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Wintrup J. Health by the people, again? The lost lessons of Alma-Ata in a community health worker programme in Zambia. Soc Sci Med 2023; 319:115257. [PMID: 36115730 DOI: 10.1016/j.socscimed.2022.115257] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 05/24/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
National community health worker (CHW) programmes were central to the vision of primary health care that emerged from the Alma-Ata declaration of 1978. CHWs were identified as agents who could offer basic medical treatment and promote community participation and empowerment. Despite the ambitions of this era, many national CHW programmes were neglected, starved of funding, or discontinued in the decades that followed. These programmes were difficult to sustain in a context of rising debt and structural adjustment, but they also suffered due to poor implementation and a lack of clarity about the role and identity of CHWs. Nevertheless, national CHW programmes have returned to the policy agenda in the past fifteen years and key figures and organisations within global health have begun to argue that they offer a way of strengthening health systems and achieving universal health coverage (UHC). Based on ethnographic research conducted between 2019 and 2020, this article examines a new national CHW programme that has been introduced in Zambia. However, as I show in this article, Zambia's new CHW programme has suffered from many of the same key problems that affected the programmes of the Alma-Ata era: insufficient funding, poor implementation, and a lack of clarity about the role of CHWs. This article shows how these mistakes have been repeated and asks why the lessons of the Alma-Ata era have been lost. Three central problems are identified: national CHW programmes continue to be underfunded and regarded as a "cheap" solution; global health organisations and actors today prioritise technical and quantitative approaches when they design and implement these programmes and therefore overlook the historical experiences and qualitative research of the past thirty years; and, finally, policymakers continue to gloss over the tensions and contradictions within the idea of the "community health worker" itself, creating unclear and unrealistic expectations for CHWs.
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Affiliation(s)
- James Wintrup
- Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway.
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2
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Dalglish SL, Sanuade OA, Topp SM. Medical Dominance in Global Health Institutions as an Obstacle to Equity and Effectiveness Comment on "Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process". Int J Health Policy Manag 2023; 12:7734. [PMID: 37579487 PMCID: PMC10125140 DOI: 10.34172/ijhpm.2022.7734] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/04/2022] [Indexed: 08/16/2023] Open
Abstract
Medical professionals exercised structural and productive power in the Global Fund's Country Coordinating Mechanism (CCM) in Nigeria, directly impacting the selection of approaches to HIV/AIDS care, as described in a case study by Lassa and colleagues. This research contributes to a robust scholarship on how biomedical power inhibits a holistic understanding of health and prevents the adoption of solutions that are socially grounded, multi-disciplinary, and co-created with communities. We highlight Lassa and colleagues' findings demonstrating the 'long arm' of global health institutions in country-level health policy choices, and reflect on how medical dominance within global institutions serves as a tool of control in ways that pervert incentives and undermine equity and effectiveness. We call for increased research and advocacy to surface these conduits of power and begin to loosen their hold in the global health policy agenda.
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Affiliation(s)
- Sarah L. Dalglish
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Institute for Global Health, University College London, London, UK
| | - Olutobi A. Sanuade
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA
| | - Stephanie M. Topp
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
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3
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Nishi M. Care during ART scale-up: surviving the HIV epidemic in Ethiopia. BIOSOCIETIES 2022; 18:1-19. [PMID: 36211250 PMCID: PMC9527715 DOI: 10.1057/s41292-022-00283-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 11/21/2022]
Abstract
Over the last decades, there has been a worldwide rise of new technologies for controlling the HIV epidemic by expanding antiretroviral medicines. This article examines how the pharmaceutical-driven model of public health, which emerged as a byproduct of antiretroviral treatment (ART) scale-up in Ethiopia, interplayed with local forms of actions, engagements, and voices through which suffering inflicted by the epidemic was cared for. Through the eyes of an Ethiopian woman with HIV, this article illustrates how the increasing emphasis on ART facilitated the defunding of some community-based care practices. Moreover, it rendered the realities of precarious life with HIV invisible in the landscape of therapeutic citizenship. However, for Ethiopians, ART scale-up unfolded amid multiple forms of HIV care practices and relationships that endured stigma, alienation, and uncertainty before and after ART. The experience of surviving the HIV epidemic in Ethiopia provides a vital premise upon which claims of meaningful care are made, and ways to otherwise develop healthcare actions and engagements are sought.
