Healthcare user fees present an important barrier for accessing services for the poorest in Burkina Faso and selective removal of fees has been incorporated in national healthcare planning. However, establishing fair, effective and sustainable mechanisms for the removal of user fees presents important challenges. A participatory action-research project was conducted in Ouargaye, Burkina Faso, to test mechanisms for identifying those who are poorest in implementing user fee removal. The authors explore stakeholder perceptions of ethical considerations relating to participation and partnership arising in the action-research in 39 in-depth interviews in the affected community, local healthcare professionals, management committees of local health clinics, researchers and regional or national policy-makers. Using constant comparative techniques, the authors carried out an inductive thematic analysis of the collected data. Stakeholder perceptions and experiences relating to the participatory approach and reliance on multiple partnerships in the project were associated with a range of ethical considerations related to 1) seeking common ground through communication and collaboration, 2) community participation and risk of stigmatisation, 3) impacts of local funding of the user fee removal, 4) efforts to promote fairness in the selection of the indigents, and 5) power relations and the development of partnerships.The investigation illuminated the distinctive ethical terrain of a participatory public health action-research project. The authors indicate that careful attention and effort is needed to establish and maintain respectful relationships amongst those involved, acknowledge and address differences of power and position, and evaluate burdens and risks for individuals and groups.
Governance and participation in health
Non-state actors (NSAs) are systematically neglected in European Union (EU) development assistance programmes, according to this report. It identifies EU practices that are violating its European Consensus on Development policy statement. It found that, despite the European Community’s (EC’s) attempts, NSAs' involvement has been limited and falls short of the sustained and structured dialogue envisaged by the EU legislation and the Commission’s own guidelines. The EC often does not commit enough time and resources to ensure that its delegations involve relevant NSAs throughout the whole process. EC's development aid programmes are reported to often engage NSAs solely as service providers or short-term consultants, without the follow-up and impact needed for sustainability and effectiveness.
The European Parliament in considering the second review of the Cotonou Agreement between European and African and Caribbean states, deplored the fact that the Parliament, the ACP-EU Joint Parliamentary Assembly (JPA), national parliaments of the ACP (African, Caribbean and Pacific) States and civil society organisations and non-state actors were not involved in the decision-making process that led to the identification of areas and articles of the Cotonou Agreement for revision and to the establishment of the negotiating mandates adopted by the Council of the European Union (EU) and the ACP Council of Ministers. This omission was argued to affect the transparency and credibility of the revision process and to alienate EU and ACP populations from their governments and institutions. The Parliament stressed the need to consolidate the political dimension of the Cotonou Agreement, particularly in respect of the commitment of the parties to implement the obligations stemming from the Rome Statute of the International Criminal Court. The European Parliament called on the Commission, the EU and the ACP Council to take into account the principles and results of the International Aid Transparency Initiative, and to launch a debate, involving also non state actors, on the future of ACP-EU relations post-2020.
Although there is a general agreement on the benefits of evidence informed health policy development given resource constraints especially in Low-Income Countries (LICs), the definition of what evidence is, and what evidence is suitable to guide decision-making is still unclear. The authors’ explored health policy actors’ views regarding what evidence they deemed appropriate to guide health policy development, with 51 key informants interviewed. Different stakeholders lay emphasis on different kinds of evidence. While external funders preferred international evidence and Ministry of Health officials looked to local evidence, district health managers preferred local evidence, evidence from routine monitoring and evaluation and reports from service providers. Service providers on the other hand preferred local evidence and routine monitoring and evaluation reports whilst researchers preferred systematic reviews and clinical trials. Although policy actors look for factual information, they also require evidence on context and implementation feasibility of a policy decision.
This paper produced by the Centre for Social Science Research (CSSR) at the University of Cape Town compares public opinion survey data from the Afrobarometer with epidemiological data about the HIV/AIDS pandemic in seven Southern African countries. The authors use this data to examine the degree to which people are aware of the pandemic, and are willing to speak about it. They also use it to examine whether it yields any palpable consequences of the disease in terms of public health. In turn, they also ask whether data on public awareness of AIDS deaths and individual health status corroborate, broadly, existing epidemiological data on HIV/AIDS. Finally, they examine the degree to which HIV/AIDS affects southern Africans' political priorities, political participation and expectations for government action.
