For the past 10 years voluntary medical male circumcision has been recommended as a way of reducing female-to-male transmission of HIV. Estimates show that it could reduce infections by 60%. Several sub-Saharan African countries with high rates of HIV prevalence but low rates of male circumcision have rolled out the procedure as part of their HIV prevention initiatives. Since 2007 more than 9 million circumcisions have been performed in eastern and southern Africa. But to cover more than 80% of men on the continent by 2025, about 20 million more men need to be circumcised. If this happens about 3.4 million new HIV infections could be averted, reducing the number of people who would need HIV treatment and care. While circumcision has been encouraged there are many places where it has faced challenges. This is linked to misconceptions about the purpose of circumcision as well as religious and cultural concerns which prevent men from getting circumcised. Uganda is argued in this article to be a case in point. By the end of 2015 the country’s health ministry aimed to circumcise 80% – or 4.2 million – men aged between 15 and 49. But between 2008 to 2013 the country only managed to circumcise 50% of this population. Most of these were young boys. This research found that religious and cultural beliefs compete with the messages about the purpose of circumcision. The authors found that this got in the way of men deciding whether or not to be circumcised medically and also affected the way they behaved afterwards. When medical circumcision is introduced in settings where there are high rates of HIV, the authors argue that it must take into account local beliefs about circumcision and local religious and social group leaders and women must be involved in the roll-out.
Governance and participation in health
Many Voices Make a City is a series of mini-dramas written, performed and produced by Chicoco Radio trainees, each explores an aspect of participatory urban design. This episode features a starchitect, a celebrity engineer and feisty market woman who knows what she wants. For those who need a little help with Pidgin English, this version is subtitled.
The study reported in this video sought to understand the role of strong social cohesion in the cities of Cape Town and Rio de Janeiro, both of which suffer from high levels of inequality, poverty, and violence. In response, local governments and non-governmental organisations in both cities have tried to counteract these phenomena through a variety of strategies, programs, and projects. This work explored the role played by social cohesion in the cycle of inequality, poverty, and violence, noting that social cohesion can act as one of a number of violence-prevention factors. The project provides theoretical, methodological, and practical insights, which contribute to better public policies in the domain of poverty and violence reduction, replicable in other regions.
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.
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.