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Affiliation(s)
- Makoto Nishi
- Hiroshima University, 1-7-1, Kagamiyama, Higashi-Hiroshima City, Hiroshima, 7398521 Japan
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4
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Ruit C, Breckenridge A. South African community health workers' pursuit of occupational security. GENDER WORK AND ORGANIZATION 2022. [DOI: 10.1111/gwao.12854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Catherine Ruit
- Health and Society, Health and Exercise Physiology 033F Hellferich Hall Ursinus College Collegeville Pennsylvania USA
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5
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D'Eer L, Quintiens B, Van den Block L, Dury S, Deliens L, Chambaere K, Smets T, Cohen J. Civic engagement in serious illness, death, and loss: A systematic mixed-methods review. Palliat Med 2022; 36:625-651. [PMID: 35287517 DOI: 10.1177/02692163221077850] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND New public health approaches to palliative care such as compassionate communities aim to increase capacity in serious illness, death, and loss by involving civic society. Civic engagement has been described in many domains of health; a description of the characteristics, processes, and impact of the initiatives in palliative care is lacking. AIM To systematically describe and compare civic engagement initiatives in palliative care in terms of context, development, impact, and evaluation methods. DESIGN Systematic, mixed-methods review using a convergent integrated synthesis approach. Registered in Prospero: CRD42020180688. DATA SOURCES Six databases (PubMed, Scopus, Sociological Abstracts, WOS, Embase, PsycINFO) were searched up to November 2021 for publications in English describing civic engagement in serious illness, death, and loss. Additional grey literature was obtained by contacting the first authors. We performed a quality appraisal of the included studies. RESULTS We included 23 peer-reviewed and 11 grey literature publications, reporting on nineteen unique civic engagement initiatives, mostly in countries with English as one of the official languages. Initiatives involved the community in their development, often through a community-academic partnership. Activities aimed to connect people with palliative care needs to individuals or resources in the community. There was a variety of evaluation aims, methods, outcomes, and strength of evidence. Information on whether or how to sustain the initiatives was generally lacking. CONCLUSIONS This is the first review to systematically describe and compare reported civic engagement initiatives in the domain of palliative care. Future studies would benefit from improved evaluation of impact and sustainability.
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Affiliation(s)
- Louise D'Eer
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, Brussels, Belgium.,Compassionate Community Centre of Expertise (COCO), Vrije Universiteit Brussel (VUB), Pleinlaan, Brussels, Belgium
| | - Bert Quintiens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, Brussels, Belgium.,Compassionate Community Centre of Expertise (COCO), Vrije Universiteit Brussel (VUB), Pleinlaan, Brussels, Belgium
| | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, Brussels, Belgium.,Compassionate Community Centre of Expertise (COCO), Vrije Universiteit Brussel (VUB), Pleinlaan, Brussels, Belgium
| | - Sarah Dury
- Belgian Ageing Studies Research Group, Vrije Universiteit Brussel (VUB), Pleinlaan, Brussels, Belgium.,Compassionate Community Centre of Expertise (COCO), Vrije Universiteit Brussel (VUB), Pleinlaan, Brussels, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, Brussels, Belgium.,Compassionate Community Centre of Expertise (COCO), Vrije Universiteit Brussel (VUB), Pleinlaan, Brussels, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, Brussels, Belgium.,Compassionate Community Centre of Expertise (COCO), Vrije Universiteit Brussel (VUB), Pleinlaan, Brussels, Belgium
| | - Tinne Smets
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, Brussels, Belgium.,Compassionate Community Centre of Expertise (COCO), Vrije Universiteit Brussel (VUB), Pleinlaan, Brussels, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, Brussels, Belgium.,Compassionate Community Centre of Expertise (COCO), Vrije Universiteit Brussel (VUB), Pleinlaan, Brussels, Belgium
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6
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Closser S, Mendenhall E, Brown P, Neill R, Justice J. The anthropology of health systems: A history and review. Soc Sci Med 2021; 300:114314. [PMID: 34400012 DOI: 10.1016/j.socscimed.2021.114314] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 12/17/2022]
Abstract
Ethnographies of health systems are a theoretically rich and rapidly growing area within medical anthropology. Critical ethnographic work dating back to the 1950s has taken policymakers and health staff as points of entry into the power structures that run through the global health enterprise. In the last decade, there has been a surge of ethnographic work on health systems. We conceptualize the anthropology of health systems as a field; review the history of this body of knowledge; and outline emergent literatures on policymaking, HIV, hospitals, Community Health Workers, health markets, pharmaceuticals, and metrics. High-quality ethnographic work is an excellent way to understand the complex systems that shape health outcomes, and provides a critical vantage point for thinking about global health policy and systems. As theory in this space develops and deepens, we argue that anthropologists should look beyond the discipline to think through what their work does and why it matters.
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Affiliation(s)
- Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Rm E5545, Baltimore, MD, 21205, USA.
| | - Emily Mendenhall
- Science, Technology and International Affairs Program, Edmund A. Walsh School of Foreign Service, Georgetown University, USA
| | - Peter Brown
- Department of Anthropology, Emory University, USA
| | - Rachel Neill
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Judith Justice
- Institute for Health and Aging, School of Nursing, University of California, San Francisco, USA
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7
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Munro J. ‘Saving our people’: health workers, medical citizenship, and vernacular sovereignties in West Papua. JOURNAL OF THE ROYAL ANTHROPOLOGICAL INSTITUTE 2020. [DOI: 10.1111/1467-9655.13318] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jenny Munro
- School of Social ScienceUniversity of Queensland Brisbane, Qld 4072 Australia
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8
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Abstract
In the era of scale up, global donor-driven HIV activities are transforming NGO work by demanding administrative, technical, and data-oriented activities. Drawing on interviews and participant observation in an NGO in the West Papuan city of Manokwari between 2011 and 2014, I attempt to understand why Indigenous Papuan NGO employees were steadily replaced by non-Indigenous migrant settlers, mainly of Javanese heritage, to deliver HIV services. I show that new rivalries, technical roles, performance targets and efficiency rhetoric intersected with existing racialization to produce a preference for Javanese employees, who were assumed to be more compliant and professional than their Papuan counterparts and to operate more easily within the technocratic regime imposed by donor expectations. I use the term technocratic racism to describe the way that global HIV rationalities intersect with ethnic stereotypes and gendered racial ideas to make possible certain HIV workers and not others. I contribute to anthropological literature on the delivery of HIV services by showing how a technocratic approach to HIV/AIDS intervention intersects with a settler-colonial context to gradually exclude Indigenous employees. Approaches that allow for relational, independent and flexible services would assist to decolonize HIV responses in West Papua.
