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Plamondon KM, Shahram SZ. Defining equity, its determinants, and the foundations of equity science. Soc Sci Med 2024; 351:116940. [PMID: 38761454 DOI: 10.1016/j.socscimed.2024.116940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/23/2024] [Accepted: 05/01/2024] [Indexed: 05/20/2024]
Abstract
Advancing equity as a priority is increasingly declared in response to decades of evidence showing the association between poorer health outcomes and the unfair distribution of resources, power, and wealth across all levels of society. Quandries present, however, through incongruence, vagueness and disparate interpretations of the meaning of equity dilute and fragment efforts across research, policy and practice. Progress on reducing health inequities is, in this context, unsurprisingly irresolute. In this article, we make a case for equity science that reimagines the ways in which we (as researchers, as systems leaders, as teachers and mentors, and as citizens in society) engage in this work. We offer a definition of equity, its determinants, and the paradigmatic foundations of equity science, including the assumptions, values, and processes., and methods of this science. We argue for an equity science that can more meaningfully promote coherent alignment between intention, knowledge and action within and beyond the health sciences to spark a more equitable future.
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Affiliation(s)
- Katrina M Plamondon
- Equity Science Lab, Faculty of Health & Social Development, School of Nursing, University of British Columbia, ART360, 1147 Research Road, Kelowna, BC, Canada.
| | - Sana Z Shahram
- Equity Science Lab, Faculty of Health & Social Development, School of Nursing, University of British Columbia, ART360, 1147 Research Road, Kelowna, BC, Canada.
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Singh S, Miller E, Closser S. Nurturing transformative local structures of multisectoral collaboration for primary health care: qualitative insights from select states in India. BMC Health Serv Res 2024; 24:634. [PMID: 38755604 PMCID: PMC11100027 DOI: 10.1186/s12913-024-11002-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Multisectoral collaboration is essential for advancing primary health care (PHC). In low- and middle-income countries (LMICs), limited institutional capacities, governance issues, and inadequate stakeholder engagement impede multisectoral collaboration. India faces similar challenges, especially at the meso-level (districts and subdistricts). Owing to its dependence on context, and insufficient evidence, understanding "How" to improve multisectoral collaboration remains challenging. This study aims to elicit specific recommendations to strengthen meso-level stewardship in India for multisectoral collaboration. The findings from this study may offer lessons for other LMICs. METHODS Using purposive, maximum variation sampling, the study team conducted semi-structured interviews with 20 diverse participants, including policymakers, implementers, development agency representatives, and academics experienced in multisectoral initiatives. The interviews delved into participants' experiences, the current situation, enablers, and recommendations for enhancing stakeholder engagement and capacities at the meso-level for multisectoral collaboration. RESULTS Context and power are critical elements to consider in fostering effective collaboration. Multisectoral collaboration was particularly successful in three distinct governance contexts: the social-democratic context as in Kerala, the social governance context in Chhattisgarh, and the public health governance context in Tamil Nadu. Adequate health system input and timely guidance instil confidence among local implementers to collaborate. While power plays a role through local leadership's influence in setting agendas, convening stakeholders, and ensuring accountability. To nurture transformative local leaders for collaboration, holistic, equity-driven, community-informed approaches are essential. The study participants proposed several concrete steps: at the state level, establish "central management units" for supervising local implementers and ensuring bottom-up feedback; at the district level, rationalise committees and assign deliverables to stakeholders; and at the block level, expand convergence structures and involve local self-governments. Development partners can support data-driven priority setting, but local implementers with contextual familiarity should develop decentralised plans collaboratively, articulating rationales, activities, and resources. Finally, innovative training programs are required at all levels, fostering humility, motivation, equity awareness, leadership, problem- solving, and data use proficiency. CONCLUSION This study offers multiple solutions to enhance local implementers' engagement in multisectoral efforts, advocating for the development, piloting, and evaluation of innovative approaches such as the block convergence model, locally-led collaboration efforts, and novel training methods for local implementers.
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Affiliation(s)
- Shalini Singh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health (JHSPH), Baltimore, USA.
- Johns Hopkins India Private Limited, New Delhi, India.
| | - Emily Miller
- Department of International Health, Johns Hopkins Bloomberg School of Public Health (JHSPH), Baltimore, USA
| | - Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health (JHSPH), Baltimore, USA
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Loffreda G, Arakelyan S, Bou-Orm I, Holmer H, Allen LN, Witter S, Ager A, Diaconu K. Barriers and Opportunities for WHO "Best Buys" Non-communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review. Int J Health Policy Manag 2024; 13:7989. [PMID: 38618832 PMCID: PMC11016278 DOI: 10.34172/ijhpm.2023.7989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 12/30/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Improving the adoption and implementation of policies to curb non-communicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policy-makers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation. METHODS We conducted a complex systematic review of articles discussing the adoption and implementation of World Health Organization's (WHO's) "best buys" NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria. RESULTS Our CLD highlights a central feedback loop encompassing three vital variables: (1) the ability to define, (re)shape, and pass appropriate policy into law; (2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); and (3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies. CONCLUSION To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions.
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Affiliation(s)
- Giulia Loffreda
- NIHR Research Unit of Health in Fragility, Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| | - Stella Arakelyan
- NIHR Research Unit of Health in Fragility, Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Musselburgh, UK
| | - Ibrahim Bou-Orm
- NIHR Research Unit of Health in Fragility, Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| | - Hampus Holmer
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Luke N. Allen
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Sophie Witter
- NIHR Research Unit of Health in Fragility, Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| | - Alastair Ager
- NIHR Research Unit of Health in Fragility, Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| | - Karin Diaconu
- NIHR Research Unit of Health in Fragility, Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
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Yashadhana A, Zwi AB, Brady B, De Leeuw E, Kingsley J, O'Leary M, Raven M, Serova N, Topp SM, Fields T, Foster W, Jopson W, Biles B. Gaawaadhi Gadudha: understanding how cultural camps impact health, well-being and resilience among Aboriginal adults in New South Wales, Australia-a collaborative study protocol. BMJ Open 2023; 13:e073551. [PMID: 38135326 DOI: 10.1136/bmjopen-2023-073551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION The health and well-being of Aboriginal Australians is inextricably linked to culture and Country. Our study challenges deficit approaches to health inequities by seeking to examine how cultural connection, practice and resilience among Aboriginal peoples through participation in 'cultural camps' held on sites of cultural significance promotes health and well-being. METHODS AND ANALYSIS The study will be undertaken in close collaboration and under the governance of traditional cultural knowledge holders from Yuwaalaraay, Gamilaraay and Yuin nation groups in New South Wales, Australia. Three cultural camps will be facilitated, where participants (n=105) will engage in activities that foster a connection to culture and cultural landscapes. A survey assessing connection to culture, access to cultural resources, resilience, self-rated health and quality of life will be administered to participants pre-camp and post-camp participation, and to a comparative group of Aboriginal adults who do not attend the camp (n=105). Twenty participants at each camp (n=60) will be invited to participate in a yarning circle to explore cultural health, well-being and resilience. Quantitative analysis will use independent samples' t-tests or χ2 analyses to compare camp and non-camp groups, and linear regression models to determine the impact of camp attendance. Qualitative analysis will apply inductive coding to data, which will be used to identify connections between coded concepts across the whole data set, and explore phenomenological aspects. Results will be used to collaboratively develop a 'Model of Cultural Health' that will be refined through a Delphi process with experts, stakeholders and policymakers. ETHICS AND DISSEMINATION The study has ethics approval from the Aboriginal Health and Medical Research Council (#1851/21). Findings will be disseminated through a combination of peer-reviewed articles, media communication, policy briefs, presentations and summary documents to stakeholders.
