Governance and participation in health

Universal Access to Healthcare Campaign: Thoughts from African Civil Society on UHC
UHC Forward: June 2013

This briefing paper elicits the perspective of the African non-governmental organisations (NGOs) on the concept of universal health coverage (UHC). It defines the basic concepts and also explores the role NGOs can play to improve the definition and implementation of UHC to improve health outcomes for all. It describes some of the common misunderstandings and misgivings expressed by NGOs, such as the belief that UHC is limited in scope and does not address the social determinants of health. Examples from African countries that have successfully implemented UHC are provided. UHC does not only mean protection from catastrophic expenditure – it means that all people are able to access health services when they need them. In this regard it specifically targets the poorest and most vulnerable. In most instances, civil society organisations have played a significant role in ensuring that national policies reflect in the reality on the ground.

Universal health coverage and community engagement
Odugleh-Kolev A; Parrish-Sprowl J: World Health Organisation 96(9)660-661, 2018

In this article, the authors reflect on how efforts towards UHC could offer an opportunity to address those aspects within health systems that continue to hinder efforts to meaningfully engage with patients, their families and local communities. The backbone of these efforts should be a health workforce that is skilled in engagement, responsive to local context and to the needs and expectations of those using their services. Community engagement was introduced in the 2013–2016 Ebola virus disease outbreak in recognition of the important role of response staff and their ability to engage with communities, in contrast to social mobilization or behaviour-change interventions. Engagement and empowerment of health service users and community members also re-emerged as a core strategy in the WHO Framework on Integrated People-Centred Health Services, which was formally adopted by Member States in 2016. To move towards a more meaningful understanding of what community engagement is and how it works, the authors suggest that several changes need to take place. First, to recognize that health systems have a fundamental responsibility and obligation for engaging with patients, their families, local communities, as well as a range of stakeholders, partners and sectors, recognising the physiological, emotional, mental and social interconnection of people. Health systems and communities are observed to be in continuous and interdependent action. If community engagement becomes a focus for UHC efforts, it could promote approaches that recognize that health and well-being are co-produced, and that empowers both health-care providers and communities.

Unlocking community capabilities for improving maternal and newborn health: participatory action research to improve birth preparedness, health facility access, and newborn care in rural Uganda
Ekirapa-Kiracho E; Namazzi G; Tetui M; et al: BMC Health Services Research 16(Suppl 7) 2016

This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. Saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women’s access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.

Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity
Accountability for Health Equity Programme: Institute of Development Studies, Sussex, 2017

While “accountability” has become an increasingly popular buzzword in health systems debates and health service delivery, it has multiple – and contested – meanings. In July 2017, IDS brought together 80 activists, researchers, public health practitioners and policy makers to examine the forces that shape accountability in health systems, from local to global levels. This workshop report records the presentations and discussions on accountability for health equity that are emerging in different country contexts, exploring how accountability relationships develop and change over time.

Urban Governance in Africa Today: Reframing, Experiences, and Lessons
Obeng-Odoom F: Growth and Change, August 2016, doi: 10.1111/grow.12164

Progress in analysing the instrumental view of governance as an engine for growth, poverty reduction, and inclusive development has been held back by the difficulty in framing governance. This essay seeks to address this problem by 1) reframing urban governance 2) evaluating its aims, processes, and outcomes, and 3) explaining those outcomes on the basis of which some lessons are teased out. Using examples from Africa and an institutional political economy approach the author argues that, overall, while urban economies are growing; both urban poverty and inequality levels have risen substantially. Urban governance has paved the way for new forms of urban development that only benefit the few, including in how differences in how urban services and resources are experienced, accessed, and controlled. The author argues that the underlying reasons for this disjuncture between “urban governance” in theory and “actually existing urban governance” are 1) difficulties in implementing urban governance theory consistently in practice, 2) problems arising because urban governance theory has been implemented in practice, 3) tensions that would entangle most policies which do not address historical and structural economic issues, 4) restrictive assumptions, and 5) incoherence among the different dimensions of urban governance. To resolve these contradictions, the author puts the case for major structural and institutional change involving: 1) the re-ordering of the roles of the state, market, and society as institutions of change; 2) re-working the relationships that bind together land, labour, capital, and the state, and 3) re-organising the channels for keeping the attainment of the ends of urban governance in check.

US military global health engagement since 9/11: Seeking stability through health
Chretien J: Global Health Governance IV(2), 2011

Following the 11 September 2001 terrorist attacks, the United States (US) military expanded its global health engagement as part of broader efforts to stabilise fragile states, formally designating “medical stability operations” as use of Department of Defense (DoD) medical assets to build or sustain indigenous health sector capacity. Medical stability operations have included medical assistance missions launched by US Africa Command throughout Africa. The public health impact of such initiatives, and their effectiveness in promoting stability is unclear, the author notes. Moreover, humanitarian actors have expressed concern about military encroachment on the “humanitarian space,” potentially endangering aid workers and populations in need, and violating core principles of humanitarian assistance. The DoD should draw on existing data to determine whether, and under what conditions, health engagement promotes stability overseas and develop a shared understanding with humanitarian actors of core principles to guide its global health engagement.

