Governance and participation in health

The lived experience of stigma and Parkinson’s disease in Kenya: a public health challenge
Fothergill-Misbah N: BMC Public Health 23: 364;1-12, 2023

Stigma is a recognised barrier to health-seeking behaviour and a social determinant of population health. This study draws on qualitative data collected from 55 people diagnosed with Parkinson’s and 23 caregivers as part of a wider ethnographic study to explore the lived experience of Parkinson’s disease in Kenya, using the Health Stigma and Discrimination Framework as a tool to understand stigma as a process. Participants reported their lived realities of stigma, and experiences of stigma practices, which had significant negative health and social outcomes, including social isolation and difficulty accessing treatment. Ultimately, stigma had a negative and corrosive effect on the health and wellbeing of patients, highlighting the interplay of structural constraints and the negative consequences of stigma experienced by people living with Parkinson’s in Kenya. Targeted and nuanced ways of tackling stigma are suggested, including educational and awareness campaigns, training, and the development of support groups.

What values drive communities’ nutrition priorities in a resource constrained urban area in South Africa?
Erzse A; Rwafa-Ponela T; Goldstein S et al: BMC Public Health 23:873;1-15, 2023

This study sought through focus group discussions to identify the priorities of community members of a South African township, Soweto, and describe the underlying values driving their prioritisation process, to improve nutrition in the first 1000 days of life. The authors used a modified public engagement tool: Choosing All Together which presented 14 nutrition intervention options and their respective costs. Participants deliberated and collectively determined their nutritional priorities. All groups demonstrated a preference to allocate scarce resources towards three priority interventions school breakfast provisioning, six months paid maternity leave, and improved food safety. All but one group selected community gardens and clubs, and five groups prioritised decreasing the price of healthy food and receiving job search assistance. Participants’ allocative decisions were guided by several values implicit in their choices, such as fairness and equity, efficiency, social justice, financial resilience, relational solidarity, and human development, with a strong focus on children.

Multi-level change strategies for health: learning from people-centered advocacy in Uganda
Bailey A; Mujune V: International Journal for Equity in Health 21(143), 1-15, 2022

This paper is based on a comparative, inductive, practitioner-led analysis of program monitoring data from 18 multi-level health advocacy campaigns. The findings emerge from analysis of a “Heat Map,” capturing grounded accounts of government responses to community-led advocacy. Officials in eight out of 18 districts were noted to have fulfilled or surpassed commitments made to community advocates. Government responses included: increased monitoring, more downward accountability, countering backlash against advocates, applying sanctions for absent health workers, and increased budget allocations. Advocates’ bottom-up advocacy worked in part through triggering top-down responses and activating governmental checks and balances. Methodologically, this article demonstrates the value of analyzing process monitoring and program data to understand outcomes from direct engagement between citizens and the state to improve health services. Survey-based research methods and quantitative analysis may fail to capture signs of government responsiveness and relational outcomes many hope to see from citizen-led accountability efforts. Practitioners’ perspectives on how accountability for health emerges in practice are argued to be important correctives to much positivist research on accountability, which has a tendency to ignore the complex dynamics and processes of building citizen power.

What happened to HIV activist Zackie Achmat?
Christie S: Bhekisisa, South Africa, November 2022

Zackie Achmat was one of the most vociferous voices against former president Thabo Mbeki’s HIV denialism in the late 1990s and early 2000s. In 1998, Zackie and a handful of others had launched what would rapidly become one of the most prominent HIV-advocacy movements in the world, the Treatment Action Campaign (TAC). This article follows what the authors call "arguably his generation’s most prominent social justice advocate" to his current work on other areas of engaging the state, and report Achmat's analysis of local movements. It also covers his understanding of the COVID-19 pandemic as a harbinger of a new normal — “a condition where emergencies such as pandemics and climate change disasters are not exotic happenings but things occurring at home on an ongoing basis, requiring a complete reorientation of emergency healthcare, and a corresponding reorientation of activism.”

Assessing the scalability of a health management-strengthening intervention at the district level: a qualitative study in Ghana, Malawi and Uganda
Bulthuis S; Kok M; Onvlee O; et al: Health Research Policy and Systems 20(85), 1-14, 2022

The scale-up of successfully tested public health interventions is critical to achieving universal health coverage. This study assessed the scalability of a tested health management-strengthening intervention (MSI) at the district level in Ghana, Malawi and Uganda. The MSI was seen as credible, as regional- and national-level Ministry of Health officials championed it and district- and national-level stakeholders seemed to be convinced of its value, due to observed positive results regarding management competencies, teamwork and specific aspects of health workforce performance and service delivery. While the relative advantages of the intervention were its participatory and sustainable nature, turnover within the district health management teams and limited (initial) management capacity complicated implementation. The authors propose from the findings that improved documentation of results of the intervention can facilitate scale-up, while embedding continuous assessment with all stakeholders involved can help to adapt to changing conditions..