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Affiliation(s)
- Aryati Yashadhana
- Centre for Primary Health Care & Equity, University of New South Wales, Sydney, New South Wales, Australia
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Anthony B Zwi
- School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Brooke Brady
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
- Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Evelyne De Leeuw
- Centre for Primary Health Care & Equity, University of New South Wales, Sydney, New South Wales, Australia
- École de Santé Publique, l'Université de Montréal, Montréal, Quebec, Canada
| | - Jonathan Kingsley
- School of Health Sciences, Swinburne University of Technology, Hawthorn, Victoria, Australia
| | - Michelle O'Leary
- Centre for Primary Health Care & Equity, University of New South Wales, Sydney, New South Wales, Australia
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Miri Raven
- Social Policy Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Nina Serova
- Centre for Primary Health Care & Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephanie M Topp
- School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, New South Wales, Australia
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Ted Fields
- Centre for Primary Health Care & Equity, University of New South Wales, Sydney, New South Wales, Australia
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Warren Foster
- Centre for Primary Health Care & Equity, University of New South Wales, Sydney, New South Wales, Australia
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Wendy Jopson
- Social Policy Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Brett Biles
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
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Gilson L, Walt G. Doing Health Policy Analysis: The Enduring Relevance of Simple Models Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses". Int J Health Policy Manag 2023; 12:8223. [PMID: 38618766 PMCID: PMC10843444 DOI: 10.34172/ijhpm.2023.8223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/19/2023] [Indexed: 04/16/2024] Open
Abstract
The analysis of health policy processes in low- and middle-income countries (LMICs) emerged as a research area in the early 1990s. In their recent editorial Powell and Mannion argue that such research can be deepened by applying public policy theory. In response, we raise three questions to consider: are public policy models fit for purpose in today's world in LMICs (and what other theory can be used)? Is using theory the most important factor in deepening such research? Why do we, as researchers, do this work? Ultimately, we argue that the value of simple models, such as those already used in health policy analysis, lies in their enduring relevance and widespread use. They are supporting the development of the shared understandings that can, in turn, provide the basis for collective action addressing inequities in health and well-being.
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Affiliation(s)
- Lucy Gilson
- Health Policy and Systems Division, School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Gill Walt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Ravi SJ, Potter CM, Paina L, Merritt MW. Post-epidemic health system recovery: A comparative case study analysis of routine immunization programs in the Republics of Haiti and Liberia. PLoS One 2023; 18:e0292793. [PMID: 37847680 PMCID: PMC10581452 DOI: 10.1371/journal.pone.0292793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 09/28/2023] [Indexed: 10/19/2023] Open
Abstract
Large-scale epidemics in resource-constrained settings disrupt delivery of core health services, such as routine immunization. Rebuilding and strengthening routine immunization programs following epidemics is an essential step toward improving vaccine equity and averting future outbreaks. We performed a comparative case study analysis of routine immunization program recovery in Liberia and Haiti following the 2014-16 West Africa Ebola epidemic and 2010s cholera epidemic, respectively. First, we triangulated data between the peer-reviewed and grey literature; in-depth key informant interviews with subject matter experts; and quantitative metrics of population health and health system functioning. We used these data to construct thick descriptive narratives for each case. Finally, we performed a cross-case comparison by applying a thematic matrix based on the Essential Public Health Services framework to each case narrative. In Liberia, post-Ebola routine immunization coverage surpassed pre-epidemic levels, a feat attributable to investments in surveillance, comprehensive risk communication, robust political support for and leadership around immunization, and strong public-sector recovery planning. Recovery efforts in Haiti were fragmented across a broad range of non-governmental agencies. Limitations in funding, workforce development, and community engagement further impeded vaccine uptake. Consequently, Haiti reported significant disparities in subnational immunization coverage following the epidemic. This study suggests that embedding in-country expertise within outbreak response structures, respecting governmental autonomy, aligning post-epidemic recovery plans and policies, and integrating outbreak response assets into robust systems of primary care contribute to higher, more equitable levels of routine immunization coverage in resource-constrained settings recovering from epidemics.
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Affiliation(s)
- Sanjana J. Ravi
- The Johns Hopkins Center for Health Security, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Christina M. Potter
- The Johns Hopkins Center for Health Security, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ligia Paina
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Maria W. Merritt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, United States of America
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Sreekumar S, Ravindran TKS. A critique of the policy discourse on primary health care under the Aardram mission of Kerala. Health Policy Plan 2023; 38:949-959. [PMID: 37354455 DOI: 10.1093/heapol/czad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 06/26/2023] Open
Abstract
In 2017, the State of Kerala in India, launched the 'Aardram' mission for health. One of the aims of the mission was to enhance the primary health care (PHC) provisioning in the state through the family health centre (FHC) initiative. This was envisaged through a comprehensive PHC approach that prioritized preventive, promotive, curative, rehabilitative and palliative services, and social determinants of health. Given this backdrop, the study aimed to examine the renewed policy commitment towards comprehensive PHC and the extent to which it remains true to the globally accepted ideals of PHC. This was undertaken using a critical discourse analysis (CDA) of the policy discourse on PHC. This included examining the policy documents related to FHC and Aardram as well as the narratives of policy-level actors on PHC and innovations for them. Through CDA we examined the discursive representation of PHC and innovations for improving it at the level of local governments in the state. Though the mission envisaged a shift from the influence of market-driven ideas of health, analysis of the current policy discourse on PHC suggested otherwise. The discourse continues to carry a curative care bias within its ideas of PHC. The disproportionate emphasis on strategies for early detection, treatment and infrastructural improvements meant limited space for preventive, protective and promotive dimensions, thus digressing from the gatekeeping role of PHC. The reduced emphasis on preventive and promotive dimensions and depoliticization of social determinants of health within the PHC discourse indicates that, in the long run, the mission puts at risk its stated goals of social justice and health equity envisioned in the FHC initiative.
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Affiliation(s)
- Sreenidhi Sreekumar
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India
| | - T K Sundari Ravindran
- International Institute for Global Health, United Nations University, Kuala Lampur 56000, Malaysia
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Witter S, Thomas S, Topp SM, Barasa E, Chopra M, Cobos D, Blanchet K, Teddy G, Atun R, Ager A. Health system resilience: a critical review and reconceptualisation. Lancet Glob Health 2023; 11:e1454-e1458. [PMID: 37591591 DOI: 10.1016/s2214-109x(23)00279-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 08/19/2023]
Abstract
This Viewpoint brings together insights from health system experts working in a range of settings. Our focus is on examining the state of the resilience field, including current thinking on definitions, conceptualisation, critiques, measurement, and capabilities. We highlight the analytical value of resilience, but also its risks, which include neglect of equity and of who is bearing the costs of resilience strategies. Resilience depends crucially on relationships between system actors and components, and-as amply shown during the COVID-19 pandemic-relationships with wider systems (eg, economic, political, and global governance structures). Resilience is therefore connected to power imbalances, which need to be addressed to enact the transformative strategies that are important in dealing with more persistent shocks and stressors, such as climate change. We discourage the framing of resilience as an outcome that can be measured; instead, we see it emerge from systemic resources and interactions, which have effects that can be measured. We propose a more complex categorisation of shocks than the common binary one of acute versus chronic, and outline some of the implications of this for resilience strategies. We encourage a shift in thinking from capacities towards capabilities-what actors could do in future with the necessary transformative strategies, which will need to encompass global, national, and local change. Finally, we highlight lessons emerging in relation to preparing for the next crisis, particularly in clarifying roles and avoiding fragmented governance.
