Community capability is the combined influence of a community’s social systems and collective resources that can address community problems and broaden community opportunities. The authors frame it as consisting of three domains that together support community empowerment: what communities have; how communities act; and for whom communities act. The authors sought to further understand these domains through a secondary analysis of a previous systematic review on community participation in health systems interventions in low and middle income countries (LMICs). The authors searched for journal articles published between 2000 and 2012 related to the concepts of “community”, “capability/participation”, “health systems research” and “LMIC.” They identified 64 with rich accounts of community participation involving service delivery and governance in health systems research for thematic analysis following the three domains framing community capability. When considering what communities have, articles reported external linkages as the most frequently gained resource, especially when partnerships resulted in more community power over the intervention. In contrast, financial assets were the least mentioned, despite their importance for sustainability. With how communities act, articles discussed challenges of ensuring inclusive participation and detailed strategies to improve inclusiveness. Very little was reported about strengthening community cohesiveness and collective efficacy despite their importance in community initiatives. When reviewing for whom communities act, the importance of strong local leadership was mentioned frequently, while conflict resolution strategies and skills were rarely discussed. Synergies were found across these elements of community capability, with tangible success in one area leading to positive changes in another. Access to information and opportunities to develop skills were crucial to community participation, critical thinking, problem solving and ownership. Although there are many quantitative scales measuring community capability, health systems research engaged with community participation has rarely made use of these tools or the concepts informing them. Overall, the amount of information related to elements of community capability reported by these articles was low and often of poor quality.
Governance and participation in health
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.
Little is known about the interventions required to build the capacity of mental health policy-makers and planners in low- and middle-income countries (LMICs). The authors conducted a systematic review with the primary aim of identifying and synthesising the evidence base for building the capacity of policy-makers and planners to strengthen mental health systems in LMICs. The authors searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Web of Science, Scopus, CINAHL, LILACS, ScieELO, Google Scholar and Cochrane databases for studies reporting evidence, experience or evaluation of capacity-building of policy-makers, service planners or managers in mental health system strengthening in LMICs. Reports in English, Spanish, Portuguese, French or German were included. Additional papers were identified by hand-searching references and contacting experts and key informants. Database searches yielded 2922 abstracts and 28 additional papers were identified. Following screening, 409 full papers were reviewed, of which 14 fulfilled inclusion criteria for the review. Data were extracted from all included papers and synthesised into a narrative review. Only a small number of mental health system-related capacity-building interventions for policy-makers and planners in LMICs were described. Most models of capacity-building combined brief training with longer term mentorship, dialogue and/or the establishment of networks of support. However, rigorous research and evaluation methods were largely absent, with studies being of low quality, limiting the potential to separate mental health system strengthening outcomes from the effects of associated contextual factors. This review demonstrates the need for partnership approaches to building the capacity of mental health policy-makers and planners in LMICs, assessed rigorously against pre-specified conceptual frameworks and hypotheses, utilising longitudinal evaluation and mixed quantitative and qualitative approaches.
After a series of multi-million-dollar scandals recently unearthed in Kenya, the Auditor General’s report for 2015 says only 1% of the national budget was properly accounted for. In this letter, civil society organisations (CSOs) in Kenya express deep concern and consternation for the worrying escalation of corruption scandals in Kenya in the recent past with little or no consequences for perpetrators, many of whom are reported by the author to have been heavily mentioned in a series of scandals and continue to unashamedly occupy, and therefore bring dishonour, to public office. The CSOs rebuke what they cite as the culture of impunity that continues owing to an apparent lack of political will to address corruption. They make 14 demands to the president and government including the immediate sacking of state and public officers within the Executive adversely mentioned in corruption scandals, initiating legal process of freezing of bank accounts of all those implicated in grand corruption scandals pending investigations, instantaneously stopping and recovering salaries paid illegally to officers who have been suspended or removed from public service on graft allegations
As special-interest associations, community-based organisations fill an institutional vacuum, providing basic services to ensure a robust response to crises of poverty. It is at this local level that people, however limited their incomes or their assets, tend to reveal their true wealth: the ingenuity that they need to solve their own problems and those of their communities. Community based organisations (CBOs) are locally based membership organisations that work to provide services to their own communities. They have emerged in response to the need for collective social action. Their main characteristic is the importance that they attach to self-help, based on the principle of traditional communal values, reciprocity and interdependence. The author argues that CBOs can serve as a channel through which African governments can facilitate development at the grassroots level. While the CBOs need capacity-building to strengthen their skills in areas such as bookkeeping and accounts, experience indicates that the related needs assessments should be carried out jointly with communities. Examples show considerable grassroots enthusiasm for decentralisation within communities that can be mobilised by winning the confidence and trust of local and traditional communities and their leaders. CBOs are argued to provide the basis for a bottom-up approach in the fight against social exclusion and in national decision-making.