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Affiliation(s)
- Jenny Munro
- Anthropology, School of Social Science, University of Queensland , Brisbane, Australia
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9
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Abstract
Physician anthropologists have contributed extensively to the anthropology of biomedicine, as well as to other aspects of medical anthropology. Their use of detailed clinical case narratives allows elucidation of what is at stake for individuals and communities in the course of any given illness. Biomedically informed observations of bodies illustrate the connections between microscopic harm and macrosocial arrangements, while observations of clinical spaces and medical knowledge production contribute to current debates over evidence, metrics, migration, and humanitarianism. In moving away from culturalist explanations for illness, physician anthropologists have drawn attention to the manifold workings of structural violence—and have often sacrificed the possibility of deep epistemological challenges to biomedicine. While raising a note of caution about the moral authority of physician anthropologists, I recognize that much of this scholarship has laid the intellectual groundwork for a movement toward equity that refuses to justify poor-quality health care for poor people.
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Affiliation(s)
- Claire L. Wendland
- Department of Anthropology and Department of Obstetrics and Gynecology, University of Wisconsin–Madison, Madison, Wisconsin 53706, USA
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10
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van de Ruit C. Unintended Consequences of Community Health Worker Programs in South Africa. QUALITATIVE HEALTH RESEARCH 2019; 29:1535-1548. [PMID: 31274060 DOI: 10.1177/1049732319857059] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Task shifting from trained clinicians to community health workers (CHWs) is a central, primary health care strategy advocated by global health policy planners in resource-poor settings where trained health professionals are scarce. The evidence base for the efficacy of these programs, however, is limited-in particular, research that identifies their potential unintended consequences. Based on sustained ethnographic study of CHWs working for AIDS projects in South Africa at the height of the country's AIDS epidemic, this article identifies how structural and local factors produced unintended consequences for CHW programs. These consequences were (a) CHWs moonlighting for multiple organizations, (b) CHWs freelancing in communities without regulation, and (c) adverse patient outcomes resulting from uncoordinated care. These consequences stemmed from structural elements of a bureaucratically weak health system and from local grassroots dynamics that jeopardized long-term CHW program sustainability and eroded national health goals.
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11
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Logan RI. 'A poverty in understanding': Assessing the structural challenges experienced by community health workers and their clients. Glob Public Health 2019; 15:137-150. [PMID: 31422746 DOI: 10.1080/17441692.2019.1656275] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Community health workers (CHWs) are crucial intermediaries between marginalised populations and health and social services. Among their unique repertoire of services includes their commitment to advocacy, a crucial skill that aids clients in addressing the social determinants of health that deleteriously affect their wellbeing. However, a plethora of structural barriers encountered by their clients complicates the caregiving of these workers. Drawing on data from a year-long ethnographic research project situated in Indiana, I analyse the diverse structural challenges experienced by these workers and their clients and assess the parallels encountered by CHWs at the global scale. Among the key barriers encountered by CHWs included difficulty in accessing resources for clients, lack of effective public transportation, barriers within the professional workforce, and the overarching negative impact of structural violence on client motivation. In spite of these issues, CHWs can positively address these barriers through a wider adoption of a structural competency approach, which further elucidates and addresses the harmful effects of structural violence.
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Affiliation(s)
- Ryan I Logan
- Department of Anthropology, Geography, & Ethnic Studies, California State University Stanislaus, Turlock, CA, USA
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12
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Cataldo F, Seeley J, Nkhata MJ, Mupambireyi Z, Tumwesige E, Gibb DM. She knows that she will not come back: tracing patients and new thresholds of collective surveillance in PMTCT Option B. BMC Health Serv Res 2018; 18:76. [PMID: 29391055 PMCID: PMC5796350 DOI: 10.1186/s12913-017-2826-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 12/29/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malawi, Uganda, and Zimbabwe have recently adopted a universal 'test-and-treat' approach to the prevention of mother-to-child transmission of HIV (Option B+). Amongst a largely asymptomatic population of women tested for HIV and immediately started on antiretroviral treatment (ART), a relatively high number are not retained in care; they are labelled 'defaulters' or 'lost-to-follow-up' patients. METHODS We draw on data collected as part of a study looking at ART decentralization (Lablite) to reflect on the spaces created through the instrumentalization of community health workers (CHWs) for the purpose of bringing women who default from Option B+ back into care. Data were collected through semi-structured interviews with CHWs who are designated to trace Option B+ patients in Uganda, Malawi and Zimbabwe. FINDINGS Lost to follow up women give a range of reasons for not coming back to health facilities and often implicitly choose not to be traced by providing a false address at enrolment. New strategies have sought to utilize CHWs' liminal positionality - situated between the experience of living with HIV, having established local social ties, and being a caretaker - in order to track 'defaulters'. CHWs are often deployed without adequate guidance or training to protect confidentiality and respect patients' choice. CONCLUSIONS CHWs provide essential linkages between health services and patients; they embody the role of 'extension workers', a bridge between a novel health policy and 'non-compliant patients'. Option B+ offers a powerful narrative of the construction of a unilateral 'moral economy', which requires the full compliance of patients newly initiated on treatment.