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Affiliation(s)
- Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK; ReBUILD for Resilience, Queen Margaret University, Edinburgh, UK.
| | - Steve Thomas
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Stephanie M Topp
- Centre for Health Policy & Management, James Cook University, Townsville, QLD, Australia
| | - Edwine Barasa
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Daniel Cobos
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Karl Blanchet
- Geneva Centre of Humanitarian Studies, Geneva, Switzerland
| | - Gina Teddy
- Ghana Institute of Management and Public Affairs, Accra, Ghana
| | - Rifat Atun
- Harvard School of Public Health, Boston, MA, USA
| | - Alastair Ager
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
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Sreekumar S. Understanding Dalit equity: a critical analysis of primary health care policy discourse of Kerala in the context of 'Aardram' mission. Int J Equity Health 2023; 22:165. [PMID: 37633913 PMCID: PMC10463961 DOI: 10.1186/s12939-023-01978-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 08/02/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND The Government of Kerala in 2017 launched the Aardram Mission with the aim to revamp public health delivery in the State. A key strategy under the mission was its focus on comprehensive primary health care to achieve equitable health care delivery through the Family Health Centre (FHC) initiative. Given this, the current study aims to examine the primary health care policy discourse for their perspectives on caste-driven inequities. METHODS The study undertook a Critical Discourse Analysis (CDA) of the primary health care policy discourse in Kerala. This included CDA of spoken words by senior health policy actors and policy texts on Aardram Mission and FHC. RESULTS Though equity was a major aspirational goal of the Mission, related policy discourse around equity failed to acknowledge caste as a potential axis of health marginalisation in the State. The dismissal of caste manifested in three major ways within the policy discourse. One, the 'invisibilisation' of caste-driven inequities through strategies of (un)conscious exclusion of Dalit issues and 'obliteration' of caste differences through the construction of abstract and homogenous groups that invisibilise Dalits. Secondly, locating caste as a barrier to primary health care initiatives and health equity in the state, and finally through the maintenance of an 'apoliticised' social determinants discourse that fails to recognize the role of caste in shaping health disparities, specifically among Dalits in Kerala. CONCLUSION Given Kerala's renewed commitment to strengthening its public health provisioning, the acknowledgment of caste-driven inequities is invariable in its path toward health equity and social justice.
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Affiliation(s)
- Sreenidhi Sreekumar
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
- Sambodhi Research and Communications, Noida, India.
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Bartel D, Coile A, Zou A, Martinez Valle A, Nyasulu HM, Brenzel L, Orobaton N, Saxena S, Addy P, Strother S, Ogundimu M, Banerjee B, Kasungami D. Exploring system drivers of gender inequity in development assistance for health and opportunities for action. Gates Open Res 2023; 6:114. [PMID: 37593453 PMCID: PMC10427755 DOI: 10.12688/gatesopenres.13639.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 08/19/2023] Open
Abstract
Background : Deep-rooted and widespread gender-based bias and discrimination threaten achievement of the Sustainable Development Goals. Despite evidence that addressing gender inequities contributes to better health and development outcomes, the resources for, and effectiveness of, such efforts in development assistance for health (DAH) have been insufficient. This paper explores systemic challenges in DAH that perpetuate or contribute to gender inequities, with a particular focus on the role of external donors and funders. Methods: We applied a co-creation system design process to map and analyze interactions between donors and recipient countries, and articulate drivers of gender inequities within the landscape of DAH. We conducted qualitative primary data collection and analysis in 2021 via virtual facilitated discussions and visual mapping exercises among a diverse set of 41 stakeholders, including representatives from donor institutions, country governments, academia, and civil society. Results: Six systemic challenges emerged as perpetuating or contributing to gender inequities in DAH: 1) insufficient input and leadership from groups affected by gender bias and discrimination; 2) decision-maker blind spots inhibit capacity to address gender inequities; 3) imbalanced power dynamics contribute to insufficient resources and attention to gender priorities; 4) donor funding structures limit efforts to effectively address gender inequities; 5) fragmented programming impedes coordinated attention to the root causes of gender inequities; and 6) data bias contributes to insufficient understanding of and attention to gender inequities. Conclusions : Many of the drivers impeding progress on gender equity in DAH are embedded in power dynamics that distance and disempower people affected by gender inequities. Overcoming these dynamics will require more than technical solutions. Groups affected by gender inequities must be centered in leadership and decision-making at micro and macro levels, with practices and structures that enable co-creation and mutual accountability in the design, implementation, and evaluation of health programs.
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Affiliation(s)
- Doris Bartel
- Independent, Washington, District of Columbia, USA
| | - Amanda Coile
- JSI Research and Training Institute, Inc., Arlington, Virginia, 22202, USA
| | - Annette Zou
- Global ChangeLabs, Portola Valley, California, 94028, USA
| | - Adolfo Martinez Valle
- Health Policy and Population Research Center (CIPPS), Universidad Nacional Autónoma de México, Mexico City, 04510, Mexico
| | | | - Logan Brenzel
- Bill & Melinda Gates Foundation, Seattle, Washington, 98109, USA
| | - Nosa Orobaton
- Bill & Melinda Gates Foundation, Seattle, Washington, 98109, USA
| | - Sweta Saxena
- U.S. Agency for International Development (USAID), Washington, District of Columbia, 20523, USA
| | - Paulina Addy
- Women in Agricultural Development, Ministry of Food and Agriculture, Accra, Ghana
| | - Sita Strother
- JSI Research and Training Institute, Inc., Arlington, Virginia, 22202, USA
| | | | - Banny Banerjee
- Global ChangeLabs, Portola Valley, California, 94028, USA
| | - Dyness Kasungami
- JSI Research and Training Institute, Inc., Arlington, Virginia, 22202, USA
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Paina L, Rodriguez DC, Zakumumpa H, Mackenzie C, Ssengooba F, Bennett S. Geographic prioritisation in Kenya and Uganda: a power analysis of donor transition. BMJ Glob Health 2023; 8:bmjgh-2022-010499. [PMID: 37236658 DOI: 10.1136/bmjgh-2022-010499] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Introduction Donor transition for HIV/AIDS programmes remains sensitive, marking a significant shift away from the traditional investment model of large-scale, vertical investments to control the epidemic and achieve rapid scaling-up of services. In late 2015, the United States President's Emergency Plan for AIDS Relief (PEPFAR) headquarters instructed their country missions to implement 'geographic prioritisation' (GP), whereby PEPFAR investments would target geographic areas with high HIV burden and reduce or cease support in areas with low burden.Methods Using Gaventa's power cube framework, we compare how power is distributed and manifested using qualitative data collected in an evaluation of the GP's impact in Kenya and Uganda.Results We found that the GP was designed with little space for national and local actors to shape either the policy or its implementation. While decision-making processes limited the scope for national-level government actors to shape the GP, the national government in Kenya claimed such a space, proactively pressuring PEPFAR to change particular aspects of its GP plan. Subnational level actors were typically recipients of top-down decision-making with apparently limited scope to resist or change GP. While civil society had the potential to hold both PEPFAR and government actors accountable, the closed-door nature of policy-making and the lack of transparency about decisions made this difficult.Conclusion Donor agencies should exercise power responsibly, especially to ensure that transition processes meaningfully engage governments and others with a mandate for service delivery. Furthermore, subnational actors and civil society are often better positioned to understand the implications and changes arising from transition. Greater transparency and accountability would increase the success of global health programme transitions, especially in the context of greater decentralisation, requiring donors and country counterparts to be more aware and flexible of working within political systems that have implications for programmatic success.
