This paper aims to provide insights into the role of traditional authorities in two maternal health programmes in Northern Malawi. Among strategies to improve maternal health, these authorities issue by-laws that are local rules to increase the uptake of antenatal and delivery care. The study uses a framework of gendered institutions to critically assess the by-law content, process and effects and to understand how responsibilities and accountabilities are constructed, negotiated and reversed, in a qualitative study in five health centre catchment areas in Northern Malawi. In the study district, traditional leaders introduced three by-laws that oblige pregnant women to attend antenatal care; bring their husbands along and; and to give birth in a health centre. If women fail to comply with these rules, they risk being fined or denied access to maternal health services. The findings show that responsibilities and accountabilities are negotiated and that by-laws are not uniformly applied. Whereas local officials support the by-laws, lower level health cadres’ and some community members contest them, in particular, the principles of individual responsibility and universality. The study adds new evidence on the understudied phenomenon of by-laws. From a gender perspective, the by-laws are problematic as they individualise the responsibility for maternal health care and discriminate against women in the definition and application of sanctions. Through the by-laws, supported by national policies and international institutions, the authors argue that women bear the full responsibility for failures in maternal health care, suggesting a form of ‘reversed accountability’ of women towards global maternal health goals. This can negatively impact on women’s reproductive health rights and obstruct ambitions to achieve gender inequality and health equity. It is suggested that contextualised gender and power analysis in health policymaking and programming as well as in accountability reforms could help to identify these challenges and potential unintended effects.
Governance and participation in health
This paper explores the different roles of male and female community health workers in rural Wakiso district, Uganda, using photovoice, as a community-based participatory research approach. The authors trained ten community health workers on key concepts about gender and photovoice. The community health workers took photographs for 5 months on their gender-related roles which were discussed in monthly meetings. The discussions from the meetings were recorded, transcribed, and translated to English, and emerging data were analysed using content analysis. Although responsibilities were the same for both male and female community health workers, they reported that in practice, community health workers were predominantly involved in different types of work depending on their gender. Social norms led to men being more comfortable seeking care from male community health workers and females turning to female community health workers. Due to their privileged ownership and access to motorcycles, male community health workers were noted to be able to assist patients faster with referrals to facilities during health emergencies, cover larger geographic distances during community mobilization activities, and take up supervisory responsibilities. Due to the gendered division of labour in communities, male community health workers were also observed to be more involved in manual work such as cleaning wells. The gendered division of labour also reinforced female caregiving roles related to child care, and also made female community health workers more available to address local problems. Community health workers reflected both strategic and conformist gendered implications of their community work. The authors argue that the differing roles and perspectives about the nature of male and female community health workers while performing their roles should be considered while designing and implementing community health workers programmes, without further retrenching gender inequalities or norms.
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.
In July 2018 i-CMiiST, a Nairobi based organisation held an Urban Dialogue for to discuss the development of two key areas of the city - Yaya junction and Luthuli avenue. The aim of the dialogue was to engage the general public on issues affecting Nairobi streets, transit and mobility to feed into future interventions and approaches in the development of these areas. The theme of the dialogue was ‘safety on our streets’ looked at from different perspectives: pedestrians, commuters, drivers and cyclist safety. The dialogue involved about 30 people from different professions and backgrounds – engineers, planners, cyclists, urban designers, state actors, NGOs, business people etc. It was also live streamed on various social media platforms to involve a wider public, viz: KPF, Naipolitans and Placemaking Network Nairobi pages. Views and contributions came from people watching locally and from other countries while the inputs were recorded and an illustrator documented what participants were saying in a visual form.
The paper seeks to investigate the effect of using volunteer screeners in active tuberculosis case-finding in South Kivu, the Democratic Republic of the Congo, especially among groups at high risk of tuberculosis infection. In order to identify and screen high-risk groups in remote communities, the authors trained volunteer screeners, mainly those who had themselves received treatment for tuberculosis or had a family history of the disease. A non-profit organization was created and screeners received training on the disease and its transmission at 3-day workshops. Screeners recorded the number of people screened, reporting a prolonged cough and who attended a clinic for testing, as well as test results. Data were evaluated every quarter during the 3-year period of the intervention (2014–2016). Acceptability of the intervention was high. Volunteers screened 650 434 individuals in their communities, 73 418 of whom reported a prolonged cough; 50 368 subsequently attended a clinic for tuberculosis testing. Tuberculosis was diagnosed in 1 in 151 people screened, costing 0.29 United States dollars per person screened and US$ 44 per person diagnosed. Although members of high-risk groups with poorer access to health care represented only 5.1% of those screened, they contributed 19.7% of tuberculosis diagnoses. The intervention resulted in an additional 4300 sputum-smear-positive pulmonary tuberculosis diagnoses, 42% of the provincial total for that period. Patient-led active tuberculosis case-finding represents a valuable complement to traditional case-finding, and should be used to assist health systems in the elimination of tuberculosis.
