Governance and participation in health

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.

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.

In Uganda, community services for febrile children are expanding from presumptive treatment of fever with anti-malarials through the home-based management of fever (HBMF) programme, to include treatment for malaria, diarrhoea and pneumonia through Integrated Community Case Management (ICCM). To understand the level of support available, and the capacity and motivation of community health workers to deliver these expanded services, the authors interviewed community medicine distributors (CMDs), who had been involved in the HBMF programme in Tororo district, shortly before ICCM was adopted. Between October 2009 and April 2010, 100 CMDs were recruited to participate by convenience sampling. The survey included questionnaires to gather information about the CMDs’ work experience and to assess knowledge of fever case management, and in-depth interviews to discuss experiences as CMDs including motivation, supervision and relationships with the community. CMDs faced multiple challenges including high patient load, limited knowledge and supervision, lack of compensation, limited drugs and supplies, and unrealistic expectations of community members. CMDs described being motivated to volunteer for altruistic reasons; however, the main benefits of their work appeared related to ‘becoming someone important’, with the potential for social mobility for self and family, including building relationships with health workers. At the time of the survey, over half of CMDs felt demotivated due to limited support from communities and the health system. Community health worker programmes rely on the support of communities and health systems to operate sustainably. When this support falls short, motivation of volunteers can wane. If community interventions, in increasingly complex forms, are to become the solution to improving access to primary health care, greater attention to what motivates individuals, and ways to strengthen health system support are required.

Rising powers such as Brazil, India and China have been criticised for their inputs in the negotiations on the post-2015 development agenda. The start of the United Nations (UN) negotiations saw high expectations for the role of these countries in shaping the Sustainable Development Goals (SDGs) that have not materialised. However, what appears to be a confrontational style of diplomacy is in fact an assertive affirmation of long-standing principles. The G77 and China have consistently
called for the reform of the UN Security Council, and of the Bretton Woods institutions, which resulted in International Monetary Fund reform being nominally approved in 2010 before being blocked by the United States (US) Congress. The issues defended by the Brazilian negotiators centred on poverty eradication, its relationship with inequality; sustainable production and consumption; financing and keeping climate change strictly within the UNFCCC process. Brazil is keen to avoid what it sees as the securitisation of development through the SDGs. It supports governance as a general principle guiding the SDGs, but is adamant in its refusal to consider security as a stand-alone goal. The Brazilians are prioritising the ‘how’ of the SDGs, concentrating on the means of implementation for sustainable development through data disaggregation and exploring how to reutilise the structure of the MDGs as well as Brazil’s experience of participatory development in implementation. The authors argue that a more nuanced understanding of these countries’ positions in the post-2015 process is required.