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Affiliation(s)
- Ligia Paina
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Henry Zakumumpa
- Health Policy Planning & Management, Makerere University School of Public Health, Kampala, Uganda
| | | | - Freddie Ssengooba
- Health Policy Planning & Management, Makerere University School of Public Health, Kampala, Uganda
| | - Sara Bennett
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Parashar R, Sriram V, Nanda S, Shekhawat F. Coloniality, Elite Networks and Intersectionality: Key Concepts in Understanding Biomedical Power and Equity in Health Policy Processes Comment on "Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process". Int J Health Policy Manag 2023; 12:7916. [PMID: 37579392 PMCID: PMC10425670 DOI: 10.34172/ijhpm.2023.7916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/18/2023] [Indexed: 08/16/2023] Open
Abstract
To understand the role of power in health policy processes in low- and middle-income country (LMIC) contexts, it is necessary to engage with global and local power structures and their historical contexts. In this commentary, we outline three dimensions that shape a dominant power in health policy processes-the biomedical power. We propose that understanding the linkages between medical power and colonialism; the close connection of public health, medicine and elite networks; and the intersectionalities that shape the powers of medical professionals can offer the means to examine the biomedical hegemony in health policy processes. Additionally we suggest that a more nuanced understanding of the interaction of local powers with global funding can offer some entry points to achieving more equitable and interdisciplinary health policy processes in LMICs.
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Affiliation(s)
- Rakesh Parashar
- Health Policy and Systems, Sambodhi Research and communications, Noida, India
| | - Veena Sriram
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- School of Public Policy and Global Affairs, University of British Columbia, Vancouver, BC, Canada
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Benson J, Brand T, Christianson L, Lakeberg M. Localisation of digital health tools used by displaced populations in low and middle-income settings: a scoping review and critical analysis of the Participation Revolution. Confl Health 2023; 17:20. [PMID: 37061703 PMCID: PMC10105546 DOI: 10.1186/s13031-023-00518-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 04/04/2023] [Indexed: 04/17/2023] Open
Abstract
BACKGROUND Forced displacement is a crucial determinant of poor health. With 31 people displaced every minute worldwide, this is an important global issue. Addressing this, the Participation Revolution workstream from the World Humanitarian Summit's Localisation commitments has gained traction in attempting to improve the effectiveness of humanitarian aid. Simultaneously, digital health initiatives have become increasingly ubiquitous tools in crises to deliver humanitarian assistance and address health burdens. OBJECTIVE This scoping review explores how the localisation agenda's commitment to participation has been adopted within digital health interventions used by displaced people in low-and-middle-income countries. METHODS This review adopted the Arksey and O'Malley approach and searched five academic databases and three online literature repositories with a Population, Concept and Context inclusion criteria. Data were synthesised and analysed through a critical power lens from the perspective of displaced people in low-and-middle-income-countries. RESULTS 27 papers demonstrated that a heterogeneous group of health issues were addressed through various digital health initiatives, principally through the use of mobile phones. The focus of the literature lay largely within technical connectivity and feasibility assessments, leaving a gap in understanding potential health implications. The varied conceptualisation of the localisation phenomenon has implications for the future of participatory humanitarian action: Authorship of reviewed literature primarily descended from high-income countries exposing global power dynamics leading the narrative. However, power was not a central theme in the literature: Whilst authors acknowledged the benefit of local involvement, participatory activities were largely limited to informing content adaptations and functional modifications within pre-determined projects and objectives. CONCLUSION With over 100 million people displaced globally, effective initiatives that meaningfully address health needs without perpetuating harmful inequalities are an essential contribution to the humanitarian arena. The gap in health outcomes evidence, the limited constructions of health, and the varying and nuanced digital divide factors are all indicators of unequal power in the digital health sphere. More needs to be done to address these gaps meaningfully, and more meaningful participation could be a crucial undertaking to achieve this. Registration The study protocol was registered before the study (10.17605/OSF.IO/9D25R) at https://osf.io/9d25r .
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Affiliation(s)
- Jennifer Benson
- Faculty of Human and Health Sciences, Public Health, The University of Bremen, Bremen, Germany.
- Department Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany.
- Leibniz Science Campus Digital Public Health, Bremen, Germany.
| | - Tilman Brand
- Department Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Lara Christianson
- Department Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Meret Lakeberg
- Faculty of Human and Health Sciences, Public Health, The University of Bremen, Bremen, Germany
- Department Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
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14
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Bennett E, Topp SM, Moodie AR. National Public Health Surveillance of Corporations in Key Unhealthy Commodity Industries - A Scoping Review and Framework Synthesis. Int J Health Policy Manag 2023; 12:6876. [PMID: 37579395 PMCID: PMC10425693 DOI: 10.34172/ijhpm.2023.6876] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/02/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Corporations in unhealthy commodity industries (UCIs) have growing influence on the health of national populations through practices that lead to increased consumption of unhealthy products. The use of government-led public health surveillance is best practice to better understand any emerging public health threat. However, there is minimal systematic evidence, generated and monitored by national governments, regarding the scope of UCI corporate practices and their impacts. This study aims to synthesise current frameworks that exist to identify and monitor UCI influence on health to highlight the range of practices deployed by corporations and inform future surveillance efforts in key UCIs. METHODS Seven biomedical, business and scientific databases were searched to identify literature focused on corporate practices that impact human health and frameworks for monitoring or assessment of the way UCIs impact health. Content analysis occurred in three phases, involving (1) the identification of framework documents in the literature and extraction of all corporate practices from the frameworks; (2) initial inductive grouping and synthesis followed by deductive synthesis using Lima and Galea's 'vehicles of power' as a heuristic; and (3) scoping for potential indicators linked to each corporate practice and development of an integrated framework. RESULTS Fourteen frameworks were identified with 37 individual corporate practices which were coded into five different themes according the Lima and Galea 'Corporate Practices and Health' framework. We proposed a summary framework to inform the public health surveillance of UCIs which outlines key actors, corporate practices and outcomes that should be considered. The proposed framework draws from the health policy triangle framework and synthesises key features of existing frameworks. CONCLUSION Systematic monitoring of the practices of UCIs is likely to enable governments to mitigate the negative health impacts of corporate practices. The proposed synthesised framework highlights the range of practices deployed by corporations for public health surveillance at a national government level. We argue there is significant precedent and great need for monitoring of these practices and the operationalisation of a UCI monitoring system should be the object of future research.
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Affiliation(s)
- Elizabeth Bennett
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, VIC, Australia
| | - Stephanie M. Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, VIC, Australia
| | - Alan Rob Moodie
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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Kinney MV, George AS, Rhoda NR, Pattinson RC, Bergh AM. From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa. GLOBAL HEALTH: SCIENCE AND PRACTICE 2023; 11:GHSP-D-22-00213. [PMID: 37116922 PMCID: PMC10141437 DOI: 10.9745/ghsp-d-22-00213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/07/2023] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Maternal and perinatal death surveillance and response (MPDSR), or related forms of maternal and perinatal death audits, can strengthen health systems. We explore the history of initiating, scaling up, and institutionalizing a national perinatal audit program in South Africa. METHODS Data collection involved 56 individual interviews, a systematic document review, administration of a semistructured questionnaire, and 10 nonparticipant observations of meetings related to the perinatal audit program. Fieldwork and data collection in the subdistricts occurred from September 2019 to March 2020. Data analysis included thematic content analysis and application of a tool to measure subdistrict-level implementation. This study expands on case study research applied to 5 Western Cape subdistricts with long histories of implementation. RESULTS Although established in the early 1990s, the perinatal audit program was not integrated into national policy and guidelines until 2012 but was then excluded from policy in 2021. A network of national and subnational structures that benefited from a continuity of actors evolved and interacted to support uptake and implementation. Intentional efforts to demonstrate impact and enable local adaptation allowed for more ownership and buy-in. Implementation requires continuous efforts. Even in 5 subdistricts with long histories of practice, we found operational gaps, such as incomplete meeting minutes, signaling a need for strengthening. Nevertheless, the tool used to measure implementation may require revisions, particularly in settings with institutionalized practice. CONCLUSION This article provides lessons on how to initiate, expand, and strengthen perinatal audit. Despite a long history of implementation, the perinatal audit program in South Africa cannot be assumed to be indefinitely sustainable or final in its current form. To monitor uptake and sustainability of MPDSR, including perinatal audit, we need research approaches that allow exploration of context, local adaptation, and underlying issues that support sustainability, such as relationships, leadership, and trust.