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Affiliation(s)
- Fabian Cataldo
- Dignitas International, Medical and Research Department, P.O.Box 1071, Zomba, Malawi
| | - Janet Seeley
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H9SH UK
- Medical Research Council /Uganda Virus Research Institute, Research Unit on AIDS, P.O.Box 49, Entebbe, Uganda
| | - Misheck J. Nkhata
- Dignitas International, Medical and Research Department, P.O.Box 1071, Zomba, Malawi
| | - Zivai Mupambireyi
- University of Zimbabwe, P.O.Box MP167, Mount Pleasant, Harare, Zimbabwe
| | - Edward Tumwesige
- Medical Research Council /Uganda Virus Research Institute, Research Unit on AIDS, P.O.Box 49, Entebbe, Uganda
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn WC1V 6LJ, London, UK
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13
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Thomann M. 'On December 1, 2015, sex changes. Forever': Pre-exposure prophylaxis and the pharmaceuticalisation of the neoliberal sexual subject. Glob Public Health 2018; 13:997-1006. [PMID: 29368990 DOI: 10.1080/17441692.2018.1427275] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The global scale-up of AIDS treatment initiatives during the first decade of the twenty-first century has been referred to as a kind of 'pharmaceuticalisation' of public health, a trend that is now building in the area of HIV prevention. This paper traces the emergence and increased uptake of pre-exposure prophylaxis (PrEP), antiretroviral medications that can keep HIV negative individuals from becoming infected, placing it within the broader (re)casting of HIV prevention as a medical and technological problem that has been central to the recent 'end of AIDS' discourse. While HIV prevention discourses have been grounded in a neoliberal calculus of individual responsibility since the late 1990s, PrEP constitutes a pharmaceutical extension of the responsibilised sexual subject. Central to this extension are the acknowledgment of one's risk and a willingness to take pre-emptive medical action to secure a future without HIV. For men who have sex with men, a population heavily targeted for biomedical interventions in the United States, PrEP marks a shift in moral discourses of what it means to be a responsible sexual subject. Characteristics of the pharmaceutical extension of the neoliberal sexual subject are explored through an examination of a New York City-based PrEP promotional campaign.
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Affiliation(s)
- Matthew Thomann
- a Department of Anthropology and Sociology , Kalamazoo College , Kalamazoo , MI , USA
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14
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Kenworthy N, Thomann M, Parker R. From a global crisis to the 'end of AIDS': New epidemics of signification. Glob Public Health 2017; 13:960-971. [PMID: 28828943 DOI: 10.1080/17441692.2017.1365373] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In the past decade, discourses about AIDS have taken a remarkable, and largely unquestioned, turn. Whereas mobilisations for treatment scale-up during the 2000s were premised on perceptions of an 'epidemic out of control', we have repeatedly been informed in more recent years that an end to AIDS is immanent. This new discourse and its resulting policies are motivated by post-recession financial pressures, a changing field of global institutions, and shifting health and development priorities. These shifts also reflect a biomedical triumphalism in HIV prevention and treatment, whereby shorter term, privatised, technological, and 'cost-effective' interventions are promoted over long-term support for antiretroviral treatment. To explore these changes, we utilise Treichler's [(1987). How to have theory in an epidemic: Cultural chronicles of AIDS. Durham, NC: Duke University Press] view of AIDS as an 'epidemic of signification' to develop a review of 'End of AIDS' discourses in recent years. We use this review to investigate the political and philanthropic interests served by efforts to rebrand and re-signify the epidemic. We also hold up these discourses against the realities of treatment access in resource-poor countries, where 'Ending AIDS' has not heralded the end of an epidemic per se, but rather the end of external support for treatment programmes, highlighting new difficulties for sustaining treatment in this new era of the epidemic.