Twenty years ago, a group of activists came together to demand access to treatment for all people living with HIV. The introduction of highly effective combination antiretroviral (ARV) therapy offered hope. Yet their high price meant that they were entirely unavailable in the public health system and out of reach for millions of people. In 1998, ARVs cost US$10 000 per year. Demanding access to treatments, activists from the Treatment Action Campaign (TAC), Médecins Sans Frontières (MSF) and the AIDS Law Project, later incorporated as SECTION27 helped to spur a global movement that radically reduced the prices of HIV medicines. Using skilled legal advocacy, high-quality research, social mobilisation, and public education, these activists transformed the global conversation on drug pricing, making it possible for millions of people to access treatment. Yet despite the remarkable success in increasing access to HIV medicines, this paper notes that systemic problems remain entrenched. New medicines to treat drug-resistant TB, cancers, and many other conditions remain far too expensive. As South Africa develops its intellectual property framework, they argue that it is worth revisiting the strategies, successes, and shortcomings of the access to medicines movement for the insights they may offer. The authors observe that a battle that began nearly twenty years ago engaging pharmaceutical giants and recalcitrant governments continues today. This interactive website showcases their story.
This presentation given at the ECSA HC Best Practices Forum 2018 provides an overview of urban poverty and global commitments to equity oriented policies for urban health; urban health challenges in Sub-Saharan Africa; examples of how youth and community engagement could inform change and how to support the development of governance and equity oriented policies. The author notes that unmanaged urban growth is linked with rising social and economic inequities that benefit the well off and negatively impact health and well-being of the poor and disadvantaged; and that densely packed areas with low levels of sanitation services offer a petri dish for infectious diseases. This contributes to higher cost of living, high risk of school dropout and teenage pregnancy and high rates of crime and violence. Shakim provides evidence of youth as agents of change in urban Tanzania through the Tandale Health Centre.
From the upheavals of recent national elections to the success of the #MyDressMyChoice feminist movement, digital platforms have already had a dramatic impact on political life in Kenya – one of the most electronically advanced countries in sub-Saharan Africa. While the impact of the Digital Age on Western politics has been extensively debated, there is still little appreciation of how it has been felt in developing countries such as Kenya, where Twitter, Facebook, WhatsApp and other online platforms are increasingly a part of everyday life. Written by a respected Kenyan activist and researcher at the forefront of political online struggles, this book presents a unique contribution to the debate on digital democracy. For traditionally marginalised groups, particularly women and the disabled, digital spaces have allowed Kenyans to build new communities which transcend old ethnic and gender divisions. But the picture is far from wholly positive. Digital Democracy, Analogue Politics explores the drastic efforts being made by elites to contain online activism, as well as how ‘fake news’, a failed digital vote-counting system and the incumbent president's recruitment of Cambridge Analytica contributed to tensions around the 2017 elections. Reframing digital democracy from the African perspective, Nyabola’s work opens up new ways of understanding our current global online era.
This article poses questions, challenges, and dilemmas for health system researchers striving to better understand how gender shapes accountability mechanisms, by critically examining the relationship between accountability and gender in health systems. It raises three key considerations, namely that: (1) power and inequities are centre stage: power relations are critical to both gender and accountability, and accountability mechanisms can transform health systems to be more gender-equitable; (2) intersectionality analyses are necessary: gender is only one dimension of marginalisation and intersects with other social stratifiers to create different experiences of vulnerability and there is a need to take account of how these stratifiers collectively shape accountability; and (3) empowerment processes that address gender inequities are a prerequisite for bringing about accountability. The authors suggest that holistic approaches to understanding health systems inequities and accountability mechanisms are needed to transform gendered power inequities, impact on the gendered dimensions of ill health, and enhance health system functioning.
Politicians, clerics, feminists and others have formed a broad coalition of Ugandans calling for an end to a social media tax. In July, Uganda's communications regulator blocked access to social media including WhatsApp, Facebook and Twitter, as well as dating sites Tinder and Grindr, unless users pay a Shs200 ($0.05) daily tax. Mobile internet users now have to input a telephone code to pay the tax before they are able to access most social media sites, although implementation has proved patchy with some blocked services still available. Some have turned to virtual private networks (VPNs) to disguise their location and avoid the levy, a trick learned during elections two years ago when the government tried to shut down social media. President Yoweri Museveni - a Twitter user with 855 000 followers - is reported to have urged the imposition of the tax earlier this year, to put an end to "gossip". The protesters are resisting the measure and calling for it to be lifted.