The Forum on Internet Freedom in Africa convened stakeholders in end September 2017 from the internet governance and online rights arenas in Africa and beyond to deliberate on gaps, concerns and opportunities for advancing the right to privacy, access to information, free expression, non-discrimination, and the free flow of information online. The Forum gathered human rights defenders, journalists, government officials, private sector players, global information intermediaries, bloggers, developers, the arts community, law enforcers and regulators – all of whom have a role to play in advancing internet freedom in Africa. Highlights at FIFAfrica include the launch of the annual State of Internet Freedom in Africa research report, as well the commemoration of the International Day for Universal Access to Information (IDUAI), which falls on September 28. Further information, thoughts and ideas can be found at the #InternetFreedomAfrica hashtag.
Governance and participation in health
Citizen-based accountability strategies to improve the lives of the poor and marginalised groups are increasingly being used in efforts to improve basic public services. The latest thinking suggests that broader, multi-pronged, multi-level, strategic approaches that may overcome the limitations of narrow, localised successes, hold more promise. This paper examines the challenges and opportunities, in theory and practice, posed by the integration of two such citizen-based accountability strategies—social accountability and legal empowerment. It traces the foundations of each of these approaches to highlight the potential benefits of integration. Consequently it examines whether these benefits have been realised in practice, by drawing upon five cases of organisations pursuing integration of social accountability and legal empowerment for health accountability in Macedonia, Guatemala, Uganda, and India. The cases highlight that while integration offers some promise in advancing the cause of social change, it also poses challenges for organisations in terms of strategies they pursue.
This introductory paper to a series suggests that rather than seeing governance as a normative health system goal addressed through the architecture and design of accountability and regulatory frameworks, it should be located in the real-world decision-making of health policy and system actors. Their multiple, routine decisions translate policy intentions into practice - and are filtered through relationships, underpinned by values and norms, influenced by organizational structures and resources, and embedded in historical and socio-political contexts. These decisions are also political acts - in that they influence who accesses benefits and whose voices are heard in decision-making, reinforcing or challenging existing institutional exclusion and power inequalities. In other words, the everyday practice of governance has direct impacts on health system equity. Analysis of governance can be viewed through diverse health policy and system issues, considers actors located at multiple levels of the system and draws on multi-disciplinary perspectives. This article introduces papers that present detailed examination of experiences in a range of African and Indian settings, led by authors who live and work in these settings, providing an empirical and embedded research perspective on governance and equity in health systems.
Peasants across Africa are intensifying their struggles against land grabs and other harmful policies that promote industrial agriculture. At a recent international conference organised by the world’s largest peasants movement, Via Campesina, African peasants had opportunities to share their experiences of struggle and to learn. This conference happens at a time when Africa is undergoing a harsh moment, as indicated by Ibrahima Coulibaly from the National Coordination of Peasant Organizations (CNOP) in Mali. They note that land, mineral resources, seeds and water are increasingly being privatised due to the myriad of investment agreements and policies driven by new institutional approaches, imposed on the continent by western powers and Bretton Woods institutions. Elizabeth Mpofu, from the Zimbabwe Smallholder Farmers Forum, is a small-scale farmer who had access to land after she took part in the radical land occupation that resulted in the fast-track land reform in the early 2000s. According to her, building alternatives is to take direct action. Domingos Buramo, from the Mozambique Peasants Union (UNAC), brought to the conference the experience of the Mozambican peasants and other civil society organisations against land grabbing and large-scale investment projects in Mozambique. He mentioned that the resistance to ProSavana, a large-scale agricultural project proposed for Mozambique, is an example of how transformative articulated struggles could be. “Now the government is changing its vision as a result of our work. We can change our societies”, he said. Africa - including the Maghreb region - was the last continent to be part of Via Campesina. Since 2004 the number of African peasant movements joining La Via Campesina has been increasing. African movements consider their membership to the peasant movement as a strategic process of amplifying their struggles and reinforcing internationalism.
CEHURD within the Coalition to Stop Maternal Mortality Due to Unsafe Abortion (CSMMUA) held a meeting in June 2017 with Uganda Women’s Parliamentary Association (UWOPA) to clarify on the legal and policy framework on sexual and reproductive health and to discuss evidence based approaches to address unsafe abortion even where the law is restrictive. In Uganda, unsafe abortion is one of the leading causes of maternal morbidity and mortality, contributing to approximately 26% of the estimated 6,000 maternal deaths every year and an estimated 40% of admissions for emergency obstetric care. The meeting was motivated by a conviction that as policy makers, Members of Parliament (MPs) have a role to play in law reform on sexual and reproductive health issues and to interact with communities in their various constituencies. The meeting paved a way for an open discussion on unsafe abortions as a public health issue and the different stakeholders’ and policy makers' roles in reducing abortion related deaths in Uganda.
The 2008–2009 Zimbabwe cholera epidemic resulted in 98,585 reported cases and caused more than 4,000 deaths. In this study, the authors used a mixed-methods approach that combined primary qualitative data from a 2008 Physicians for Human Rights-led investigation with a systematic review and content analysis of the scientific literature. Their initial investigation included semi-structured interviews of 92 key informants, which the authors supplemented with reviews of the social science and human rights literature, as well as international news reports. The authors investigation revealed that the 2008–2009 Zimbabwean cholera epidemic was exacerbated by a series of rights abuses, including the politicisation of water, health care, aid, and information. The authors argue that the failure of the scientific community to directly address the political determinants of the epidemic exposes the challenges to maintaining scientific integrity in the setting of humanitarian responses to complex health and human rights crises. While the period of the cholera epidemic is now a decade in the past, the findings remain relevant for contexts where health and rights interact and in contexts where governance concerns affect improvements in health.
