Social movements have been successful in beating back the tide of water privatisation that swept the world in the 1990s, forcing the retreat of water multinational companies in the poorest countries of the global South. With global temperatures rising, unions in the energy sector can learn from these struggles – many of which were worker-led – to give rise to a strong counter-movement for energy democracy. While the political economy of the energy and water sectors are different, the author argues that we can build on water justice victories and draw lessons on how to frame demands for local control over the commons. Further lessons learned include the importance of building broad coalitions with unlikely allies; and practising internal democracy in social movements. While there have been significant victories in the water sector, the author argues that community-based struggles on energy have a long way to go. The struggle for energy democracy is argued to require movements to “resist, reclaim and restructure” communities to draw on locally sourced, decentralised, alternative energy resources.
Governance and participation in health
This blog reports on the Third People’s Health Assembly (PHA) held in Cape Town, South Africa, in July 2012. Participants reported on the extraordinary gains in human development occurring in Thailand and Brazil, where millions of people are moving out of poverty and for the first time accessing health care and social support, as well as the impotence of global leadership to effectively deal with climate change, and massive land grabs. Key strategies agreed on at the PHA were supporting countries to act on the PHM’s Right to Health Campaign; a global campaign on the adverse health and environmental effects of extractive industries; a food security campaign focusing on the health consequences of the growth of transnational food corporations, and a campaign against the privatisation of health services, which will document the ways in which public ownership and control of health services is being undermined by various forms of public private partnerships and by the outsourcing of previously publicly provided services.
In this article, the author evaluates developments in the field of community participation in health, arguing that in many national experiences, the distinction between the different forms of participation remains blurry. In particular, there is little distinction between community participation as a way to devolve services to community members and community participation as the community (co-)management of health centres. This confusion in part reflects two decades of debate on participation as either an end in itself or as a means for other purposes. Although free care and performance-based financing are two of the most popular health policies currently being developed in Africa, they have implications for participation. Performance-based financing strategies raise a need to ensure that the voice of the people continues to be heard when financial incentives drive the system. Free health care on a large scale also poses new challenges because, with the removal of user fees, the financial interest community members have in the health centre management disappears. Research about community participation has evolved in the last 25 years, with new methods for quantitative approaches mixed with qualitative insights, contrasting with the ethnographic and sociological approaches used in the past.
In this interview with Susan Rifkin of the London School of Economics and London School of Hygiene & Tropical Medicine, she talks about the past and future of community participation and community participation research. Community participation, she argues, cannot be limited to an intervention; the next big challenge of research will be to understand the processes that tie community participation and health outcomes. She points to a growing recognition by policy makers that community participation is critical and necessary but not sufficient for improvement of the health of the populations. As communities become aware of their rights and their obligations, they become in a much better position to negotiate policy and the provision of services with policy-makers, she argues. At this moment most research views community participation as an intervention and therefore uses a natural scientific paradigm to look at it linearly as a causal effect. This approach is inductive and very narrow; direct causes have effects. Instead, Rifkin calls for a closer investigation of processes and how community monitoring leads to better health outcomes. The other question about the research in this area is how we address issues around power and control, key to community ownership of health programmes.
In this Call to Action, the People’s Health Movement (PHM) argues that the underlying cause of health inequities are the neoliberal economic policies that are the hallmark of present day capitalism. PHM says the global health crisis is a consequence of the failure to address the social, political and environmental determinants of health. Ironically, the response of national and international institutions to the current financial crisis has been merely to restore the confidence’ of the same institutions and financial markets that caused the crisis in the first place. Governments have meanwhile enacted an austerity agenda by cutting health and social spending, effectively deepening and reinforcing inequities between rich and poor. PHM puts forward an alternative vision in which a reformed economic system values individuals over capital, with just, fair and democratic political and economic processes and institutions, and better and transformed global heath governance that is free from corporate influence and the influence of unaccountable private actors. It calls for equitable public health systems that are universal, integrated and comprehensive, and also provide a platform for appropriate action on social determination of health.