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Affiliation(s)
- Nora Kenworthy
- a School of Nursing and Health Studies , University of Washington Bothell , Bothell , WA , USA
| | - Matthew Thomann
- b Anthropology and Sociology , Kalamazoo College , Kalamazoo , MI , USA
| | - Richard Parker
- c ABIA (Brazilian Interdisicplinary AIDS Association) , Rio de Janeiro , Brazil.,d Sociomedical Sciences and Anthropology , Columbia University , New York City , NY , USA
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15
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Closser S, Rosenthal A, Justice J, Maes K, Sultan M, Banerji S, Amaha HB, Gopinath R, Omidian P, Nyirazinyoye L. Per Diems in Polio Eradication: Perspectives From Community Health Workers and Officials. Am J Public Health 2017; 107:1470-1476. [PMID: 28727538 DOI: 10.2105/ajph.2017.303886] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Nearly all global health initiatives give per diems to community health workers (CHWs) in poor countries for short-term work on disease-specific programs. We interviewed CHWs, supervisors, and high-level officials (n = 95) in 6 study sites across sub-Saharan Africa and South Asia in early 2012 about the per diems given to them by the Global Polio Eradication Initiative. These per diems for CHWs ranged from $1.50 to $2.40 per day. International officials defended per diems for CHWs with an array of arguments, primarily that they were necessary to defray the expenses that workers incurred during campaigns. But high-level ministry of health officials in many countries were concerned that even small per diems were unsustainable. By contrast, CHWs saw per diems as a wage; the very small size of this wage led many to describe per diems as unjust. Per diem polio work existed in the larger context of limited and mostly exploitative options for female labor. Taking the perspectives of CHWs seriously would shift the international conversation about per diems toward questions of labor rights and justice in global health pay structures.
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Affiliation(s)
- Svea Closser
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Anat Rosenthal
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Judith Justice
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Kenneth Maes
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Marium Sultan
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Sarah Banerji
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Hailom Banteyerga Amaha
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Ranjani Gopinath
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Patricia Omidian
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Laetitia Nyirazinyoye
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
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Benton A, Sangaramoorthy T, Kalofonos I. Temporality and Positive Living in the Age of HIV/AIDS--A Multi-Sited Ethnography. CURRENT ANTHROPOLOGY 2017; 58:454-476. [PMID: 29075043 DOI: 10.1086/692825] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Drawing on comparative ethnographic fieldwork conducted in urban Mozambique, United States, and Sierra Leone, the article is broadly concerned with the globalization of temporal logics and how specific ideologies of time and temporality accompany health interventions like those for HIV/AIDS. More specifically, we explore how HIV-positive individuals have been increasingly encouraged to pursue healthier and more fulfilling lives through a set of moral, physical, and social practices called "positive living" since the advent of antiretroviral therapies. We describe how positive living, a feature of HIV/AIDS programs throughout the world, has taken root across varied political, social and economic contexts and how temporal rationalities, which have largely been under-examined in the HIV/AIDS literature, shape communities' responses and interpretations of positive living. Our approach is ethnographic and comparative, with implications for how anthropologists might think about collaboration and its analytical possibilities.
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Affiliation(s)
- Adia Benton
- Department of Anthropology and Program of African Studies at Northwestern University (1810 Hinman Avenue, Evanston, llinois 60208, USA)
| | - Thurka Sangaramoorthy
- Department of Anthropology at the University of Maryland (1111 Woods Hall, 4302 Chapel Lane, College Park, Maryland 20742, USA)
| | - Ippolytos Kalofonos
- Department of Psychiatry and Behavioral Sciences and the International Institute at the University of California, Los Angeles (760 Westwood Plaza, Box #62, Los Angeles, California 90095, USA) and West Los Angeles Veterans Affairs Healthcare System (11301 Wilshire Boulevard, Los Angeles, California 90073, USA)
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17
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Winchester MS, McGrath JW, Kaawa-Mafigiri D, Namutiibwa F, Ssendegye G, Nalwoga A, Kyarikunda E, Birungi J, Kisakye S, Ayebazibwe N, Walakira EJ, Rwabukwali C. Routines, Hope, and Antiretroviral Treatment among Men and Women in Uganda. Med Anthropol Q 2016; 31:237-256. [PMID: 27159357 DOI: 10.1111/maq.12301] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 11/25/2022]
Abstract
Antiretroviral treatment programs, despite biomedical emphases, require social understanding and transformations to be successful. In this article, we draw from a qualitative study of HIV treatment seeking to examine the drug-taking routines and health-related subjectivities of men and women on antiretroviral treatment (ART) at two sites in Uganda. We show that while not all participants in ART programs understand clinical protocols in biomedical terms, they adopt treatment-taking strategies to integrate medication into daily practices and social spaces. In turn, these embedded practices and understandings shape long-term hopes and fears for living with HIV, including the possibility of a cure. More significant than new forms of citizenship or sociality, we suggest that quotidian dimensions of treatment normalization shape the long-term experience of medication and outlook for the future.
