This study explores how health facility committees monitor the quality of health services and how they demand accountability of health workers for their performance in Malawi. Documentary analysis and key informant interviews were complemented by interviews with purposefully selected health facility committees members and health workers regarding their experiences with health facility committees. The informal and constructive approach that most health facility committees use is shaped both by formal definition and expectations of their role and resource constraints. The primary social accountability role of health facility committees appeared to be co-managing the social relations around the health facility and promoting access to and quality of services. The results suggest that health facility committees can address poor health worker performance and the authors suggest that social accountability approaches with health facility committees be integrated in existing quality of care programs and that accountability arrangements and linkages with upward accountability approaches be clarified.
Governance and participation in health
The G20 plays an important role in global rule-making. Africa is significantly under-represented in this body, with only South Africa a permanent member. This makes Africa a rule-taker. At the same time the G20 has started to pay more attention to Africa and the continent’s future development now occupies a somewhat more central position on the grouping’s agenda. The G20 Initiative on Supporting Industrialization in Africa and Least Developed Countries, launched under China’s G20 presidency of 2016, and the 2017 German presidency’s Compact with Africa offered unprecedented moments of engagement. However, the question remains how Africa can use these initiatives to deepen its engagement with the G20 and boost its own development. This paper draws on extensive interviews with key stakeholders to analyse G20–Africa engagement by focusing on three presidencies: China in 2016, Germany in 2017, and Argentina in 2018. It shows how China’s Industrialisation Initiative was crucially informed by its pre-existing African engagement, while Germany’s Compact with Africa both gained and suffered from a more narrowly focused commercial engagement. It then shows how Argentina, despite lacking a similar African initiative, managed to continue G20–Africa engagement through person-to-person diplomacy. The paper points out both the benefits and the limits of these engagements and suggests a series of further initiatives that could allow Africa a more significant say in the G20.
The authors write that definitions of “global health” are generally depoliticized and invoke trans-national health issues and collaboration. Yet they argue that global health is only the newest iteration of what was formerly “international health”, “tropical medicine” and “colonial medicine”, with historical roots lie in colonial endeavours and imperial interests. They report a widespread frustration with how global health is taught in universities in ways that create and perpetuate neo-colonial relations; and a desire for alternative conceptualizations of the “global” that fundamentally tackle structures of power. The authors observe in the paper the various issues that need to be tackled if there is an intent to 'decolonise' global health, commenting that it is not a one-day event or a checkbox. It is a process that leads to futures that are unknown, but that one should dare to imagine.
The ever increasing evidence and technical developments supporting population health have not yet reached the goal of health for all. The decision making for population health has not led to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. This presentation discusses Zambia as a case study country, finding that national governance results in policy based choices are not necessarily helpful at implementation and community levels. The authors present evidence that if one comprehensively addresses a particular disease burden it does decrease, but limits other action. The Sustainable Development goals included democratic cross sector processes in their formulation, but the targets applied in health still tend to receive funding from competing sectors and programs.
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.
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.