Each year, the Southern African Development Community (SADC) holds a special Southern Africa Civil Society Forum. The 13th annual Forum took place in mid August in Johannesburg. Members of the SAIIA Youth Policy Committee and alumni of the SAIIA Young Leaders Conference were there, to provide an eye-witness account of the proceedings. Civil society is defined as a ‘community of citizens linked by common interests and collective activity.’ This was evident at the 13th SADC Civil Society Forum from day one.
The Forum serves as a platform for civil society organisations from all over the region to meet and consolidate their stance, which is then presented as a declaration to the SADC secretariat. The theme for this year’s forum was ‘Building People’s Organisations, Securing Our Common Future, Consolidating Our Gains and Confronting Our Challenges’. These four blogs present the voice and reflections of young people attending various sessions at the Forum.
Dr Tedros Ghebreyesus is the first African to be elected as the Director-General of the World Health Organisation (WHO) in its 70 year history. The massive margin for Tedros – 133 votes vs 50 for the UK candidate – suggests that the entire Global South voted for him. Professor David Sanders in this interview suggests that the vote almost certainly represents a vote against big power domination and machinations in the WHO which often appears to ignore the main challenges and aspirations of low and middle income countries. Professor Sanders notes that Dr Ghebreyesus needs to use his strong mandate – notably from the Global South – to truly reform the WHO and its operations in favour of the world’s poor majority. To do this, he needs to push strongly for member states to honour their commitments to the WHO and to rapidly and significantly increase their financial contributions. He also needs to ensure that the influence of the food, beverage, alcohol and tobacco industries to control non communicable diseases is resisted. This will be difficult given that a framework has been passed that allows non-state actors to participate in WHO policy-making processes. Further he argues that Dr Ghebreyesus must ensure that the health systems of low and middle income countries are strengthened so that health emergencies such as infectious disease outbreaks can be contained. This will ensure that agenda for health security isn’t focused on securing the health of rich country populations against contagion from the poor but on protecting all, particularly the most vulnerable. Hi raises that what will be interesting to watch over the next five years is whether the evident solidarity between low and middle income counties in voting in Dr Ghebreyesus as their candidate is maintained during the debates and decisions about world health.
Uganda has released the result of Demographic Health Survey (UDHS 2016) highlighting the success in family planning and reproductive health. Uganda’s population is the second youngest in the world, with half of the country younger than 15.7 years old (just older than Niger’s median age of 15.5 years). As of January 2017, the population of Uganda was estimated to be 40 million, the age structure defines 49.9% in the below 15 years, 48.1% in 15-64 year of age group and the rest 2.1% are 64+ n the past 10 years, showing increasing growth rate (3.24 in 2016 est.), the country has added more than 10 million, from 24 to 35 million. DHS 2016 showed noteworthy success in maternal health care. Nearly three-quarters (74%) of live births were delivered by a skilled provider and almost the same proportion (73%) were delivered in a health facility which was almost half in 15 years back. Throughout the course of their lifetimes, Ugandan women have a 1-in-35 chance of dying due to pregnancy-related causes; every day, 16 women die in childbirth. However, the overall trend indicates a decline of pregnancy-related mortality over the time. Infant and child mortality rates are basic indicators of a country’s socioeconomic situation and quality of life. The country’s infant mortality rate was one of the highest in the world, but 2016 DHS showed steep declining trend. The Contraceptive Prevalence Rate (CPR) has risen steadily from a low starting point and moved upward sharply in most years in Uganda, on the other hand the unmet need of contraceptive is showing gradual decreasing trend. As the country’s population continues to grow, the majority of that growth is taking place in rural areas, where access to health services is extremely limited. PPD argues that with the call for universal access to reproductive health and family planning, the country is moving rapidly towards this goal. Such progress will help the country move closer to the targeted demographic that are linked with the larger development goals. Significant effort is argued to still be required to mitigate rural-urban disparity. Political commitment beyond the health sector, partner collaboration, community provision to increase community engagement is reported to lie behind the trends in the DHS key indicators report.
This paper seeks to advance the authors’ understanding of health policy agenda setting and formulation processes in a lower middle income country, Ghana, by exploring how and why maternal health policies and programmes appeared and evolved on the health sector programme of work agenda between 2002 and 2012. The authors theorised that the appearance of a policy or programme on the agenda and its fate within the programme of work is predominately influenced by how national level decision makers use their sources of power to define maternal health problems and frame their policy narratives. National level decision makers used their power sources as negotiation tools to frame maternal health issues and design maternal health policies and programmes within the framework of the national health sector programme of work. The power sources identified included legal and structural authority; access to authority by way of political influence; control over and access to resources (mainly financial); access to evidence in the form of health sector performance reviews and demographic health surveys; and knowledge of national plans such as Ghana Poverty Reduction Strategy. The authors argue that understanding of power sources and their use as negotiation tools in policy development should not be ignored in the pursuit of transformative change and sustained improvement in health systems in low- and middle income countries.