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Affiliation(s)
- Mary V. Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Asha S. George
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Natasha R. Rhoda
- Mowbray Maternity Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Robert C. Pattinson
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council and Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Anne-Marie Bergh
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council and Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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Kihlström L, Siemes L, Huhtakangas M, Keskimäki I, Tynkkynen LK. Power and politics in a pandemic: Insights from Finnish health system leaders during COVID-19. Soc Sci Med 2023; 321:115783. [PMID: 36863240 PMCID: PMC9933459 DOI: 10.1016/j.socscimed.2023.115783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
Power and politics are both critical concepts to engage with in health systems and policy research, as they impact actions, processes, and outcomes at all levels in health systems. Building on the conceptualization of health systems as social systems, we investigate how power and politics manifested in the Finnish health system during COVID-19, posing the following research question: in what ways did health system leaders and experts experience issues of power and politics during COVID-19, and how did power and politics impact health system governance? We completed online interviews with health system leaders and experts (n = 53) at the local, regional, and national level in Finland from March 2021 to February 2022. The analysis followed an iterative thematic analysis process in which the data guided the codebook. The results demonstrate that power and politics affected health system governance in Finland during COVID-19 in a multitude of ways. These can be summarized through the themes of credit and blame, frame contestation, and transparency and trust. Overall, political leaders at the national level were heavily involved in the governance of COVID-19 in Finland, which was perceived as having both negative and positive impacts. The politicization of the pandemic took health officials and civil servants by surprise, and events during the first year of COVID-19 in Finland reflect recurring vertical and horizontal power dynamics between local, regional, and national actors. The paper contributes to the growing call for power-focused health systems and policy research. The results suggest that analyses of pandemic governance and lessons learned are likely to leave out critical factors if left absent of an explicit analysis of power and politics, and that such analyses are needed to ensure accountability in health systems.
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Affiliation(s)
- Laura Kihlström
- Cultural, Behavioral, and Media Insights Centre, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00300, Helsinki, Finland; Department of Anthropology, University of South Florida, 4202 E Fowler Avenue, Tampa, FL, 33602, United States.
| | - Lea Siemes
- Maastricht University, Minderbroedersberg 4-6, 6211, LK Maastricht, Netherlands; Welfare State Research and Reform, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00300, Helsinki, Finland.
| | - Moona Huhtakangas
- Welfare State Research and Reform, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00300, Helsinki, Finland.
| | - Ilmo Keskimäki
- Welfare State Research and Reform, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00300, Helsinki, Finland; Faculty of Social Sciences, Tampere University, Kalevantie 4, 33100, Tampere, Finland.
| | - Liina-Kaisa Tynkkynen
- Welfare State Research and Reform, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00300, Helsinki, Finland; Faculty of Social Sciences, Tampere University, Kalevantie 4, 33100, Tampere, Finland.
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17
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How gender is socially constructed in policy making processes: a case study of the Adolescent and Youth Health Policy in South Africa. Int J Equity Health 2023; 22:36. [PMID: 36829217 PMCID: PMC9955531 DOI: 10.1186/s12939-022-01819-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/22/2022] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Gender equality remains an outstanding global priority, more than 25 years after the landmark Beijing Platform for Action. The disconnect between global health policy intentions and implementation is shaped by several conceptual, pragmatic and political factors, both globally and in South Africa. Actor narratives and different framings of gender and gender equality are one part of the contested nature of gender policy processes and their implementation challenges. The main aim of this paper is to foreground the range of policy actors, describe their narratives and different framings of gender, as part exploring the social construction of gender in policy processes, using the Adolescent Youth Health Policy (AYHP) as a case study. METHODS A case study design was undertaken, with conceptual underpinnings combined from gender studies, sociology and health policy analysis. Through purposive sampling, a range of actors were selected, including AYHP authors from government and academia, members of the AYHP Advisory Panel, youth representatives from the National Department of Health Adolescent and Youth Advisory Panel, as well as adolescent and youth health and gender policy actors, in government, academia and civil society. Qualitative data was collected via in-depth, semi-structured interviews with 30 policy actors between 2019 and 2021. Thematic data analysis was used, as well as triangulation across both respondents, and the document analysis of the AYHP. RESULTS Despite gender power relations and more gender-transformative approaches being discussed during the policy making process, these were not reflected in the final policy. Interviews revealed an interrelated constellation of diverse and juxtaposed actor gender narratives, ranging from framing gender as equating girls and women, gender as inclusion, gender as instrumental, gender as women's rights and empowerment and gender as power relations. Some of these narrative framings were dominant in the policy making process and were consequently included in the final policy document, unlike other narratives. The way gender is framed in policy processes is shaped by actor narratives, and these diverse and contested discursive constructions were shaped by the dynamic interactions with the South Africa context, and processes of the Adolescent Youth Health Policy. These varied actor narratives were further contextualised in terms of reflections of what is needed going forward to advance gender equality in adolescent and youth health policy and programming. This includes prioritising gender and intersectionality on the national agenda, implementing more gender-transformative programmes, as well as having the commitments and capabilities to take the work forward. CONCLUSIONS The constellation of actors' gender narratives reveals overlapping and contested framings of gender and what is required to advance gender equality. Understanding actor narratives in policy processes contributes to bridging the disconnect between policy commitments and reality in advancing the gender equality agenda.
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Kersey K, Hutton F, Lyons AC. Women, alcohol consumption and health promotion: the value of a critical realist approach. Health Promot Int 2023; 38:6974794. [PMID: 36617295 DOI: 10.1093/heapro/daac177] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Research on women's drinking occurs in largely disparate disciplines-including public health, health promotion, psychology, sociology, and cultural studies-and draws on differing philosophical understandings and theoretical frameworks. Tensions between the aims and paradigmatic underpinnings of this research (across and within disciplines) have meant that knowledge and insight can be frequently disciplinary-specific and somewhat siloed. However, in line with the social and economic determinants of the health model, alcohol research needs approaches that can explore how multiple gender-related factors-biological, psycho-social, material, and socio-cultural-combine to produce certain drinking behaviours, pleasures and potential harms. We argue that critical realism as a philosophical underpinning to research can accommodate this broader conceptualization, enabling researchers to draw on multiple perspectives to better understand women's drinking. We illustrate the benefit of this approach by presenting a critical realist theoretical framework for understanding women's drinking that outlines interrelationships between the psychoactive properties of alcohol, the role of embodied individual characteristics and the material, institutional and socio-cultural contexts in which women live. This approach can underpin and foster inter-disciplinary research collaboration to inform more nuanced health promotion practices and policies to reduce alcohol-related harm in a wide range of women across societies.
