This paper examines health for vulnerable individuals following devolution in Kenya through a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from across the health system in ten counties, 14 focus group discussions with community members in two of these counties and photovoice participatory research with nine young people. The authors adopted an intersectionality lens to reveal how power relations intersect to produce vulnerabilities for specific groups in specific contexts, and to identify examples of the tacit knowledge about these vulnerabilities held by priority-setting stakeholders. The authors identified a range of ways in which longstanding social forces and discriminations limit the power and agency individuals can exercise. These are mediated by social determinants of health, their exposure to risk of ill health from their living environments, work, or social context, and by social norms relating to their gender, age, geographical residence or socio-economic status. While a range of policy measures have been introduced to encourage participation by typically ‘unheard voices’, devolution processes have yet to adequately challenge the social norms and power relations which contribute to discrimination and marginalisation. The authors conclude that if key actors in devolved decision-making structures are to ensure progress towards universal health coverage, there is need for intersectoral action to address these social determinants and to identify ways to challenge and shift power imbalances in priority-setting processes.
Governance and participation in health
In response to the announcement that World Bank President Robert Zoellick will step down at the end of his term on 30 June 2012, a global coalition of campaigners has called for an open and merit-based process to elect the next World Bank leader, and for developing countries to determine the selection. The campaigners, including many major development organisations, have also asked the United States to announce that it will no longer seek to monopolise the Presidential position. A “gentlemen’s agreement” between Europe and the US dating back to World War II has so far ensured that the President of the World Bank is always an American, and the International Monetary Fund’s Managing Director is European. In this open letter, the campaigners demand that the new President is selected by a majority of World Bank member countries, not just a majority of voting shares, as most members are low- and middle-income countries. They also demand that the selection process be opened to anyone to apply, with interviews held in public and with open voting procedures. A clear job description and necessary qualifications should be set out, requiring candidates to have a strong understanding and experience of the particular problems facing developing countries.
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.
Government of Botswana partners with two international organisations: U.S. Centers for Disease Control and Prevention and Africa Comprehensive HIV/AIDS Partnership to implement Voluntary Medical Male Circumcision with the target of circumcising 80 % of HIV negative men in 5 years. This paper uses a systems model to establish how the functioning of the partnership on Safe Male Circumcision in Botswana contributed to the outcome. Data were collected using observations, focus group discussions and interviews. Thirty participants representing all three partners were observed in a 3-day meeting; followed by three rounds of in-depth interviews with five selected leading officers over 2 years and three focus group discussions. Financial resources, “ownership” and the target were found to influence the success or failure of partnerships. A combination of inputs by partners brought progress towards achieving set program goals. Although there were tensions between partners, they worked together in strategising to address some challenges of the partnership and implementation. The authors found that pressure to meet the expectations of the international funders caused tension and challenges between the in-country partners to the extent of Development Partners retreating and not pursuing the mission further. Target achievement, the link between financial contribution and ownership expectations caused antagonistic outcomes.
This paper argues that it is necessary to conduct a participatory, cross-national assessment and action-planning programme on civil society in all developing and developed countries. It acknowledges the scarcity of sound empirical studies on civil society and identifies some of the causes for this situation, including the elusive and highly disputed nature of the concept of civil society and a lack of valid data in many regions of the world, as well as the trend of confusing the tasks of advancing the normative ideal of civil society with honestly assessing its current reality. CIVICUS believes that reflections on the current reality of civil society are necessary to strengthen civil society. In other words, only by knowing the current state of civil society, can one work to successfully improve it. The paper argues that cross-national research, covering a wide range of different contexts, is a conceptual, methodological, cultural and logistical minefield. But by designing an assessment tool based on context, and by designing it in a way which, in principle, should make it applicable in every country, the Civil Society Index aims to push the boundaries of existing comparative work on the topic.
The authors of this study evaluated community-based education and service (COBES) programmes at Makerere University College, Uganda, from a community perspective. A stratified random sample of eleven COBES sites was selected to examine the community’s perception of the programmes. Key informant interviews were held with 11 site tutors and 33 community members. Communities reported that the university students consistently engaged with them with culturally appropriate behavior and rated the student’s communication as very good even though translators were frequently needed. They also reported positive changes in health and health-seeking behaviours but remarked that some programmes were not financially sustainable. The major challenges from the community included community fatigue, and poor motivation of community leaders to continue to take in students without any form of compensation.
This desk review provides an update on practice and experiences of civil society participation in the development of Poverty Reduction Strategy Papers (PRSPs). It was commissioned by Department for International Development (DFID) and conducted from August–October 2001 by the Participation Group at the Institute of Development Studies (IDS) in the UK.
This study sought to analyse and better understand the relationship between health centre committees in Zimbabwe as a mechanism of participation and specific health system outcomes, including: Improved representation of community interests in health planning and management at health centre level; Improved allocation of resources to health centre level, to community health activities and to preventive health services o improved community access to and coverage by selected priority promotive and preventive health interventions; Enhanced community capabilities for health (through improved health knowledge and health seeking behaviour; Appropriate early use of services); Improved quality of health care as perceived both by providers and users of services.
This study sought to analyse and better understand the relationship between health centre committees in Zimbabwe as a mechanism of participation and specific health system outcomes, including: Improved representation of community interests in health planning and management at health centre level; Improved allocation of resources to health centre level, to community health activities and to preventive health services; Improved community access to and coverage by selected priority promotive and preventive health interventions; Enhanced community capabilities for health (through improved health knowledge and health seeking behaviour, appropriate early use of services); Improved quality of health care as perceived both by providers and users of services.
This study's aim was to explore whether adding a gender and HIV training programme to microfinance initiatives can lead to health and social benefits beyond those achieved by microfinance alone. Cross-sectional data were derived from three randomly selected matched clusters in rural South Africa. Adjusted risk ratios (aRRs) employing village-level summaries compared associations between groups in relation to indicators of economic well-being, empowerment, intimate partner violence (IPV) and HIV risk behaviour. The magnitude and consistency of aRRs allowed for an estimate of incremental effects. A total of 1,409 participants were enrolled, all female, with a median age of 45. After two years, both the microfinance-only group and the IMAGE group showed economic improvements relative to the control group. However, only the IMAGE group demonstrated consistent associations across all domains with regard to women's empowerment, intimate partner violence and HIV risk behaviour. In conclusion, the addition of a training component to group-based microfinance programmes may be critical for achieving broader health benefits. Donor agencies should encourage intersectoral partnerships that can foster synergy and broaden the health and social effects of economic interventions such as microfinance.