In the past three decades in Ghana, the number of city dwellers has risen from four to 14 million; more than 5.5 million of whom live in slums. Urban growth exerts intense pressure on government and municipal authorities to provide infrastructure, affordable housing, public services and jobs. It has exacerbated informality, inequality, underdevelopment and political patronage. Some commentators warn of an impending urban crisis. Policymakers and international donors continue to prescribe better urban planning, slum upgrading, infrastructure investment and “capacity building” to “fix” African cities. While these are necessary, the authors argue that the success of any urban strategy depends on an informed appraisal of the political dynamics of urban neighbourhoods that define governance in Ghana’s cities and slums, in the interaction between politicians, entrepreneurs, traditional authorities and community leaders. The authors note that informal networks pervade formal political institutions and shape political strategy, and that political clientelism and the role of informal institutions are deepening alongside the strengthening of formal democratic institutions, but are often overlooked.
Governance and participation in health
The author argues that destruction of the environment, human rights abuses and mass displacement have been ignored in the name of “development” that works to intensify neoliberal inequality. In response to legal attempts to hold it to account, the author argues that the World Bank has declared itself above the law. The latest attempt at accountability is a lawsuit filed in the U.S. federal court in Washington by EarthRights International, a human rights and environmental non-governmental organisation, charging that the World Bank has turned a blind eye to systematic abuses associated with palm-oil plantations in Honduras that it has financed. EarthRights International alleges that the World Bank has “repeatedly and consistently provided critical funding to Dinant, Honduran palm oil companies, knowing that Dinant was waging a campaign of violence, terror, and dispossession against farmers, and that their money would be used to aid the commission of gross human rights abuses.” The lawsuit reports that the International Finance Corporation’s ombudsman said the World Bank division “failed to spot or deliberately ignored the serious social, political and human rights context.” These failures arose “from staff incentives ‘to overlook, fail to articulate, or even conceal potential environmental, social and conflict risk’ and ‘to get money out the door.’ ” Despite this internal report, the suit says, the World Bank continued to provide financing and that the ombudsman has “no authority to remedy abuses.”
With the renewed call for community participation in health interventions after the Alma Ata Declaration, interest has been raised in volunteer community health workers (CHWs) acting as representatives of local communities. This study interrogates the dynamic interface between local communities and the government in the selection of CHW volunteers in a rural community. Data were collected through participant observation of community events, 35 in-depth interviews, 20 focus groups and 15 informal conversations and review of documents about Luwero district. Ambiguous national guidelines and poor supervision of the selection process enabled the powerful community leaders to influence the selection of village health teams (VHTs). Intended to achieve community involvement, the selection process was found to produce a disconnect in the local community where many members saw the selected VHTs as having been ‘taken away’. The authors argue that community involvement in the selection of VHTs took a form that, instead of empowering the local community, reinforced the responsibility of those in power and thus maintained the asymmetrical status quo.
During a recent civil society consultative meeting held in Karamoja sub-region in North Eastern Uganda to discuss with locals the review of mining law and policy in Uganda, participants from the community made statements about mining operations in the region: One participant stated; “As we talk here trucks and trucks ferry marble and the people of Rupa swallow dust.” Another participant said; “ they come here and cordon off large pieces of land beyond what is allowed under their licenses and the locals have nowhere to graze their cattle. They forget we are a pastoralist community. No one asks us whether we want the mining in the first place. We just see companies show up in our midst.” Karamoja sub-region in Uganda is endowed with a number of minerals including gold, marble limestone, gemstones and silver among others, and plays host to roughly 20 companies involved in the mining sector at different stages. However, this report suggests that there is a disconnect between local communities and the mining companies. Community members said they had very limited information about the sector, and complained of lack of consultation, exploitation and human rights abuses by the mining companies. The authors argue that local communities and indigenous people have the right to be consulted about mining projects because they bear the brunt of the negative impacts of mining, and as prior, informed consent is now a well recognised international best practice. This should, they propose, be included in law. They point, for example, to the Tanzania Mining Act 2010 that ensures that no discussions of mining can be engaged in without the representation of civil society and local small scale miners. In Ghana, New Mont Gold Company has adopted the use of community agreements, while the World Bank has published a Source Book – Mining Community Development Agreements, 2012 on how to develop and implement such community agreements.
Effective district management, particularly leadership is considered to be crucial element of the district health system. Internationally, the debate around developing leadership competencies such as motivation or empowerment of staff, managing relationships, being solution driven as well as fostering teamwork are argued to be possible through formal and informal training. This paper reports findings on the significance of informal learning and its practical value in developing leadership competencies. A qualitative case study was conducted in one district in the Gauteng province, South Africa. Purposive and snowballing techniques yielded a sample of 18 participants, primarily based at a district level. Primary data collected through in-depth interviews and observations (participant and non-participant) were analysed using thematic analysis. Results indicate the sorts of complexities, particularly financial management challenges which staff face and draws attention to the use of two informal learning strategies—learning from others (how to communicate, delegate) and fostering team-based learning. Such strategies played a role in developing a cadre of leaders at a district level who displayed essential competencies such as motivating staff, and problem solving. It is crucial for health systems, especially those in financially constrained settings to find cost-effective ways to develop leadership competencies such as being solution driven or motivating and empowering staff. The authors note that the study illustrates that it is possible to develop such competencies through creating and nurturing a learning environment (on-the-job training) which could be incorporated into everyday practice.
