The accountability for reasonableness (AFR) concept has been developed and discussed for over two decades. Its interpretation has been studied in several ways partly guided by the specific settings and the researchers involved. Its potential use in health technology assessments (HTAs) has recently been identified another justification for AFR-based process guidance, but it has also raised concerns from those who primarily support the consistency and objectivity of more quantitative and reproducible evidence. With reference to studies of AFR-based interventions, the authors argue that increasing evidence and technical expertise are necessary but at times contradictory and do not in isolation lead to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. They suggest that legitimacy, accountability and fairness do not come about without an inclusive and agreed process guidance that can reconcile differences of opinion and differences in evidence to arrive at a decision.
Governance and participation in health
The book is a review of the June 1999 democratic elections in South Africa and has extensive chapters on the role of civil society and voter education and election monitoring of the elections as well as a 25 page chapter on the role of the media in the election process.
Claudio Schuftan
The People's Charter for Health (PCH), The PHM's manifesto, is one and a half years old. It has been disseminated quite widely world-wide.
2. The world has moved on since. But, clearly, for the worse in almost all fronts the PHM has strong feelings about. Most worrisome is the fact that most of the world's shifts for the worse have become so depressingly predictable, and nobody seems to be succeeding in doing much about them.
3. The PCH's 'Call for Action' predicted much of what we are witnessing; we were "on the dot". So, to continue to be "on the dot", we simply have to reassess where we are and what we have, and have not, achieved. Just to make yet further predictions of doom would be to utterly fail all that and those we stand for.
Much theorising about global health governance has taken a view from above and the authors of this article aimed to complement this with perspectives from grassroots organisations and service providers. Based on a qualitative field study conducted in 2009, they investigated the implications of multiple major international financing structures for HIV on local and district-level responses in Kenya, Malawi and Zambia. They conducted 130 interviews at national level and in six districts, triangulated across public and private sectors. The authors found positive as well as negative experiences of engagement with global health initiatives, concluding that these initiatives should engage with each other, with governments and with local stakeholders to develop a joint Code of Practice for more coherent systems down to community levels.
The single most important message of this paper is that development outcomes in poor countries depend fundamentally on the political incentives facing political elites and leaders. Political will has usually been treated as an inexplicable ‘black box’. The authors seek in this paper open up the black box, to say some definite things about the specific contexts in which political ambitions are shaped and policy choices are made in different parts of the world and at different stages of countries’ development processes. They argue that economic growth without economic transformation is limited. The authors raise the case that democracy depends on the formation of social classes, including productive capitalists, and organised professional groups and wage-earning workers. This only happens as a result of economic diversification and the accumulation of technological capacities. If the formal sector cannot generate adequate incomes and taxes for state revenues, the ruling elites draw resources to meet the demands of crucial coalition groups from various kinds of off-budget transfers and informal sharing of rents. The paper explores country contexts in Africa where there is evidence of diversity in the relationship between ruling elites and state bureaucracies, to better understand the reasons for this diversity and its implications for development aid.
Amadasun reviews several of the important international mechanisms which channel aid to Africa, finding that the many instruments developed outside Africa are ineffective because they have design, accountability and ownership flaws. These criticisms apply to International Monetary Fund (IMF) programmes, debt relief and also budget support. Despite some changes in the way that the IMF and other international agencies operate – for example linking their interventions to Poverty Reduction Strategies – their fundamental way of working remains to pressure governments to take certain actions even at the expense of citizens’ views. Amadasun suggests that new mechanisms that originate in Africa, for Africa, stand a better chance of enabling decisions that empower and support large numbers of impoverished people. These mechanisms include the Pan-African Parliament (PAP) and the African Peer Review Mechanism (APRM). However these institutions are nascent and have yet to fulfill their full potential. To reach their potential these African bodies must develop authority to scrutinise the interventions of the international financial institutions (IFIs). These bodies will have to overcome several challenges. These include improving who is selected to represent African citizens, increasing public awareness and discussion of the bodies, and developing an independent source of financing for their own operations. If they overcome these challenges the PAP and APRM may be able to prevent international agencies from imposing policies and pressures from outside the region and enable a flourishing of democracy from below.
In an initiative to promote the decentralizing of the health system, the government of Uganda through Ministry of Health called for an establishment of Health Unit Management Committees (HUMCs) at each government health facility as a way of empowering community members to participate in influencing health system for better service delivery. As part of an action research process, the Center for Health Human Rights and Development (CEHURD) carried out a case study on two HUMCs in Kikoolimbo health center III in Kyankwanzi district and Nyamiringa health center II Kiboga district. The purpose of this case study was to provide an understanding of the experiences of HUMCs in performing their roles and what role Civil Society can play to support them perform their roles and responsibilities as well as advancing health rights and addressing health inequities using the human rights based approach. The findings revealed that these two health unit management committees had limited knowledge of the HUMCs guidelines. The committee members were trained by CEHURD and community dialogues held to inform community members about the existence of these committees as well as their roles and responsibilities. The author noted that when communities are empowered, they can differentiate between performing and non-performing committees.
This Drum Beat is one of a series of commentary and analysis pieces. Getting communication included is an integral element in development programmes, for example improving maternal health. Addressing this challenge needs actions at many levels, all of which entail particular types of communication.
This Agency for Co-operation and Research in Development (Acord) report features two country case studies (Uganda and Burundi) which explored the role of community-based research in responding to HIV stigma and discrimination. The research found that issues of stigma and discrimination reached all spheres of life, including the home, family, the workplace, school, health settings and the larger community. It also identified a number of key factors that contribute to stigma and discrimination. These include ignorance and fear, cultural norms and values, some religious teachings, the lack of legal sanctions, lack of rights awareness, the design of government and other programmes, and inaccurate or irresponsible media coverage.
This study took place in Northern Ghana to assess the impact of male involvement in reproductive health and Family Planning (FP) services. Twelve focus group discussions were held with both male and female community members, six in communities with functional community health-based planning and services strategy (CHPS) and six for communities with less/no-functional CHPS. Fifty-nine in-depth interviews were held with other stakeholders at both district and regional levels. The results revealed a general high perception of an improved health status of children in the last ten years in the communities; however, participants reported that malnutrition was still rife in the community. The results also revealed that women still needed to get spousal approval to use contraceptives; however, the matrilineal system appears to give more autonomy to women in decision-making. The CHPS strategy was perceived as very helpful with full community participation at all levels of the implementation process. Males were more involved in FP services in communities with functioning CHPS than those without functioning CHPS. The authors argue that involving males in reproductive health issues including FP is important to attain reproductive health targets.