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Affiliation(s)
- Margaret S Winchester
- Department of Health Policy and Administration, Pennsylvania State University.,Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda and Case Western Reserve University
| | - Janet W McGrath
- Department of Anthropology, Case Western Reserve University.,Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda
| | - David Kaawa-Mafigiri
- Department of Anthropology, Case Western Reserve University.,Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda
| | - Florence Namutiibwa
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - George Ssendegye
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Amina Nalwoga
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Emily Kyarikunda
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Judith Birungi
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Sheila Kisakye
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Nicholas Ayebazibwe
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Eddy J Walakira
- Department of Social Work and Social Administration, Makerere University, Kampala.,Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda
| | - Charles Rwabukwali
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Department of Sociology and Anthropology, Makerere University, Kampala, Uganda
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Assessment of linkages from HIV testing to enrolment and retention in HIV care in Central Mozambique. J Int AIDS Soc 2016; 19:20846. [PMID: 27443273 PMCID: PMC4956731 DOI: 10.7448/ias.19.5.20846] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 04/22/2016] [Accepted: 05/02/2016] [Indexed: 12/30/2022] Open
Abstract
Introduction Effectiveness of the rapid expansion of antiretroviral therapy (ART) throughout sub-Saharan Africa is highly dependent on adequate enrolment and retention in HIV care. However, the measurement of both has been challenging in these settings. This study aimed to assess enrolment and retention in HIV care (pre-ART and ART) among HIV-positive adults in Central Mozambique, including identification of barriers and facilitators. Methods We assessed linkages to and retention in HIV care using a mixed quantitative and qualitative approach in six districts of Manica and Sofala provinces. We analyzed routine district and health facility monthly reports and HIV care registries from April 2012 to March 2013 and used single imputation and trimmed means to adjust for missing values. In eight health facilities in the same districts and period, we assessed retention in HIV care among 795 randomly selected adult patient charts (15 years and older). We also conducted 25 focus group discussions and 53 in-depth interviews with HIV-positive adults, healthcare providers and community members to identify facilitators and barriers to enrolment and retention in HIV care. Results Overall, 46% of the monthly HIV testing reports expected at the district level were missing, compared to 6.4% of the pre-ART registry reports. After adjustment for missing values, we estimated that the aggregate numbers of adults registered in pre-ART was 75% of the number of persons tested HIV-positive in the six districts. In the eight health facilities, 40% of the patient charts for adults enrolled in pre-ART and 44% in ART were missing. Of those on ART for whom charts were found, retention in treatment within 90 and 60 days prior to the study team visit was 34 and 25%, respectively. Combining these multiple data sources, the overall estimated retention was 18% in our sample. Individual-level factors were perceived to be key influences to enrolment in HIV care, while health facility and structural-level factors were perceived to be key influences of retention. Conclusions Efforts to increase linkages to and retention in HIV care should address individual, health facility, and structural-level factors in Central Mozambique. However, their outcomes cannot be reliably assessed without improving the quality of routine health information systems.
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Lessons learned and study results from HIVCore, an HIV implementation science initiative. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.5.21261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Manderson L, Block E, Mkhwanazi N. Fragility, fluidity, and resilience: caregiving configurations three decades into AIDS. AIDS Care 2016; 28 Suppl 4:1-7. [PMID: 27410678 DOI: 10.1080/09540121.2016.1195487] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
HIV and AIDS have impacted on social relations in many ways, eroding personal networks, contributing to household poverty, and rupturing intimate relations. With the continuing transmission of HIV particularly in resource-poor settings, families and others must find new ways to care for those who are living with HIV, for those who are ill and need increased levels of personal and medical care, and for orphaned children. These needs occur concurrently with changes in family structure, as a direct result of HIV-related deaths but also due to industrialization, urbanization, and labor migration. In this special issue, the contributing authors draw on ethnographies from South Africa, Swaziland, Lesotho, Zambia, and - by way of contrast - China, to illustrate how people find new ways of constituting families, or of providing alternatives to families, in order to provide care and support to people infected with and afflicted by HIV.
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Affiliation(s)
- Lenore Manderson
- a School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa.,b Institute at Brown for Environment and Society, Brown University , Providence , RI , USA
| | - Ellen Block
- c Sociology Department , College of Saint Benedict & Saint John's University , Collegeville , MN , USA
| | - Nolwazi Mkhwanazi
- d Department of Anthropology , University of the Witwatersrand , Johannesburg , South Africa
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Nxumalo N, Goudge J, Manderson L. Community health workers, recipients' experiences and constraints to care in South Africa - a pathway to trust. AIDS Care 2016; 28 Suppl 4:61-71. [PMID: 27345712 DOI: 10.1080/09540121.2016.1195484] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Community health workers (CHWs) affiliated with community-based organisations are central to the implementation of primary health care in district health services in South Africa. Here, we explore factors that affect the provision of and access to care in two provinces - Gauteng and Eastern Cape. Drawing on narratives of care recipients and the CHWs who support them, we illustrate the complex issues surrounding health maintenance and primary care outreach in poor communities, and describe how the intimate interactions between providers and recipients work to build trust. In the study we report here, householders in Gauteng Province had poor access to health care and other services, complicating the impoverished circumstances of their everyday lives. The limited resources available to CHWs hindered their ability to meet householders' needs and for householders to benefit from existing services. CHWs in the Eastern Cape were better able to address the needs of poor householders because of the organisational support available to them. Based on an ethos of integrated and holistic care, this enabled the CHWs to address the recipients' context-related needs, and health and medical needs, while building greater levels of trust with their clients.