Cities can care for people and enable them to care for others, making urban health possible
Obando F; Keith M: PEAK Urban Programme, University of Oxford, 2022

By creating the conditions for health in many ways - through healthcare, childcare, public safety, community and economic development, parks and recreation, among others - local governments care for people. In this paper, three significant ways are discussed. A closer look at the role of local governments in providing water, sanitation and hygiene (WASH), urban planning, and transport shows that the local government contribution to healthy urban lives and equity is unparalleled but faces significant challenges. A contestation of public goods and private interests make the role of a local arbitrator essential. With local governments key actors in collective wellbeing and in generating equity, the authors argue that when they fall short, the consequences for health are disastrous. They provide a framework for navigating complexity and present and draw lessons from the participation of local governments in urban governance during the COVID-19 pandemic.

The importance of prioritizing politics in Good Governance for Medicines Initiative in Zimbabwe: a qualitative policy analysis study
Mhazo AT; Maponga CC: Health Policy and Planning 37(5) 634–643, doi:, 2022

In 2004, the World Health Organization (WHO) launched the Good Governance for Medicines (GGM) initiative, with the aim of fighting corruption in the pharmaceutical sector. In the case of Zimbabwe, implementation of the initiative slowed down after the development phase. Often, lack of funding and technical considerations are cited as major reasons for issue de-prioritization whilst ignoring the influence of politics in mediating policy diffusion. Between June and August 2021, an in-depth document review was conducted and individuals involved with GGM in Zimbabwe interviewed to understand the political determinants of GGM prioritization in Zimbabwe. The Shiffman and Smith framework was used to guide and direct the analysis. The authors found that the inception of GGM was facilitated by capable leaders, effective guiding institutions and resonance of the idea with the political environment. Prioritization from inception to implementation was constrained by limited citizen engagement, restriction of the issue to the pharmaceutical domain and a political transition that re-oriented policy priorities and reconfigured individual actor power. The portrayal of corruption as a priority problem requiring policy action has been hampered by the political sensitivity of the issue, lack of credible indicators on the prevalence and severity of the problem and challenges to measure the effectiveness of interventions such as the GGM. Despite the slowdown, from 2018 GGM actors have taken advantage of momentous policy windows to reconstitute their power by opportunistically framing GGM within the broader framework of access to essential medicines leading to the creation of new policy alliances and establishment of strategic political structures. To sustain the political prioritization, the author argues that actors need to lobby for the institutionalization of GGM within the Ministry of Health strategy, sensitize citizens on the initiative, involve multiple stakeholders and frame the issue as a strategic intervention that underpins pharmaceutical sector performance within the national developmental framework.

Africa CDC is Elevated to the Status of a Continental Public Health Agency
Adepoju P: Health Policy Watch, February 2022

The African Union (AU) has decided to elevate its African Centres for Disease Control and Prevention (Africa CDC) to the status of an autonomous public health agency for the continent – rather than operating simply as technical arm of the AU. The elevation of the Africa CDC – which will now report directly to Heads of State of AU Member Countries – is reported to signal the growing member state commitment to strengthening the continent’s response to current and future disease outbreaks.

Promoting social dialogue to improve working conditions for Community Health Workers in Malawi
Public Services International: PSI, Malawi, 2021

Community Health Workers (CHWs) occupy a unique position in-between the community and state bureaucracy, which the authors report to be challenging for CHWs to balance as they are accountable to both. This intermediary position poses disadvantages for CHWs when the expectations of the community and the state bureaucracy differ, leading to high workload and demotivation among CHWs. Nevertheless, given the acute shortage in the health workforce in Malawi, CHWs are an essential cadre in driving forward efforts to achieve universal health coverage. This publication aims to support efforts to understand the working conditions of CHWs and to achieve decent work for CHWs.

Promoting social dialogue to improve working conditions for Community Health Workers in South Africa
Public Services International: PSI, South Africa, 2021

This manual looks at Community Health Workers (CHWs) in South Africa and their crucial role in the health system. The official health policy of the National Department of Health, “Restructuring the national health system for universal Primary Health Care (NDOH 1996) mentioned the important role of CHWs but did not incorporate them into the health system. More recent policies acknowledge CHWs as a vital part of the health team, for the success of Primary Health Care (PHC), but implementation has been delayed. The publication draws attention to the present working conditions of CHWs, their demands and how trade unions can assist them.