In this systematic review the authors assessed progress with climate change adaptation in the health sector in South Africa, providing useful lessons for other African countries. Very few of the studies found presented findings of an intervention or used high-quality research designs. Several policy frameworks for climate change have been developed at national and local government levels. These, however, pay little attention to health concerns and the specific needs of vulnerable groups. Systems for forecasting extreme weather, and tracking malaria and other infections appear well established. Yet, there is little evidence about the country’s preparedness for extreme weather events, or the ability of the already strained health system to respond to these events. Seemingly, few adaptation measures have taken place in occupational and other settings. To date, little attention has been given to climate change in training curricula for health workers. Overall, the authors note that the volume and quality of research is disappointing, and disproportionate to the threat posed by climate change in South Africa. This is surprising given that the requisite expertise for policy advocacy, identifying effective interventions and implementing systems-based approaches rests within the health sector. They suggest that more effective use of data, a traditional strength of health professionals, could support adaptation and promote accountability of the state. With increased health-sector leadership, climate change could be reframed as a health issue, one necessitating an urgent, adequately-resourced response.
Governance and participation in health
The author points to how women and feminist activists are on the front line of the battle for ecological sustainability on the continent. Their everyday struggles, commitment, and willingness to envision a future in which justice, equity and rights harmonise with environmental sovereignty is said to have the potential to save us all. Wangari Maathai and her Green Belt Movement are said to epitomise the essence of African ecofeminism and the collective activism that defines it. As the first environmentalist to win the Nobel Peace Prize, in 2004, Maathai highlighted the close relationship between African feminism and African ecological activism, which challenge both the patriarchal and neo-colonial structures undermining the continent. Lesser -known activists, however, have also long been at the intersection of gender, economic, and ecological justice. Ruth Nyambura of the African Eco Feminist Collective, for example, uses radical and African feminist traditions to critique power, challenge multinational capitalism, and re-imagine a more equitable world. Organisations like African Women Unite Against Destructive Resource Extraction (WoMin) campaign against the devastation of extractive industries. Meanwhile, localised organising is also resisting ecologically-damaging corporatisation: in South Africa, Women Mapella residents fought off land grabs by mining companies; in Ghana, the Concerned Farmers Association, led largely by women, held mining companies accountable for pollution of local watersheds; and in Uganda, women of the Kizibi community seed bank are preserving local biodiversity in the face of the commercialisation of seeds by corporate multinationals. From Ghana to South Africa and beyond, women-organised seed-sharing initiatives continue to resist corporatisation. Activists like Mariama Sonko in Senegal continue to lead on agroecological farming initiatives for localised and sustainable food production. The author argues that the crisis of Africa’s current trajectory is a crisis of visioning: the inability of the continent’s leaders to imagine a process of development less destructive, more equitable, less unjust, more uniquely African, and – quite simply – more exciting. The positions, passions, and holistic approaches offered by African ecofeminism are argued to provide key ingredients for an alternative to the capital-centric ideals of economic growth that have defined progress so far.
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.
Country-wide peaceful demonstrations against the regime in Sudan have involved women as organised activists. Women in marginalized areas of conflict such as Darfur, South Sudan, the Nuba Mountains and the Blue Nile have lost their children, family and livelihood to war and famine. In addition to their experience of socio-economic deprivation, many of those who fled to the capital Khartoum have been abandoned by their husbands who are unable to support their families. The women’s group No To Women’s Oppression provides legal aid, advocacy and awareness campaigns and monitors violations of human rights, a solid and active component of the resistance. Women activist in the Central Committee for Doctors and other organisations has, however, made them particularly prone to arrests and harassment. Women have also played a vital part in documenting the movement from the inside, especially in providing footage and proof of women's experiences of activism and of their conditions and the brutality they face.
December 2018 marked the 20th anniversary of the birth of the Treatment Action Campaign (TAC); a story that began with a T-shirt with the slogan “HIV-positive” and came to be a thorn in government’s side, a symbol of hope for people dying from HIV/Aids and an icon of activism still needed in an age of democracy. Days before the protest that founded the TAC, co-founder Zackie Achmat had spoken at the funeral of Aids activist Simon Nkoli. He vowed to fight for access to treatment, knowing from his own experience that if the right medicines were affordable and accessible people would not be dying. Four days after that protest action, activist Gugu Dlamini, who had disclosed her HIV status publicly, speaking on radio in Zulu on World Aids Day, was beaten to death in KwaMashu. “Those two events created the anger and passion that would become the momentum for organising and mobilising,” says co-founder Mark Heywood. As one more person put on an “HIV-positive” T-shirt and stood to challenge HIV stigma, more people joined. Recruitment and empowerment came through a strong treatment literacy programme rooted in spreading the word from neighbour to neighbour, patient to patient. This patient-driven, community activism would become a hallmark of the movement. It meant that people could see the power and the purpose in marching to the opening of Parliament each year, taking part in in civil disobedience campaigns and joining rallies for AZT for pregnant women and pushing big pharmaceutical companies to make drugs available.
