The single most important message of this paper is that development outcomes in poor countries depend fundamentally on the political incentives facing political elites and leaders. Political will has usually been treated as an inexplicable ‘black box’. The authors seek in this paper open up the black box, to say some definite things about the specific contexts in which political ambitions are shaped and policy choices are made in different parts of the world and at different stages of countries’ development processes. They argue that economic growth without economic transformation is limited. The authors raise the case that democracy depends on the formation of social classes, including productive capitalists, and organised professional groups and wage-earning workers. This only happens as a result of economic diversification and the accumulation of technological capacities. If the formal sector cannot generate adequate incomes and taxes for state revenues, the ruling elites draw resources to meet the demands of crucial coalition groups from various kinds of off-budget transfers and informal sharing of rents. The paper explores country contexts in Africa where there is evidence of diversity in the relationship between ruling elites and state bureaucracies, to better understand the reasons for this diversity and its implications for development aid.
Governance and participation in health
Amadasun reviews several of the important international mechanisms which channel aid to Africa, finding that the many instruments developed outside Africa are ineffective because they have design, accountability and ownership flaws. These criticisms apply to International Monetary Fund (IMF) programmes, debt relief and also budget support. Despite some changes in the way that the IMF and other international agencies operate – for example linking their interventions to Poverty Reduction Strategies – their fundamental way of working remains to pressure governments to take certain actions even at the expense of citizens’ views. Amadasun suggests that new mechanisms that originate in Africa, for Africa, stand a better chance of enabling decisions that empower and support large numbers of impoverished people. These mechanisms include the Pan-African Parliament (PAP) and the African Peer Review Mechanism (APRM). However these institutions are nascent and have yet to fulfill their full potential. To reach their potential these African bodies must develop authority to scrutinise the interventions of the international financial institutions (IFIs). These bodies will have to overcome several challenges. These include improving who is selected to represent African citizens, increasing public awareness and discussion of the bodies, and developing an independent source of financing for their own operations. If they overcome these challenges the PAP and APRM may be able to prevent international agencies from imposing policies and pressures from outside the region and enable a flourishing of democracy from below.
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.
This Drum Beat is one of a series of commentary and analysis pieces. Getting communication included is an integral element in development programmes, for example improving maternal health. Addressing this challenge needs actions at many levels, all of which entail particular types of communication.
This Agency for Co-operation and Research in Development (Acord) report features two country case studies (Uganda and Burundi) which explored the role of community-based research in responding to HIV stigma and discrimination. The research found that issues of stigma and discrimination reached all spheres of life, including the home, family, the workplace, school, health settings and the larger community. It also identified a number of key factors that contribute to stigma and discrimination. These include ignorance and fear, cultural norms and values, some religious teachings, the lack of legal sanctions, lack of rights awareness, the design of government and other programmes, and inaccurate or irresponsible media coverage.
This study took place in Northern Ghana to assess the impact of male involvement in reproductive health and Family Planning (FP) services. Twelve focus group discussions were held with both male and female community members, six in communities with functional community health-based planning and services strategy (CHPS) and six for communities with less/no-functional CHPS. Fifty-nine in-depth interviews were held with other stakeholders at both district and regional levels. The results revealed a general high perception of an improved health status of children in the last ten years in the communities; however, participants reported that malnutrition was still rife in the community. The results also revealed that women still needed to get spousal approval to use contraceptives; however, the matrilineal system appears to give more autonomy to women in decision-making. The CHPS strategy was perceived as very helpful with full community participation at all levels of the implementation process. Males were more involved in FP services in communities with functioning CHPS than those without functioning CHPS. The authors argue that involving males in reproductive health issues including FP is important to attain reproductive health targets.
There is growing concern that health policies and programmes may be contributing to disparities in health and wealth between and within households in low-income settings. However, there is disagreement concerning which combination of health and non-health sector interventions might best protect the poor. Potentially promising interventions include those that build on the social resources that have been found to be particularly critical for the poor in preventing and coping with illness costs. In this paper we present data on the role of one form of social resource— community-based organisations (CBOs)—in household ability to pay for health care on the Kenyan coast. Data were gathered from a rural and an urban setting using individual interviews (n = 24), focus group discussions (n = 18 in each setting) and cross-sectional surveys (n = 294 rural and n = 576 urban households). We describe the complex hierarchy of CBOs operating at the strategic, intermediate and local level in both settings, and comment on the potential of working through these organisations to reach and protect the poor. We highlight the challenges around several interventions that are of particular international interest at present: community-based health insurance schemes; micro-finance initiatives; and the removal of primary care user fees. We argue the importance of identifying and building upon organizations with a strong trust base in efforts to assist households to meet treatment costs, and emphasize the necessity of reducing the costs of services themselves for the poorest households.
The configuration of economic actors has shifted dramatically in recent decades as a consequence of the shift from an international to global economy, according to this article. The 21st century thus faces a fundamentally different economic landscape, with governance far less about formal nation-state negotiation, and far more about informal mechanisms of state and non-state negotiation. Although economic power has always played a role in defining international health governance, this changing global economic context has increased the role of economic power in the development of global health governance. To ensure the continued protection and enhancement of global health, the author argues it is imperative for the health profession to recognise and more actively engage with this changing economic context, in order to seize opportunities and minimise risks to global health. If it does not, the danger is that global health governance will increasingly be determined by economic organisations with the principle concern not of health but of market liberalisation, ultimately constraining the capacity of nation-states to undertake measures to protect and enhance the health of their populations.
Non-governmental organisations (NGOs) have become key actors in responding to poverty and related suffering. In Africa, NGOs play a leading role in providing health care and education. But NGOs also have their detractors who argue that they are receiving growing amounts of external aid, but aren’t the most suitable actors for really improving people’s lives. Some critics insist that the neoliberal policies advanced by international actors have limited the influence of the state and that NGOs have benefited as a result. NGOs are criticised for their focus on technical solutions to poverty instead of the underlying issues, and for being more dependent and accountable to their funders than those they serve. Instead of empowering local populations to organise themselves, the authors argue that there is a risk that NGOs empower people to attain licensed, rather than emancipatory, freedoms; these are freedoms achieved “within the system” which improve lives, but don’t dramatically change power dynamics.
The People's Health Movement (PHM) is a global network of people oriented health professionals and activists, academcis and researchers, campaigners and people organizations that have actively promoted the re endorsement of the 'Health for All' principles of the Alma Ata Declaration and the importance of social determinants of health and health care. The paper outlines a series of ongoing advocacy initiatives through a PHM - WHO advocacy circle that has consistently since 2001 nudged WHO to reaffirm the Alma Ata principles and focus on the social determinants of health. This has led to an evolving dialogue with PHM and the setting up of the WHO commission on social determiants of health, in which the PHM, is actively engaged.