Use and understanding of nutrition labels among consumers in Lilongwe (Malawi)
Kasapila W and Shawa P: African Journal of Food, Agriculture, Nutrition and Development 11(5): 5171-5186, September 2011

In this study, researchers investigated use and understanding of nutrition labels on food packages among urban and rural consumers in Lilongwe, Malawi. They also examined the effect of socio-demographic factors and nutrition knowledge on use of nutrition labels. The researchers surveyed 206 consumers, approached randomly after they checked out at grocery stores. Shop managers and owners gave their consent to conduct the study outside the shops to avoid affecting customer behaviour and revenues. A pre-tested questionnaire was used to collect data for analysis and interpretation. The findings show that self-reported use and understanding of nutrition labels were low, suggesting much lower use and comprehension in real-life retail environments. Urban, educated and female consumers were more likely to read nutrition panels when purchasing food. Nutrition labels were seen as important, particularly when purchasing a product for the first time and when considering buying certain products. In terms of nutrition knowledge, rural consumers were as knowledgeable as urban consumers, but they were less likely to connect their knowledge to emerging non-communicable diseases. The researchers caution that the study had some limitations: for example, they surveyed a small sample of shoppers drawn from one geographical area, therefore their findings are not conclusive. Objective, cross-sectional and longitudinal investigations in future would improve understanding of actual consumer behaviour in retail shops and homes in Malawi, the researchers argue. As this study is the first of its kind in Malawi, it is intended to provide baseline information useful to the healthcare professionals, the government, the food industry and consumers.

Use of health information technology among racial and ethnic underserved communities
Gibbons MC: Perspectives in Health Information Management 8(Winter), 1 January 2011

In this article, the author examines the potential role of health information technology (IT) in addressing healthcare disparities among racial and ethnic minority populations. The author’s overview of health IT utilisation among healthcare providers reveals that use of health IT among racial and ethnic minorities carries significant promise and potential. Yet realising the potential will not come without surmounting several significant technical, practical and human challenges. In order to measure success or failure, he argues for ongoing surveillance and monitoring of progress at a national level. However, because of the great diversity in the types of technologies, types of users, and settings in which health IT may be employed, obtaining accurate estimates of adoption and utilisation will be a significant challenge. In addition, the development of the ‘meaningful use’ criteria and the linking of meaningful use to provider reimbursement will help, the author adds. As patients become more involved in accessing, managing, and using their health information, a need to develop ‘meaningful patient use’ criteria may arise, he predicts, which will help refine systems.

Using Health Committees to Promote Community Participation as a Social Determinant of the Right to Health: Lessons from Uganda and South Africa
Mulumba M; London L; Nantaba J; Ngwena C: Health and Human Rights Journal 20(2), PMID: 30568398, 2018

This paper provides perspectives from a three-year intervention whose general objective was to develop and test models of good practice for health committees in South Africa and Uganda. It describes the aspects that the authors found critical for enhancing the potential of such committees in driving community participation as a social determinant of the right to health. Interventions in South Africa and Uganda indicate that community participation is not only a human right in itself but an essential social determinant of the right to health. The interventions show that health committees provide a mechanism that enables communities to be active and informed participants in the creation of a responsive health system that serves them efficiently. The results are argued to confirm the effectiveness of rights-based trainings and exchanges in strengthening committee members’ sense of agency, their capacity to engage the health system, and their ability to exercise claims to health rights. They also contribute evidence of health committees’ potential to play a critical role in advancing community participation as a social determinant of the right to health.
These participatory spaces are observed to bridge the gap between communities and health facilities, making services responsive to community needs and contributing to the realization of health as a human right.

Using Minecraft for Youth Participation in Urban Design and Governance
Banks N: Global Development Institute, 2015

UN-Habitat believes that ICT can be a catalyst to improve governance in towns and cities and help increase levels of participation, efficiency and accountability in public urban policies, provided that the tools are appropriately used, accessible, inclusive and affordable. Research shows that ICT use by youth can have a direct impact on increasing civic engagement, giving them new avenues through which to become informed, shape opinions, get organised, collaborate and take action. Youth are at the centre of the ICT revolution, both as drivers and consumers of technological innovation. They are almost twice as networked as the global population as a whole, with the ICT age gap more pronounced in least developed countries where young people are up to three times more likely to be online than the general population. This video shows UN-Habitat’s approach to using Minecraft to encourage youth participation in urban design and governance, to design and present their vision for public spaces in the city, as an input to planning. UN-Habitat’s experiences of using the video game Minecraft as a community participation tool for public space design is reported to show that providing youth with ICT tools can promote improved civic engagement.

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