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.
At the recent HSR2018 Symposium delegates explored how to challenge embedded power dynamics in health systems research through participatory methodologies. One of the innovations that the Local Organising Committee (LOC) introduced for HSR2018 was the inclusion in the programme of a multi-project Photovoice exhibition. Photovoice is a participatory action research methodology that involves the taking of images by individuals, the discussion and analysis of these images and the use of the images to communicate the lived experiences, strengths and challenges of the photographers. Colleagues commented that this was the largest health based Photovoice exhibition to date but more significant was the scope of the material displayed. The author argues that Photovoice exhibition activities are a great representation of the strength and challenges of using this visual participatory methodology. Using photos can promote the voice of the less powerful seems such a laudable and simple aim but it is important not to overlook the underlying power shifting aims of the methodology.
Botswana Labour Migrants Association (BoLAMA) is a non-profit organization registered in accordance with the laws of Botswana. The organization is comprised of former migrant mineworkers and their beneficiaries. The organization provides assistance to ex-miners and their beneficiaries by facilitating their access to social security benefits most of which involves occupational compensation from mines. Among other issues BoLAMA works to address social determinants of TB in mining communities. TB is the leading cause of death among ex-miners and it contributes to the socio-economic status of ex-miners. BoLAMA’s mandate is in line with various prescribes and targets set in global, continental, regional and national mining sector related instruments, protocols and frameworks. BoLAMA carries out its work under three (3) thematic areas:- extractives, labour migration and economic empowerment.
This brief was developed in consultation with key local government stakeholders. It provides an outline of key concerns and issues regarding devolution and proffers recommendations for consideration by government and parliament in crafting the new legislation to guide the implementation of devolution in Zimbabwe. The issue of devolution is topical and government has indicated its commitment to implementing it. However, the delay in the crafting of legislation to guide devolution is a serious cause for concern for citizens and other local government stakeholders. The devolution of power to local and provincial councils helps to achieve fair and balanced development through provincial and metropolitan councils, which are allowed by the Constitution to set local development priorities. The authors argue that governmental powers must be devolved to the local people so that there is increased transparency and accountability in governance and decision-making as well as management of public affairs and resources by local authorities. Provincial governments must be fully in control of their local authorities whilst central government plays an oversight role to ensure that public resources are used in a transparent manner.
From 2013, the Zambian Corrections Service (ZCS) worked with partners to strengthen prison health systems and services. One component of that work led to the establishment of facility-based Prison Health Committees (PrHCs) comprising of both inmates and officers. The authors present findings from a nested evaluation of the impact of eight PrHCs 18 months after programme initiation. In-depth-interviews were conducted with 11 government ministry and Zambia Corrections Service officials and 6 facility managers. Sixteen focus group discussions were convened separately with Prison Health Committees members and non-members in 8 facilities. Memos were generated from participant observation in workshops and meetings preceding and after implementation. The authors sought evidence of Prison Health Committees impact, refined with reference to Joshi’s three domains of impact for social accountability interventions in state, society, and state-society relations. Further analysis considered how project outcomes influenced structural dimensions of power, ability and justice relating to accountability. Data pointed to a compelling series of short- and mid-term outcomes, with positive impact on access to, and provision of, health services across most facilities. Inmates reported being empowered via a combination of improved health literacy and committee members’ newly-given authority to seek official redress for complaints and concerns. Inmates and officers described committees as improving inmate-officer relations by providing a forum for information exchange and shared decision making. Contributing factors included more consistent inmate-officer communications through committee meetings, which in turn enhanced trust and co-production of solutions to health problems. Nonetheless, long-term sustainability of accountability impacts may be undermined by permanently skewed power relations, high rates of inmate turnover, variable commitment from some officers in-charge, and the anticipated need for more oversight and resources to maintain members’ skills and morale. The authors showed that Prison Health Committees do have potential to facilitate improved social accountability in both state and societal domains and at their intersection, for an extremely vulnerable population. However, sustained and meaningful change will depend on a longer-term strategy that integrates structural reform and is delivered through meaningful cross-sectoral partnership.