines and
technologies of assured quality, safety, and efficacy at any point in time in order
to satisfy the priority health care needs of the population.
5. Health system financing (HSF): In many countries of the world, provision of
access to health financing arrangements which ensure that people have access to
adequate health care is the cornerstone of modern health financing system (WHO,
2000). The main aim of HSF is to make funds for health systems available in a
way that will ensure that all groups of people have access to needed services
without any financial hardship. However, in many developing countries (e.g.
Nigeria), out-of-pocket payments constitute the greatest percentage of health
financing.
6. Leadership/ governance: According to WHO (2010). “leadership and governance
in building a health system involve ensuring that strategic policy frameworks exist
and are combined with effective oversight, coalition-building, regulation,
attention to system design and accountability between various stakeholders in
health, including individuals, households, communities, firms, governments, non-
governmental organizations, private firms and other entities that have the
responsibility to finance, monitor, deliver and use health services”
In other to monitor these building blocks effectively a set of indicators have been
recommended for each block.
Note: For complete details on building blocks, indicators, data collection methods and
sources, see WHO (2010) at
http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf
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Figure 5.6 shows the relationship between HSS, UHC and SDGs
Figure 5.5: WHO health Systems Framework: The Six Building Blocks of a health System, aims
and desirable attributes
Source: WHO (2010)
Figure 5.6: Relationship between HSS, UHC and SDGs
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7.0 REFERENCES
CGI (2014). Healthcare Challenges and Trends The Patient at the Heart of Care. White
Paper, 6pp.
https://www.cgi.com/sites/default/files/white-papers/cgi-health-challenges-white-
paper.pdf
USAID’s Vision for Health Systems Strengthening

https://www.usaid.gov/sites/default/files/documents/1864/HSS-Vision.pdf
WHO (2000). Who Pays for Health Systems? In World Health

Report 2000: health systems: improving performance Chapter 5:93 - 115 Geneva:
WHO.
http://www.who.int/whr/2000/en/whr00_ch5_en.pdf?ua=1
WHO (2007). Everybody business: strengthening health systems to improve health

outcomes: WHO’s framework for action.
http://www.who.int/healthsystems/strategy/everybodys_business.pdf
WHO (2010). Monitoring the building blocks of health systems: a handbook of indicators
and their measurement strategies, Geneva, WHO, 93pp
http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf
http://www.who.int/healthinfo/systems/monitoring/en/
WHO (2017). Health Systems Strengthening Glossary

http://www.who.int/healthsystems/hss_glossary/en/index5.html
World health statistics (2017). Monitoring health for the SDGs, Sustainable Development
Goals. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO
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UNIT 4: GLOBAL HEALTH IN NIGERIA: PRACTICUM
The Global Health Practicum is an integrated aspect of the Global Health- PHS 812 course.
It is designed to bridge the theory and practice in a variety of health-related settings. The
Practicum will be a unique opportunity for students to learn how to apply global health
concepts, methods, and theory in health-related occupations in Nigeria. It will also enable
them to develop the attributes needed for career development.
The practicum will be for four weeks during which the student will investigate a selected
global health issue based on knowledge of the PHS 812 course. Students will use the
prescribed logbook and will be supervised and evaluated. Students will be mentored and
supported by qualified supervisors in the placement workplace as well as the course
coordinator/lecturer. Upon completion of the practicum, students will submit their report
(Logbook) and present their findings (this will also be graded). The student’s
application/agreement form is attached as Appendix1
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APPENDIX 1
Practicum Approval – Sign off by Global Health Programme Coordinator
Student Name (please

print, surname first)
Fore name(s) Last name
Student Number
E-mail Address
Telephone No.
The student has fulfilled the academic requirements for PHS 812: Global Health
Programme Coordinator’s Comments:

------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------
Name: ---------------------------------------------------------------------------------------------------
Signature: ----------------------------------------- Date: ----------------------------------
170

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NATIONAL OPEN UNIVERSITY OF NIGERIA

FACULTY OF HEALTH SCIENCES

COURSE CODE: PHS 812

COURSE TITLE: GLOBAL HEALTH

Course Developers: Dr. Elizabeth O. Oloruntoba &

Course Editor: Dr Olufemi O. Aluko

Programme Leader: Prof Grace Okoli-Nnabuenyi.

Programme Coordinator: Dr Gloria O. Anetor.

NATIONAL OPEN UNIVERSITY OF NIGERIA

National Open University of Nigeria,

All Rights Reserved

WHAT YOU WILL LEARN IN THIS COURSE

• describe the social determinants of health

WORKING THROUGH THIS COURSE

Module 1 Concepts in Globalization and Health

Module 2 Global Health Economics

Module 3 Leadership and Political Economy of Health Sector Reform

Module 4 Global Health and Diseases

Module 5 Health Services Monitoring and Evaluation

TEXTBOOKS AND REFERENCES

FINAL EXAMINATION AND GRADING

Module 1 Concepts in Globalization and

Unit 1 Fundamentals of global

Module 2 Global Health Economics....................... 30

Unit 1 Introduction to health economics.......... 30

Leadership and Political Economy of 63

Unit 1 Health services administration........................ 63

Unit 2 Health sector reform: a worldwide 74

Global health politics and policy.............. 92

Unit 5 The political economy of global health.......... 99

Module 4 Global Health and Diseases................ 105

Unit 1 Case studies in tropical diseases…….. 105

Module 5 Health Services Monitoring and 140

Unit 1 Introduction to quality management for 140

Unit 2 Programme monitoring and evaluation methods 154

Unit 3 Health systems strengthening 162

Unit 4 Global health in Nigeria: practicum 169

MODULE 1: CONCEPTS IN GLOBALIZATION AND HEALTH

UNIT 1 FUNDAMENTALS OF GLOBAL HEALTH

At the end of this unit, you will be able to:

• Explain the effects of globalization on health governance

3.0 MAIN CONTENT

3.1 Global Health Governance

1. Increased globalization has brought about, or aggravated, transborder human health

According to literature, Global Health Governance (GHG) can be defined as strategies

3.2 Health Indicators and Burden of Disease

In general, health indicators can be defined as directly or indirectly measurable health

Figure 1.1: Health status indicators (World Health Organization, 2015)

Figure 1.2: Risk factors indicators (World Health Organization, 2015)

Figure 1.3: Service coverage indicators (World Health Organization, 2015)

Figure 1.4: Health systems indicators (World Health Organization, 2015)

3.3 Mixed-Method Approaches in Global Health Research

In the past, public health has followed a predominantly quantitative, epidemiological

• An exploratory, or explanatory sequential mixed-method research. Here, results

When it comes to research, however, it is important to be able to distinguish what is right

3.4 Ethics in Global Health Research

• Utilitarianism is a concept in which an action is deemed right if the greatest number

In addition, we learnt that mixed-method approaches to global health research is a mash-