As a key principle of Primary Health Care (PHC) and Health Systems Reform, community participation has a prominent place in the current global dialogue. Participation is not only promoted in the context of provision and utilization of health services. Advocates also highlight participation as a key factor in the wider context of the importance of social determinants of health and health as a human right. However, the evidence that directly links community participation to improved health status is not strong. Its absence continues to be a barrier for governments, funding agencies and health professionals to promote community participation. The purpose of this article is to review research seeking to link community participation with improved health status outcomes programmes. It updates a review undertaken by the author in 2009. The search includes published articles in the English language and examines the evidence of in the context of health care delivery including services and promotion where health professionals have defined the community’s role. The results show that in most studies community participation is defined as the intervention seeking to identify a direct causal link between participation and improved health status modeled on Randomized Control studies (RCT). The majority of studies show it is not possible to examine the link because there is no standard definition of ‘community’ and ‘participation’. Where links are found, they are situation-specific and are unpredictable and not generalizable. In the discussion, an alternative research framework is proposed arguing that community participation is better understood as a process. Once concrete interventions are identified (i.e. improved birth outcomes) then the processes producing improved health status outcomes can be examined. These processes may include and can lead to community uptake, ownership and sustainability for health improvements. However, more research is needed to ensure their validity.
EThis report shares the highlights and lessons learned from the third year of "Community Lessons, Global Learning", a collaboration between the International HIV/AIDS Alliance and Positive Action, GlaxoSmithKline. The report includes approaches to the HIV/AIDS pandemic over the past twenty years that work. It highlights applications for moving from successful small scale projects that reach relatively few individuals to effective strategies that really make an impact on the pandemic is the challenge. Posing the question, “How can individual NGOs/CBOs scale-up their own contribution to effective responses.”
To address the research gap on health care leadership in low-income settings, researchers in this qualitative study documented the experiences of individuals in key health-care leadership roles in sub-Saharan Africa. They conducted in-person interviews with health care leaders in four countries in sub-Saharan Africa: Ethiopia, Ghana, Liberia and Rwanda. Individuals were identified by their country's minister of health as key leaders in the health sector and were nominated to serve as delegates to a global health leadership conference in June 2010, at Yale University in the United States. Five key themes emerged as important to participants in their leadership roles: having an aspirational, value-based vision for improving the future health of their countries, being self-aware and having the ability to identify and use complementary skills of others, tending to relationships, using data in decision making, and sustaining a commitment to learning. While current models of leadership capacity building only address the need for core technical and management competencies, skills relevant to managing relationships are also critical in the sub-Saharan African context, the authors argue. Developing such skills may require more time and a deeper level of engagement and collaboration than is typically invested in efforts to strengthen health systems.
This paper reports on work to explore how primary healthcare facility managers’ use of information for decision-making is influenced by governance across levels of the health system in Cape Town, South Africa. Central governance shaped what information and knowledge was valued – and, therefore, generated and used at lower system levels. The central level valued formal health information generated in the district-based health information system which therefore attracted management attention across the levels of the health system in terms of design, funding and implementation. This information was useful in the top-down practices of planning and management of the public health system. However, in facilities at the frontline of service delivery, there was a strong requirement for local, disaggregated information and experiential knowledge to make locally-appropriate and responsive decisions, and to perform the people management tasks required. Despite central level influences, modes of governance operating at the sub-district level had influence over what information was valued, generated and used locally. Strengthening local level managers’ ability to create enabling environments is an important leverage point in supporting informed local decision-making, and, in turn, translating national policies and priorities, including equity goals, into appropriate service delivery practices.
Kenya is currently revising its community health strategy (CHS) alongside political devolution, revisioning responsibility for local services. This explores drivers of policy change from key informant perspectives and perceptions of current community health services from community and sub-county levels, including perceptions of what is and what is not working well. It highlights implications for managing policy change. The authors conducted 40 in-depth interviews and 10 focus group discussions with a range of participants to capture plural perspectives from policymakers, sub-county health management teams, facility managers, community health extension worker (CHEW), community health workers (CHWs), clients and community members in two purposively selected counties: Nairobi and Kitui. There was widespread community appreciation for the existing strategy. High attrition, lack of accountability for voluntary CHWs and lack of funds to pay CHW salaries, combined with high CHEW workload were seen as main drivers for strategy change. Areas that informants felt should change included: lack of clear supervisory structure and adequate travel resources, uneven coverage and inequity in community health services, limited community knowledge about the strategy and home-based HIV testing and counselling. The recommendations point towards a more people-centred health system for improved equity and effectiveness, if the policy is to be effectively implemented.