In 2015 Good Governance Africa (GGA), in conjunction with specialist researchers MarkData, conducted a survey to test public attitudes towards key aspects of governance in South Africa. In 2016 GGA commissioned MarkData to conduct a Voter Sentiment Survey. Respondents were selected using a random multistage sampling process. The survey findings are to some extent in line with the 2011 South African Reconciliation Barometer. The survey showed that in cases relating to government performance, the widely held view was that all areas (administration, economic development and service delivery) required attention and improvement. Participants suggested that service delivery is the priority, followed by economic development and then administration. It was also found that more voters are deploying their vote strategically in relation to their perceptions of governance, despite feeling that they have little say in how they are governed. The authors argue that this reinforces the need for further research and for greater engagement with the voters on the ground, particularly in areas where poor local government performance has been detected.
The prevalence of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa. At the same time, the use of mobile phones is rising, expanding the opportunities for the implementation of mobile phone-based health (mHealth) interventions. This review aims to understand how, why, for whom, and in what circumstances mHealth interventions against NCDs improve treatment and care in sub-Saharan Africa. Four main databases and references of included articles were searched for studies up to March 2015 reporting effects of mHealth interventions on patients with NCDs in sub-Saharan Africa. All studies published up until May 2015 were included in the review. Following a realist review approach, middle-range theories were identified and integrated into a 'Framework for Understanding the Contribution of mHealth Interventions to Improved Access to Care for patients with NCDs in sub-Saharan Africa'. The main indicators of the framework consist of predisposing characteristics, needs, enabling resources, perceived usefulness, and perceived ease of use. Studies were analysed in depth to populate the framework. The search identified 6137 titles for screening, of which 20 were retained for the realist synthesis. The contribution of mHealth interventions to improved treatment and care is that they facilitate (remote) access to previously unavailable (specialised) services. Three contextual factors (predisposing characteristics, needs, and enabling resources) influence if patients and providers believe that mHealth interventions are useful and easy to use. Only if they believe mHealth to be useful and easy to use, will mHealth ultimately contribute to improved access to care. The analysis of included studies showed that the most important predisposing characteristics are a positive attitude and a common language of communication. The most relevant needs are a high burden of disease and a lack of capacity of first-contact providers. Essential enabling resources are the availability of a stable communications network, accessible maintenance services, and regulatory policies. Policy makers and program managers should consider predisposing characteristics and needs of patients and providers as well as the necessary enabling resources prior to the introduction of an mHealth intervention. The authors argue that researchers would benefit from placing greater attention on the context in which mHealth interventions are being implemented instead of focusing (too strongly) on the technical aspects of these interventions.
The new chairperson of the African Union (AU) Commission Moussa Faki Mahamat formally took office in Addis Ababa in March, outlining his top priorities for his four-year tenure. Mahamat said he would focus on implementing structural and financial reforms at the AU, place women and youth at the centre of Africa’s development agenda, accelerate intra-African trade and free movement of people, goods and services in the continent, silence the guns by 2020 and strengthen Africa’s voice in the global arena. However, it is the financing plan that is likely to get the most attention in the short term. It was unveiled at the 2015 AU summit in Kigali by Donald Kaberuka, former president of the African Development Bank (AfDB). As of 2015, more than half of the African Union’s budget is funded by outside funders, compromising the independence of the organisation. The Kaberuka plan is intended to change that, and would see member states finance 100% of the AU’s operating budget, three-quarters of the programmes budget and a quarter of the peace and security budget, starting from January 2016 and phased in incrementally over five years.
The disease burden in urban sub-Saharan Africa is changing rapidly. Mortality and morbidity from chronic physical disease (heart, disease, stroke and cancer) is rising rapidly and believed to equal that from infections. Other increasing disease burdens in sub Saharan Africa include mental illness, substance abuse and accidents, especially road traffic collisions (RTC). Newspaper readership is rising in Uganda. This study used content analysis to examine health-related coverage in one major Ugandan newspaper (New Vision). Twenty-nine consecutive paper copies from September/October 2013 were examined independently by two researchers. Health-related articles were identified, counted and coded according to clinical content. Clinical and healthcare-related coverage was present in every edition and represented approximate proportions of 2.6% and 0.4% respectively of total newspaper content. Of 214 news articles identified, these covered the following clinical themes: general well-being (15.4%), healthcare services (14.5%), HIV (12.1%), violence/accidents (11.2%), chronic physical disease (11.2%), sexual, maternal and reproductive health (SMRH) (10.8%), non-HIV infective diseases (10.8), malnutrition (7.9%), substance misuse (3.3%) and mental health (2.8%). Coverage of RTCs, alcohol, smoking, and cancers other than of the breast and cervix was minimal. Health-related content was dominated by infections, healthcare quality, general wellbeing, SMRH and malnutrition. This does not represent the changing burden of disease in Uganda. There may be scope for targeted interventions with editors to promote coverage of growing challenges, including lifestyle advice to prevent chronic diseases.
Ghana’s president Nana Akufo-Addo came under fire for naming what has been described as an ‘elephant’ cabinet – with 31 cabinet portfolios, several ministries have two or more deputies, bringing the total size of cabinet to 110 ministers and perhaps more. Such a large team may have significant financial implications, in a country where the debt-to-GDP ratio is about 74%, with a $1 billion bailout from the International Monetary Fund (IMF) in 2015. Looking at Africa more broadly, the median size of cabinets is 30 (excluding deputies). The largest such cabinet is in Cameroon with 63 ministers. Uganda’s cabinet has 31 full cabinet ministers and 49 ministers of state, bringing the total number to 80. In Africa, larger cabinets are more common in post-conflict countries that are trying to build a broader national consensus, especially in countries with high political or ethnic fragmentation, as ministerial appointments are an easy way to build loyalty to the regime of the day. The author indicates that they are also common in resource-rich countries, and in those that have had long-serving heads of state, which tend to have heavy patronage networks. In that way, they serve an important political, if not economic or technocratic function – they create compromise and cohesion within the political class.