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Affiliation(s)
- Kate Kersey
- School of Health, Victoria University of Wellington, Kelburn Campus, Wellington, New Zealand
| | - Fiona Hutton
- Institute of Criminology, Victoria University of Wellington, Kelburn Campus, Wellington, New Zealand
| | - Antonia C Lyons
- Department of Social and Community Health; Centre for Addiction Research, University of Auckland, Auckland, New Zealand
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Jeebhay MF, Naidoo RN, Naidoo S, Adams S, Zungu M, Kgalomono S, Naicker N, Kistnasamy B. Strengthening Social Compact and Innovative Health Sector Collaborations in Addressing COVID-19 in South African Workplaces. New Solut 2023; 32:288-303. [PMID: 36650981 PMCID: PMC9852971 DOI: 10.1177/10482911221150237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Workplaces are nodes for Severe Acute Respiratory Syndrome Coronavirus 2 transmission and require strategies to protect workers' health. This article reports on the South African national coronavirus disease 2019 (COVID-19) strategy that sought to ensure workers' health, protect the economic activity, safeguard livelihoods and support health services. Data from the Occupational Health Surveillance System, Surveillance System of Sentinel Hospital Sites, and government databases (public sector health worker and Compensation Fund data) was supplemented by peer-reviewed articles and grey literature. A multipronged, multi-stakeholder response to occupational health and safety (OHS) policy development, risk management, health surveillance, information, and training was adopted, underpinned by scientific input, through collaboration between government, organized labour, employer bodies, academia, and community partners. This resulted in government-promulgated legislation addressing OHS, sectoral guidelines, and work-related COVID-19 worker's compensation. The OHS Workstream of the National Department of Health provided leadership and technical support for COVID-specific workplace guidelines and practices, surveillance, information, and training, as well as a workplace-based vaccination strategy.
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Affiliation(s)
- Mohamed F. Jeebhay
- Occupational Medicine Division, School of Public Health, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Rajen N. Naidoo
- Discipline of Occupational and Environmental Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa,Rajen N. Naidoo, Discipline of Occupational and Environmental Health, School of Nursing and Public Health, University of KwaZulu-Natal, Room 321, George Campbell Building, Durban, 4041, South Africa.
| | - Saloshni Naidoo
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Shahieda Adams
- Occupational Medicine Division, School of Public Health, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Muzimkhulu Zungu
- National Institute for Occupational Health, National Health Laboratory Service, Johannesburg, Gauteng, South Africa,School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Spo Kgalomono
- National Institute for Occupational Health, National Health Laboratory Service, Johannesburg, Gauteng, South Africa
| | - Nisha Naicker
- National Institute for Occupational Health, National Health Laboratory Service, Johannesburg, Gauteng, South Africa,Department of Environmental Health, University of Johannesburg, Johannesburg, Gauteng, South Africa
| | - Barry Kistnasamy
- Medical Bureau for Occupational Diseases, National Department of Health, Pretoria, South Africa
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20
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Schaaf M, Jaffe M, Tunçalp Ö, Freedman L. A critical interpretive synthesis of power and mistreatment of women in maternity care. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000616. [PMID: 36962936 PMCID: PMC10021192 DOI: 10.1371/journal.pgph.0000616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Labouring women may be subjected to physical and verbal abuse that reflects dynamics of power, described as Mistreatment of Women (MoW). This Critical Interpretive Synthesis on power and MoW consolidates current research and advances theory and practice through inter-disciplinary literature exploration. The review was undertaken in 3 phases. Phase 1 consisted of topic scoping; phase 2 entailed exploration of key power-related drivers emerging from the topic scoping; and phase 3 entailed data synthesis and analysis, with a particular focus on interventions. We identified 63 papers for inclusion in Phase 1. These papers utilized a variety of methods and approaches and represented a wide range of geographic regions. The power-related drivers of mistreatment in these articles span multiple levels of the social ecological model, including intrapersonal (e.g. lack of knowledge about one's rights), interpersonal (e.g. patient-provider hierarchy), community (e.g. widespread discrimination against indigenous women), organizational (e.g. pressure to achieve performance goals), and law/policy (e.g. lack of accountability for rights violations). Most papers addressed more than one level of the social-ecological model, though a significant minority were focused just on interpersonal factors. During Phase 1, we identified priority themes relating to under-explored power-related drivers of MoW for exploration in Phase 2, including lack of conscientization and normalization of MoW; perceptions of fitness for motherhood; geopolitical and ethnopolitical projects related to fertility; and pressure to achieve quantifiable performance goals. We ultimately included 104 papers in Phase 2. The wide-ranging findings from Phase 3 (synthesis and analysis) coalesce in several key meta-themes, each with their own evidence-base for action. Consistent with the notion that research on power can point us to "drivers of the drivers," the paper includes some intervention-relevant insights for further exploration, including as relating to broader social norms, health systems design, and the utility of multi-level strategies.
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Affiliation(s)
- Marta Schaaf
- Independent Consultant, Brooklyn, New York, United States of America
| | - Maayan Jaffe
- Independent Consultant, Brooklyn, New York, United States of America
| | - Özge Tunçalp
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Lynn Freedman
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, United States of America
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Knittel B, Coile A, Zou A, Saxena S, Brenzel L, Orobaton N, Bartel D, Williams CA, Kambarami R, Tiwari DP, Husain I, Sikipa G, Achan J, Ajiwohwodoma JO, Banerjee B, Kasungami D. Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance. Gates Open Res 2023; 6:116. [PMID: 36415884 PMCID: PMC9646484 DOI: 10.12688/gatesopenres.13632.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 01/19/2023] Open
Abstract
Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.
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Affiliation(s)
- Barbara Knittel
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
| | - Amanda Coile
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
| | - Annette Zou
- Global ChangeLabs, Portola Valley, CA, 94028, USA
| | - Sweta Saxena
- United States Agency for International Development, Washington, DC, 20523, USA
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Nosa Orobaton
- Bill & Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Doris Bartel
- Independent Researcher, Washington, District of Columbia, USA
| | | | | | | | - Ishrat Husain
- United States Agency for International Development, Washington, DC, 20523, USA
| | | | | | | | | | - Dyness Kasungami
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
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Hennessey M, Ebata A, Samanta I, Mateus A, Arnold JC, Day D, Gautham M, Alarcon P. Pharma-cartography: Navigating the complexities of antibiotic supply to rural livestock in West Bengal, India, through value chain and power dynamic analysis. PLoS One 2023; 18:e0281188. [PMID: 36730354 PMCID: PMC9894437 DOI: 10.1371/journal.pone.0281188] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/18/2023] [Indexed: 02/03/2023] Open
Abstract
Antibiotic resistance threatens provision of healthcare and livestock production worldwide with predicted negative socioeconomic impact. Antibiotic stewardship can be considered of importance to people living in rural communities, many of which depend on agriculture as a source of food and income and rely on antibiotics to control infectious diseases in livestock. Consequently, there is a need for clarity of the structure of antibiotic value chains to understand the complexity of antibiotic production and distribution in community settings as this will facilitate the development of effective policies and interventions. We used a value chain approach to investigate how relationships, behaviours, and influences are established during antibiotic distribution. Interviews were conducted with key informants (n = 17), value chain stakeholders (n = 22), and livestock keeping households (n = 36) in Kolkata, and two rural sites in West Bengal, India. Value chain mapping and an assessment of power dynamics, using manifest content analysis, were conducted to investigate antibiotic distribution and identify entry points for antibiotic stewardship. The flow of antibiotics from manufacturer to stockists is described and mapped and two local level maps showing distribution to final consumers presented. The maps illustrate that antibiotic distribution occurred through numerous formal and informal routes, many of which circumvent antibiotic use legislation. This was partly due to limited institutional power of the public sector to govern value chain activities. A 'veterinary service lacuna' existed resulting in livestock keepers having higher reliance on private and informal providers, who often lacked legal mandates to prescribe and dispense antibiotics. The illegitimacy of many antibiotic prescribers blocked access to formal training who instead relied on mimicking the behaviour of more experienced prescribers-who also lacked access to stewardship guidelines. We argue that limited institutional power to enforce existing antibiotic legislation and guide antibiotic usage and major gaps in livestock healthcare services make attempts to curb informal prescribing unsustainable. Alternative options could include addressing public sector deficits, with respect to both healthcare services and antibiotic provision, and by providing resources such as locally relevant antibiotic guidelines to all antibiotic prescribers. In addition, legitimacy of informal prescribers could be revised, which may allow formation of associations or groups to incentivise good antibiotic practices.