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Affiliation(s)
- Nonhlanhla Nxumalo
- a Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg
| | - Jane Goudge
- a Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg
| | - Lenore Manderson
- b School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg
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Give CS, Sidat M, Ormel H, Ndima S, McCollum R, Taegtmeyer M. Exploring competing experiences and expectations of the revitalized community health worker programme in Mozambique: an equity analysis. HUMAN RESOURCES FOR HEALTH 2015; 13:54. [PMID: 26323393 PMCID: PMC4556211 DOI: 10.1186/s12960-015-0044-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 06/11/2015] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Mozambique launched its revitalized community health programme in 2010 in response to inequitable coverage and quality of health services. The programme is focused on health promotion and disease prevention, with 20 % of community health workers' (known in Mozambique as Agentes Polivalentes Elementares (APEs)) time spent on curative services and 80 % on activities promoting health and preventing illness. We set out to conduct a health system and equity analysis, exploring experiences and expectations of APEs, community members and healthcare workers supervising APEs. METHODS This exploratory qualitative study captured the perspectives of a range of participants including women caring for children under 5 years (service clients), community leaders, service providers (APEs) and their supervisors. Participants in the Moamba and Manhiça districts, located in Maputo Province (Mozambique), were selected purposively. In total, 29 in-depth interviews and 9 focus group discussions were conducted in the local language and/or Portuguese. A framework approach was used for analysis, assisted by NVivo10 software. RESULTS Our analysis revealed that health equity is viewed as linked to the quality and coverage of the APE programme. Demand and supply factors interplay to shape health equity. The availability of responsive and appropriate services led to tensions between community expectations for curative services (and APEs' willingness to perform them) and official policy focusing APE efforts mainly on preventive services and health promotion. The demand for more curative services by community members is a result of having limited access to healthcare services other than those offered by APEs. CONCLUSION This study highlights the need to pay attention to the determinants of demand and supply of community interventions in health, to understand the opportunities and challenges of the difficult interface role played by APEs and to create communication among stakeholders in order to build a stronger, more effective and equitable community programme.
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Affiliation(s)
- Celso Soares Give
- Department of Community Health, Faculty of Medicine, University Eduardo Mondlane, Av. Salvador Allende no.702, Maputo, Mozambique.
| | - Mohsin Sidat
- Department of Community Health, Faculty of Medicine, University Eduardo Mondlane, Av. Salvador Allende no.702, Maputo, Mozambique.
| | - Hermen Ormel
- Department of Health, Royal Tropical Institute, Amsterdam, Netherlands.
| | - Sozinho Ndima
- Department of Community Health, Faculty of Medicine, University Eduardo Mondlane, Av. Salvador Allende no.702, Maputo, Mozambique.
| | - Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
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Ndima SD, Sidat M, Give C, Ormel H, Kok MC, Taegtmeyer M. Supervision of community health workers in Mozambique: a qualitative study of factors influencing motivation and programme implementation. HUMAN RESOURCES FOR HEALTH 2015; 13:63. [PMID: 26323970 PMCID: PMC4556309 DOI: 10.1186/s12960-015-0063-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 07/20/2015] [Indexed: 05/29/2023]
Abstract
BACKGROUND Community health workers (CHWs) in Mozambique (known as Agentes Polivalentes Elementares (APEs)) are key actors in providing health services in rural communities. Supervision of CHWs has been shown to improve their work, although details of how it is implemented are scarce. In Mozambique, APE supervision structures and scope of work are clearly outlined in policy and rely on supervisors at the health facility of reference. The aim of this study was to understand how and which aspects of supervision impact on APE motivation and programme implementation. METHODS Qualitative research methodologies were used. Twenty-nine in-depth interviews were conducted to capture experiences and perceptions of purposefully selected participants. These included APEs, health facility supervisors, district APE supervisors and community leaders. Interviews were recorded, translated and transcribed, prior to the development of a thematic framework. RESULTS Supervision was structured as dictated by policy but in practice was irregular and infrequent, which participants identified as affecting APE's motivation. When it did occur, supervision was felt to focus more on fault-finding than being supportive in nature and did not address all areas of APE's work - factors that APEs identified as demotivating. Supervisors, in turn, felt unsupported and felt this negatively impacted performance. They had a high workload in health facilities, where they had multiple roles, including provision of health services, taking care of administrative issues and supervising APEs in communities. A lack of resources for supervision activities was identified, and supervisors felt caught up in administrative issues around APE allowances that they were unable to solve. Many supervisors were not trained in providing supportive supervision. Community governance and accountability mechanisms were only partially able to fill the gaps left by the supervision provided by the health system. CONCLUSION The findings indicate the need for an improved supervision system to enhance support and motivation and ultimately performance of APEs. Our study found disconnections between the APE programme policy and its implementation, with gaps in skills, training and support of supervisors leading to sub-optimal supervision. Improved methods of supervision could be implemented including those that maximize the opportunities during face-to-face meetings and through community-monitoring mechanisms.
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Affiliation(s)
- Sozinho Daniel Ndima
- Department of Community Health, University Eduardo Mondlane, Maputo, Mozambique.