Since the Global Fund to Fight AIDS, Tuberculosis and Malaria announced its new model for allocating funds in September 2012, African civil society organisations have stated that they were not included in the process, arguing that consultations were held behind closed doors and that most non-governmental organisations (NGOs) on the continent are unaware that a new model exists. The Rights Alliance of Southern Africa (ARASA), the South Africa-based World AIDS Campaign and almost 40 African non-governmental organisations (NGOs) have called for the Fund to develop a more robust and inclusive communication and consultation process around the model's development, which is ongoing.
In this open letter to the World Bank, a group of 110 international civil society organisations (CSOs) call on the Bank to play a truly progressive and transformative role in health by supporting countries to achieve universal health coverage (UHC). The World Bank is well-placed to be a vocal champion of UHC by deploying its knowledge and experience in health system reform, as well as its financial support. However, the Bank must reform the approach of its programmes and policy advice in order to deliver on this potential, and ensure it positively impacts poor and vulnerable populations. The CSOs call on the Bank to actively support countries to offer care that is free at the point-of-use for all people, as well as scale up investment in public health systems in developing countries, by supporting them to expand public financing, and by offering balanced policy advice that does not privilege private sector solutions over publicly financed and delivered health systems. The Bank can take further steps to promote UHC by ensuring all Bank programs benefit the poorest two quintiles in the countries where it works, actively supporting involvement of civil society in national health policy development, in order to improve democratic oversight and accountability for improved health outcomes, and collaborating with the World Health Organization and other global health institutions in the push for UHC.
This cross-sectional study was carried out in Jinja Town in Uganda in order to assess the level of awareness of occupational hazards and the use of safety measures among small-scale industrial welders in a low-income setting. A total of 218 roadside welders with a mean age of 31 years participated in the study. The researchers found that these roadside welders had a high level of awareness of occupational hazards (83%), but their use of safety measures was less than optimal. Awareness was positively influenced by age, educational status, marital status, work experience, type of training and supervision. The researchers speculate that the great discrepancy between the level of awareness and the use of personal protective equipment could be attributed to factors such as discomfort of wear, not being aware that even ‘simple tasks’ require protection and the unavailability of personal protective equipment because of the high costs associated with their acquisition, leading to sharing of the equipment available among colleagues. Strategies are therefore needed not only to enforce policy but also to cover the informal work sector, in order to ensure the safety of welders. Generally, their high level of awareness may be used as a window of opportunity for involving welders in decision-making as regards their working conditions.
Implementation of policies (decisions) in the health sector is sometimes defeated by the system’s response to the policy itself. This can lead to counter-intuitive, unanticipated, or more modest effects than expected by those who designed the policy. The health sector fits the characteristics of complex adaptive systems (CAS) and complexity is at the heart of this phenomenon. Anticipating both positive and negative effects of policy decisions, understanding the interests, power and interaction between multiple actors and planning for the delayed and distal impact of policy decisions are essential for effective decision making in CAS. Failure to appreciate these elements often leads to a series of reductionist approach interventions or ‘fixes’. This in turn can initiate a series of negative feedback loops that further complicates the situation over time. In this paper, researchers use a case study of the Additional Duty Hours Allowance (ADHA) policy in Ghana to illustrate these points. Using causal loop diagrams, they unpack the intended and unintended effects of the policy and how these effects evolved over time. The overall goal is to advance our understanding of decision making in complex adaptive systems; and through this process identify some essential elements in formulating, updating and implementing health policy that can help to improve attainment of desired outcomes and minimise negative unintended effects.
State of the Union (SOTU), a coalition of 10 civil society organisations, has urged national, regional and continental Parliaments to take a leading role in promoting the ratification and implementation of key African Union (AU) instruments and policy standards. SOTU says that the slow rate of ratification and domestication of key instruments is alarming and undermines the credibility of the AU and all its key organs, while denying millions of African citizens their fundamental freedoms and basic human rights as intended by the protocols. Although there has been some progress in the rate of ratification with a total of 118 new ratifications have been entered against the 43 instruments, more needs to be done to ensure the ratifications go hand in hand with domestication and implementation. In east, central and southern Africa, Zambia, Congo and Rwanda have performed best, having ratified five instruments each. By August 2012, only two countries, Kenya and Mauritius, had ratified the African Charter on the Values and Principles of Public Service & Administration (2011) and only 14 countries had ratified the Charter for Democracy, Elections and Governance. At this current rate, universal ratification of AU treaties would not be complete before 2053, says SOTU.