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Affiliation(s)
- Mathew Hennessey
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, London, United Kingdom
- * E-mail:
| | - Ayako Ebata
- Institute of Development Studies, Brighton, United Kingdom
| | - Indranil Samanta
- Department of Veterinary Microbiology, West Bengal University of Animal and Fishery Sciences, Kolkata, India
| | - Ana Mateus
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, London, United Kingdom
| | - Jean-Christophe Arnold
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, London, United Kingdom
| | - Dominic Day
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Meenakshi Gautham
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Pablo Alarcon
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, London, United Kingdom
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23
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Lassa S, Saddiq M, Owen J, Burton C, Balen J. Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process. Int J Health Policy Manag 2022; 11:2876-2885. [PMID: 35461207 PMCID: PMC10105204 DOI: 10.34172/ijhpm.2022.6097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/28/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Health workers are central to health policy-making. Given health systems' complex, dynamic and political nature, various forms of 'hidden power' are at play as health workers navigate health systems. This study aims to explore the dynamics of power and its sources, and how this shapes policy-making and implementation within the Nigerian health systems context. METHODS The case study was the Global Fund grant in Nigeria, and results are based on an in-depth qualitative study involving 34 semi-structured key informant interviews (KIIs), board-meeting observations, and documentary analysis conducted in 2014 and 2016. Participants held mid to senior-level positions (eg, Director, Programme Manager) within organisations involved with Global Fund activities, particularly proposal development and implementation. Data were analysed using thematic analysis in order to gain insight into the power dynamics of health professionals in policy processes. RESULTS Medical professionals maintained dominance and professional monopoly, thereby controlling policy spaces. The structural and productive power of the biomedical discourse in policy-making encourages global actors and the local government's preference for rapid biomedical models that focus on medications, test kits, and the supply of health services, while neglecting aspects that would help us better understand the poor uptake of these services by those in need. The voices of the repressed groups (eg, non-clinical experts, patients and community based organisations) that better understand barriers to uptake of services are relegated. CONCLUSION Professional monopoly theories help illustrate how medical professionals occupy and maintain an elite position in the health system of Nigeria. Structural and agential factors specific to the contexts are key in maintaining this professional monopoly while limiting the opportunities for other health occupations' rise up the social status ladder.
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Affiliation(s)
- Samuel Lassa
- School of Health and Health Related Research, University of Sheffield, Sheffield, UK
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
- The Department of Community Medicine, University of Jos, Jos, Nigeria
| | - Muhammed Saddiq
- School of Health and Health Related Research, University of Sheffield, Sheffield, UK
| | - Jenny Owen
- School of Health and Health Related Research, University of Sheffield, Sheffield, UK
| | - Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Julie Balen
- School of Health and Health Related Research, University of Sheffield, Sheffield, UK
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24
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Fraser A, Jones L, Lorne C, Stewart E. "Attending to Collaboration" in Major System Change in Healthcare in England: A Response Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration". Int J Health Policy Manag 2022; 12:7661. [PMID: 37579460 PMCID: PMC10125045 DOI: 10.34172/ijhpm.2022.7661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/08/2022] [Indexed: 08/16/2023] Open
Abstract
In this short article we comment upon the recent article by Perry et al "Attending to History" in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration. We welcome the engagement with power, history and heuristics in the Perry et al paper. Our article discusses the importance of researcher positionality in Major System Change research, alongside managerial power and the centrality of politics to remaking health and care services. Additionally, we highlight the work of Ansell and Gash focused on 'collaborative governance' and its potential to offer insight in relation to Major System Change.
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Affiliation(s)
- Alec Fraser
- King’s Business School, King’s College London, London, UK
| | - Lorelei Jones
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Colin Lorne
- School of Social Sciences and Global Studies, Faculty of Arts and Social Sciences, The Open University, Milton Keynes, UK
| | - Ellen Stewart
- Department of Social Work and Social Policy, University of Strathclyde, Glasgow, UK
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25
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Whitley E, McCartney G, Bartley M, Benzeval M. Examining the impact of different social class mechanisms on health inequalities: A cross-sectional analysis of an all-age UK household panel study. Soc Sci Med 2022; 312:115383. [PMID: 36155357 DOI: 10.1016/j.socscimed.2022.115383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 08/24/2022] [Accepted: 09/16/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Socioeconomic inequalities are well established across health, morbidity and mortality measures. Social class theory describes how social groups relate, interact and accrue advantages/disadvantages relative to one another, with different theorists emphasising different dimensions. In the context of health inequalities, different social class measures are used interchangeably to rank population groups in terms of health rather than directly exploring the role of social class in creating inequalities. We aim to better understand how four distinct social class mechanisms explain differences in a range of self-reported and biological health outcomes. METHODS We use data from the UK Household Longitudinal Study, a representative population survey of UK adults, to identify measures pertaining to Early years, Bourdieusian, Marxist, and Weberian social class mechanisms. Using logistic and least-squares regression we consider the relative extent to which these mechanisms explain differences in health (Self-reported health, SF12 Physical (PCS) and Mental (MCS) Component Scores, General Health Questionnaire; N = 21,446) and allostatic load, a biomarker-based measure of cumulative stress (N = 5003). RESULTS Respondents with higher social position according to all social class measures had better self-rated, physical and mental health, and lower allostatic load. Associations with Marxist social class were among the strongest (e.g. Relative Index of Inequality for very good/excellent self-rated health comparing highest versus lowest Marxist social class: 4.96 (4.45, 5.52), with the Weberian measure also strongly associated with self-rated (4.35 (3.90, 4.85)) and physical health (Slope Index of Inequality for SF12-PCS: 7.94 (7.39, 8.48)). Health outcome associations with Bourdieusian and Marxist measures were generally stronger for women and older respondents, and physical health associations with all measures were stronger among those aged 50+ years. CONCLUSIONS The impact of social class on health is multi-faceted. Policies to reduce health inequalities should focus more on unequal capital ownership, economic democracy and educational inequalities, reflecting Marxist and Weberian mechanisms.
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Affiliation(s)
- Elise Whitley
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, G3 7HR, UK.
| | - Gerard McCartney
- School of Social and Political Sciences, University of Glasgow, Glasgow, G12 8RT, UK
| | - Mel Bartley
- Institute of Epidemiology & Health, University College London, London, WC1E 7HB, UK
| | - Michaela Benzeval
- Institute for Social and Economic Research, University of Essex, Colchester, CO4 3SQ, UK; Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, UK
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26
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D’Ambruoso L, Mabetha D, Twine R, van der Merwe M, Hove J, Goosen G, Sigudla J, Witter S. 'Voice needs teeth to have bite'! Expanding community-led multisectoral action-learning to address alcohol and drug abuse in rural South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000323. [PMID: 36962488 PMCID: PMC10022044 DOI: 10.1371/journal.pgph.0000323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 07/01/2022] [Indexed: 03/26/2023]
Abstract
There is limited operational understanding of multisectoral action in health inclusive of communities as active change agents. The objectives were to: (a) develop community-led action-learning, advancing multisectoral responses for local public health problems; and (b) derive transferrable learning. Participants representing communities, government departments and non-governmental organisations in a rural district in South Africa co-designed the process. Participants identified and problematised local health concerns, coproduced and collectively analysed data, developed and implemented local action, and reflected on and refined the process. Project data were analysed to understand how to expand community-led action across sectors. Community actors identified alcohol and other drug (AOD) abuse as a major problem locally, and generated evidence depicting a self-sustaining problem, destructive of communities and disproportionately affecting children and young people. Community and government actors then developed action plans to rebuild community control over AOD harms. Implementation underscored community commitment, but also revealed organisational challenges and highlighted the importance of coordination with government reforms. While the action plan was only partially achieved, new relationships and collective capabilities were built, and the process was recommended for integration into district health planning and review. We created spaces engaging otherwise disconnected stakeholders to build dialogue, evidence, and action. Engagement needed time, space, and a sensitive, inclusive approach. Regular engagement helped develop collaborative mindsets. Credible, actionable information supported engagement. Collectively reflecting on and adapting the process supported aligning to local systems priorities and enabled uptake. The process made gains raising community 'voice' and initiating dialogue with the authorities, giving the voice 'teeth'. Achieving 'bite', however, requires longer-term engagement, formal and sustained connections to the system. Sustaining in highly fluid contexts and connecting to higher levels are likely to be challenging. Regular learning spaces can support development of collaborative.