- Faculty of Medicine, University Eduardo Mondlane, Salvador Allende Avenue, 702, Maputo, Mozambique.
| | - Mohsin Sidat
- Department of Community Health, University Eduardo Mondlane, Maputo, Mozambique.
| | - Celso Give
- Department of Community Health, University Eduardo Mondlane, Maputo, Mozambique.
| | - Hermen Ormel
- Royal Tropical Institute, Amsterdam, Netherlands.
| | | | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
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MAES KENNETH, CLOSSER SVEA, VOREL ETHAN, TESFAYE YIHENEW. Using community health workers:. ANNALS OF ANTHROPOLOGICAL PRACTICE 2015. [DOI: 10.1111/napa.12064] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Affiliation(s)
- JONATHAN N. MAUPIN
- Associate Professor of Anthropology; School of Human Evolution and Social Change; Arizona State University
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Abstract
An estimated 58 million persons aged 60-plus live in sub-Saharan Africa; by 2050 that number will rise sharply to 215 million. Older Africans traditionally get care in their old age from the middle generation. But in East and Southern Africa, HIV has hollowed out that generation, leaving many older persons to provide care for their children's children without someone to care for him or herself in old age. Simultaneously, the burden of disease among older persons is changing in this region. The result is a growing care deficit. This article examines the existing literature on care for and by older persons in this region, highlighting understudied aspects of older persons' experiences of ageing and care--including the positive impacts of carework, variation in the region and the role of resilience and pensions. We advance a conceptual framework of gendered identities--for both men and women--and intergenerational social exchange to help focus and understand the complex interdependent relationships around carework, which are paramount in addressing the needs of older persons in the current care deficit in this region, and the Global South more generally.
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Affiliation(s)
- Enid Schatz
- a Department of Health Sciences , University of Missouri , Columbia , MO , USA.,b Institute of Behavioral Science , University of Colorado , Boulder , CO , USA.,c MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Janet Seeley
- d Social Science Programme , MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda.,e Department of Global Health and Development , London School of Hygiene and Tropical Medicine , London , UK
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Cataldo F, Kielmann K, Kielmann T, Mburu G, Musheke M. 'Deep down in their heart, they wish they could be given some incentives': a qualitative study on the changing roles and relations of care among home-based caregivers in Zambia. BMC Health Serv Res 2015; 15:36. [PMID: 25627203 PMCID: PMC4324023 DOI: 10.1186/s12913-015-0685-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 01/07/2015] [Indexed: 11/10/2022] Open
Abstract
Background Across Sub-Saharan Africa, the roll-out of antiretroviral treatment (ART) has contributed to shifting HIV care towards the management of a chronic health condition. While the balance of professional and lay tasks in HIV caregiving has been significantly altered due to changing skills requirements and task-shifting initiatives, little attention has been given to the effects of these changes on health workers’ motivation and existing care relations. Methods This paper draws on a cross-sectional, qualitative study that explored changes in home-based care (HBC) in the light of widespread ART rollout in the Lusaka and Kabwe districts of Zambia. Methods included observation of HBC daily activities, key informant interviews with programme staff from three local HBC organisations (n = 17) and ART clinic staff (n = 8), as well as in-depth interviews with home-based caregivers (n = 48) and HBC clients (n = 31). Results Since the roll-out of ART, home-based caregivers spend less time on hands-on physical care and support in the household, and are increasingly involved in specialised tasks supporting their clients’ access and adherence to ART. Despite their pride in gaining technical care skills, caregivers lament their lack of formal recognition through training, remuneration or mobility within the health system. Care relations within homes have also been altered as caregivers’ newly acquired functions of monitoring their clients while on ART are met with some ambivalence. Caregivers are under pressure to meet clients and their families’ demands, although they are no longer able to provide material support formerly associated with donor funding for HBC. Conclusions As their responsibilities and working environments are rapidly evolving, caregivers’ motivations are changing. It is essential to identify and address the growing tensions between an idealized rhetoric of altruistic volunteerism in home-based care, and the realities of lay worker deployment in HIV care interventions that not only shift tasks, but transform social and professional relations in ways that may profoundly influence caregivers’ motivation and quality of care.
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Affiliation(s)
- Fabian Cataldo
- Dignitas International, Research Department, Zomba, Malawi.
| | - Karina Kielmann
- Institute for International Health and Development, Queen Margaret University, Edinburgh, Scotland.
| | | | - Gitau Mburu
- International HIV/AIDS Alliance, Brighton, UK. .,Division of Health Research, Lancaster University, Lancaster, UK.
| | - Maurice Musheke
- Zambia AIDS Related Tuberculosis Project, University of Zambia, Lusaka, Zambia.
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Maes K. "Volunteers are not paid because they are priceless": community health worker capacities and values in an AIDS treatment intervention in urban Ethiopia. Med Anthropol Q 2014; 29:97-115. [PMID: 25257547 DOI: 10.1111/maq.12136] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article analyzes community health workers' (CHW) capacities for empathic service within an AIDS treatment program in Addis Ababa. I show how CHWs' capacities to build relationships with stigmatized people, reconcile family disputes, and confront death draw on a constellation of values, desires, and emotions encouraged by CHWs' families and religious teachings. I then examine the ways in which the capacities of CHWs were valued by the institutions that deployed them. NGO and government officials recognized that empathic care was crucial to both saving and improving the quality of people's lives. These institutional actors also defended a policy of not financially remunerating CHWs, partly by constructing their capacities as so valuable that they become "priceless" and therefore only remunerable with immaterial satisfaction. Positive change within CHW programs requires ethnographic analysis of how CHWs exercise capacities for empathic care as well as consideration of how global health institutions value these capacities.
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Affiliation(s)
- Kenneth Maes
- Department of Anthropology, Oregon State University.
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