This paper explores the implications of the increasing role of informal as well as formal markets in the health systems of many low and middle-income countries. It focuses on institutional arrangements for making the benefits of expert medical knowledge widely available in the face of the information asymmetries that characterise health care. The paper argues that social arrangements can be understood as a social contract between actors, underpinned by shared behavioural norms, and embedded in a broader political economy. This contract is expressed through a variety of actors and institutions, not just through the formal personnel and arrangements of a health sector. Such an understanding implies that new institutional arrangements, such as the spread of reputation-based trust mechanisms can emerge or be adapted from other parts of the society and economy. The paper examines three relational aspects of health systems: the encounter between patient and provider; mechanisms for generating trust in goods and services in the context of highly marketised systems; and the establishment of socially legitimated regulatory regimes. This analysis is used to review experiences of health system innovation and change from a number of low income and transition countries.
Governance and participation in health
The author of this paper argues that corruption in public procurement is the chief cause of poverty in Africa. It is fostered by poor governance and weak legislation and may be costing the continent up to US$148-billion a year. Yet it can be countered if there is the will and skill to do so. Combatting corruption in public procurement is a multi-faceted problem, which requires a comprehensive package of measures to be implemented concurrently. The author presents proposals for this: The first line of defence is to ensure a sound legal framework that incorporates an anti-corruption law with real authority and effective sanctions. An explicit commitment to eradicate corruption in all forms must be made at the highest level of government. To keep clients and officials accountable, a comprehensive legal and regulatory framework governing public procurement must be implemented. There should be transparency and accountability for all in the bidding process, as well as public service reforms.
Drawing on international best practice, this paper argues that a number of conditions are required to ensure that anti-corruption reforms in any context are effective, sustainable and not easily subverted. These conditions include having the necessary data to inform policy and strategy, comprehensive legal and institutional safeguards to prevent corruption and protect public interest, and the necessary political leadership and will to tackle corruption credibly and put in place long-term reforms. It is clear that to be effective, national anti-corruption/integrity systems require more than a single agency approach. Rather, they need to be supported by an institutional matrix of legal and oversight systems to ensure effective prosecution of offenders. Partnerships, including active engagement by civil society and the media, are also important. Above all, reforms need to be implemented by ethical leaders who scrupulously observe the rule of law.
Improving quality of primary care is a key focus of international health policy. Two methods of improving the quality of interpersonal care in primary care have been proposed. One involves the feedback of patient assessments of interpersonal care to physicians, and the other involves brief training and education programmes. This study therefore reviewed the efficacy of (i) feedback of real patient assessments of interpersonal care skills, (ii) brief training focused on the improvement of interpersonal care and (iii) interventions combining both (i) and (ii). Nine studies were included (two patient based feedback studies and seven brief training studies). Of the two feedback studies, one reported a significant positive effect. The authors conclude that there is limited evidence concerning the effects of patient based feedback. There is reasonable evidence that brief training as currently delivered is not effective, although the evidence is not definitive, due to the small number of trials and the variation in the training methods and goals.
This report covers the Civicus Participatory Governance Programme: How can we build political for participatory governance, 17-18 June 2008. Although participatory governance offers important concrete benefits for citizens and state actors alike, there is often initial resistance from political actors and government offiicals who are unfamiliar with such approaches. This small working group session involved three case studies which describe and analyse Civil Society Organisation approaches to building political will for participatory governance.
This paper examines the cultural and structural difficulties surrounding effective prevention of mother-to-child HIV transmission (PMTCT) in rural Lesotho. It argues for three strategies to improve PMTCT interventions: community-based research and outreach, addressing cultural and structural dynamics, and working with the relevant social groups that impact on HIV prevention. These conclusions are based on interviews and participant observation conducted within the rural Mokhotlong district and capital city of Maseru, involving women and men of reproductive age, grandmothers serving as primary caretakers, HIV and AIDS programme staff and medical professionals. Qualitative analysis focused on rural women's socio-medical experience with the four measures of PMTCT (educational outreach, voluntary counselling and testing, antiretroviral interventions and safe infant feeding). Based on these results, the paper concludes that intervention models must move beyond a myopic biomedical ‘best-practices' approach to address the social groups and contextual determinants impacting on vertical HIV transmission. Given the complexities of effective PMTCT, our results show that it is necessary to consider the biomedical system, women and children, and the community as valuable partners in achieving positive health outcomes.
Community-led total sanitation (CLTS) is a participatory process focused on promoting change in sanitation behaviour through social action - stimulated by facilitators from within or outside the community. Aimed at empowering local communities this handbook is a source of ideas and experiences to be used for CLTS orientation workshops, advocacy to stakeholders as well as for implementing CLTS activities. It is intended as a tool for field staff, facilitators and trainers to plan, implement and follow up on CLTS activities. A sequence of possible steps and tools, including do’s and don’ts, are provided to help trigger CLTS in a community. They include pre-triggering, selecting a community, introduction and building rapport, triggering participatory sanitation, profile analysis, ignition moment, post-triggering action, planning by the community, follow up, scaling up and going beyond CLTS. Users are encouraged to use and modify the processes outlined in this handbook as they see fit for their given context.
This report aims to shed light on the way innovative solutions have arisen to address local sustainable development challenges, examining the determinants of success and the scope for replication. The report focuses on the African experience. The volume is composed of ten case studies, selected for their truly innovative nature, effective implementation, significant outputs and generation of real social welfare improvements, grouped under five headings: enhancement of agriculture and fisheries, protection of ecosystems, water management, health improvement and sustainable tourism. Practical conclusions drawn from the case studies include: sustainable projects need to link environmental goals to income generation, draw upon local knowledge and ideas, ensure effective buy-in from stakeholders through local community involvement in project design and implementation, and employ financially self-sustaining business models external forces which impact on a project and affect conditions for success, including international markets and national legislation. In some cases though, local success can provide arguments for more accommodating national policies to facilitate replication and scaling up simplicity in project design. Committed seed capital and integration of local traditions and cultural heritage appear to be important success factors for innovative local initiatives.
In many parts of Asia and sub-Saharan Africa there is a growing gap between official accounts of how health systems operate and realities on the ground. Researchers in this study looked at how to gain access to competent health care in environments where there are growing but unorganised markets in goods and services, blurred boundaries between the public and private health care sectors, and a lack of state regulation. The researchers used the frame of the ‘social contract’ (an implicit agreement among people that results in the organisation of society) and focused on the problem of information asymmetry (inequalities in access to information) and associated power relationships, in particular those between patient and health care provider. Their paper highlights the importance of trust to relationships at all levels of the health system. Findings show that different ways of generating trust in goods and services, and new forms of regulation have emerged. The researchers call for greater understanding of the institutional context in which health systems operate in developing countries. They also stress the need to avoid dictating policy according to the experiences of developed countries. Instead, future debates will need to focus on how governments can create regulatory partnerships and enable improved access to information, building on the new social contracts that are already emerging.
About 300 delegates representing organisations from across the drug policy spectrum met in Vienna for the Beyond 2008 NGO Forum, an effort to provide civil society input on global drug policy. Building on a series of regional meetings last year, the forum was part of an ongoing campaign to reshape the United Nations' drug policy agenda as the world organisation grapples with its next 10-year plan. The NGO meeting, which included drug treatment, prevention, education and policy reform groups, harm reduction groups and human rights groups from around the world, resulted in a resolution that will be presented to the UN Commission on Narcotic Drugs (CND) at its meeting in March 2009. At that meeting, the CND will draft the next UN 10-year global drug strategy.