This paper aims at contributing to the debate on ways in which actors in development cooperation such as international NGOs or bilateral agencies could engage in a relevant, legitimate and effective way to achieving universal access to health. MMI identify that relevant, legitimate and effective health cooperation contributes to achieving universal access to health and is fully aware of its structural role, responsibilities and limitations; and continuously reflects on how to improve its approaches and practices. MMI argue that there is still a lack of platforms in which actors in health cooperation can critically reflect their own practices and approaches, share information and experiences, learn from each other and have an opportunity to further develop their institutional and personal skills and practices. They also suggest that a paradigm shift is required that breaks with the continuum process of development cooperation for health as it has been conducted during the last 50 years.
The author observes that the role and reach of the World Health Organisation has been contested since it was created in 1948. The debate is commonly couched in terms of whether the organisation is ‘fit for purpose’ although whose purpose is not always made clear. There have been several attempts at WHO reform since its establishment, directed to making it fitter for a still contested purpose. The current round of ‘WHO reform’ was launched in 2010 following a budget crisis and it continues as the new director‐general settles into the job. The current reform program addresses: funds mobilisation, budgeting, evaluation, relationships with non‐state actors, relationships within the secretariat (between headquarters, the regions and the country offices), WHO’s role in global health governance, the emergency program and the management of the WHO’s staff. The capacity, effectiveness and accountability of WHO is critical to the project of equitable health development globally. Nevertheless, there have been shortfalls. The root causes of WHO’s disabilities are argued to include the freeze on WHO revenues, the dysfunctions associated with WHO’s highly decentralised organisational structure, and the lack of accountability of member states for their contribution to WHO decision making and their implementation of WHO resolutions. In this paper the author reviews the evolution of the current reform program and some of the major elements of the reform, with the shortfalls, disabilities and reform options within the broader context of global health governance. The author argues that the reform of WHO, to realise the vision of its Constitution, will require a global mobilisation around the democratisation of global health governance.
Maternal and child health issues have gained global political attention and resources in the past 10 years, due in part to their prominence on the Millennium Development Goal agenda and the use of evidence-based advocacy by policy networks. This paper identifies key factors for this achievement, and raises questions about prospective challenges for sustaining attention in the transition to the post-2015 Sustainable Development Goals, far broader in scope than the Millennium Development Goals. The paper uses participant observation methods and document analysis to develop a case study of the behaviours of global maternal and child health advocacy networks during 2005–2015. The development of coordinated networks of heterogeneous actors facilitated the rise in attention to maternal and child health during the past 10 years. The strategic use of epidemiological and economic evidence by these networks enabled policy attention and promoted network cohesion. The time-bound opportunity of reaching the 2015 Millennium Development Goals created a window of opportunity for joint action. As the new post-2015 goals emerge, networks seek to sustain attention by repositioning their framing of issues, network structures, and external alliances, including with networks that lay both inside and outside of the health domain. Issues rise on global policy agendas because of how ideas are constructed, portrayed and positioned by actors within given contexts. Policy networks play a critical role by uniting stakeholders to promote persuasive ideas about policy problems and solutions. The author argues that the behaviours of networks in issue-framing, member-alignment, and strategic outreach can force open windows of opportunity for political attention -- or prevent them from closing.
In a penetrating analysis of events in South Africa, Jonathan Grossman writes a linked analysis of the student mobilisations and of the workers at Marikana. The author that an old legacy of struggle is being rediscovered and rescued, reflecting a solidarity between workers and students taking action. Grossman argues that the struggle for free education and against outsourcing in the public sector at the universities now needs to become the struggle for free education at all levels and free basic services, against outsourcing and for a living wage across the whole of the public sector. He argues that this is necessary for the renewal of the workers movement to tap into the vitality of a student-worker alliance that enriches both struggles in South Africa with a more holistic vision.
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.