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Affiliation(s)
- Lucia D’Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, South Africa
- Department of Epidemiology and Global Health, Umeå University, Sweden
- Public Health, National Health Service (NHS) Grampian, Scotland, United Kingdom
| | - Denny Mabetha
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, South Africa
| | - Maria van der Merwe
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, South Africa
- Maria van der Merwe Consulting, White River, South Africa
| | - Jennifer Hove
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, South Africa
| | | | - Jerry Sigudla
- Mpumalanga Department of Health, Mbombela, South Africa
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Scotland, United Kingdom
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Burgess RA. Working in the wake: transformative global health in an imperfect world. BMJ Glob Health 2022; 7:bmjgh-2022-010520. [PMID: 36130778 PMCID: PMC9557323 DOI: 10.1136/bmjgh-2022-010520] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Rochelle A Burgess
- Institute for Global Health, University College London (UCL), London, UK .,Department of Social Work, University of Johannesburg, Auckland Park, South Africa
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28
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Bartel D, Coile A, Zou A, Martinez Valle A, Nyasulu HM, Brenzel L, Orobaton N, Saxena S, Addy P, Strother S, Ogundimu M, Banerjee B, Kasungami D. Exploring system drivers of gender inequity in development assistance for health and opportunities for action. Gates Open Res 2022. [DOI: 10.12688/gatesopenres.13639.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Deep-rooted and widespread gender-based bias and discrimination threaten achievement of the Sustainable Development Goals. Despite evidence that addressing gender inequities contributes to better health and development outcomes, the resources for, and effectiveness of, such efforts in development assistance for health (DAH) have been insufficient. This paper explores systemic challenges in DAH that perpetuate or contribute to gender inequities, with a particular focus on the role of external donors and funders. Methods: We applied a co-creation system design process to map and analyze interactions between donors and recipient countries, and articulate drivers of gender inequities within the landscape of DAH. We conducted qualitative primary data collection and analysis in 2021 via virtual facilitated discussions and visual mapping exercises among a diverse set of 41 stakeholders, including representatives from donor institutions, country governments, academia, and civil society. Results: Six systemic challenges emerged as perpetuating or contributing to gender inequities in DAH: 1) insufficient input and leadership from groups affected by gender bias and discrimination; 2) decision-maker blind spots inhibit capacity to address gender inequities; 3) imbalanced power dynamics contribute to insufficient resources and attention to gender priorities; 4) donor funding structures limit efforts to effectively address gender inequities; 5) fragmented programming impedes coordinated attention to the root causes of gender inequities; and 6) data bias contributes to insufficient understanding of and attention to gender inequities. Conclusions: Many of the drivers impeding progress on gender equity in DAH are embedded in power dynamics that distance and disempower people affected by gender inequities. Overcoming these dynamics will require more than technical solutions. Groups affected by gender inequities must be centered in leadership and decision-making at micro and macro levels, with practices and structures that enable co-creation and mutual accountability in the design, implementation, and evaluation of health programs.
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29
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Knittel B, Coile A, Zou A, Saxena S, Brenzel L, Orobaton N, Bartel D, Williams CA, Kambarami R, Tiwari DP, Husain I, Sikipa G, Achan J, Ajiwohwodoma JO, Banerjee B, Kasungami D. Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance. Gates Open Res 2022; 6:116. [PMID: 36415884 PMCID: PMC9646484 DOI: 10.12688/gatesopenres.13632.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 02/02/2023] Open
Abstract
Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.
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Affiliation(s)
- Barbara Knittel
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
| | - Amanda Coile
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
| | - Annette Zou
- Global ChangeLabs, Portola Valley, CA, 94028, USA
| | - Sweta Saxena
- United States Agency for International Development, Washington, DC, 20523, USA
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Nosa Orobaton
- Bill & Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Doris Bartel
- Independent Researcher, Washington, District of Columbia, USA
| | | | | | | | - Ishrat Husain
- United States Agency for International Development, Washington, DC, 20523, USA
| | | | | | | | | | - Dyness Kasungami
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
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30
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Mirzoev T, Topp SM, Afifi RA, Fadlallah R, Obi FA, Gilson L. Conceptual framework for systemic capacity strengthening for health policy and systems research. BMJ Glob Health 2022; 7:bmjgh-2022-009764. [PMID: 35922082 PMCID: PMC9353002 DOI: 10.1136/bmjgh-2022-009764] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/24/2022] [Indexed: 11/17/2022] Open
Abstract
Health policy and systems research (HPSR) is critical in developing health systems to better meet the health needs of their populations. The highly contextualised nature of health systems point to the value of local knowledge and the need for context-embedded HPSR. Despite such need, relatively few individuals, groups or organisations carry out HPSR, particularly in low-income and middle-income countries. Greater effort is required to strengthen capacity for, and build the field of, HPSR by capturing the multilevel and nuanced representation of HPSR across contexts. No comprehensive frameworks were found that inform systemic HPSR capacity strengthening. Existing literature on capacity strengthening for health research and development tends to focus on individual-level capacity with less attention to collective, organisational and network levels. This paper proposes a comprehensive framework for systemic capacity strengthening for HPSR, uniquely drawing attention to the blurred boundaries and amplification potential for synergistic capacity strengthening efforts across the individual, organisational and network levels. Further, it identifies guiding values and principles that consciously acknowledge and manage the power dynamics inherent to capacity strengthening work. The framework was developed drawing on available literature and was peer-reviewed by the Board and Thematic Working Groups of Health Systems Global. While the framework focuses on HPSR, it may provide a useful heuristic for systemic approaches to capacity strengthening more generally; facilitate its mainstreaming within organisations and networks and help maintain a focused approach to, and structure repositories of resources on, capacity strengthening.
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Affiliation(s)
- Tolib Mirzoev
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK .,Capacity Strengthening Working Group, Health Systems Global, Ottawa, Ontario, Canada
| | - Stephanie M Topp
- Capacity Strengthening Working Group, Health Systems Global, Ottawa, Ontario, Canada.,College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Rima A Afifi
- Capacity Strengthening Working Group, Health Systems Global, Ottawa, Ontario, Canada.,Department of Community and Behavioral Health, University of Iowa, Iowa City, Iowa, USA
| | - Racha Fadlallah
- Capacity Strengthening Working Group, Health Systems Global, Ottawa, Ontario, Canada.,Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Felix Abrahams Obi
- Capacity Strengthening Working Group, Health Systems Global, Ottawa, Ontario, Canada.,Nigeria Country Office, Results for Development Institute, Abuja, Nigeria.,Health Policy Research Group, University of Nigeria-Enugu Campus, Enugu, Nigeria
| | - Lucy Gilson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.,Capacity Strengthening Working Group, Health Systems Global, Ottawa, Ontario, Canada.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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31
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Hudson MF. Short‐ and
long‐term
strategies for navigating
research‐ambivalent
organizational cultures besetting embedded researchers. Learn Health Syst 2022; 7:e10329. [PMID: 37066096 PMCID: PMC10091197 DOI: 10.1002/lrh2.10329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/19/2022] [Accepted: 07/04/2022] [Indexed: 12/23/2022] Open
Abstract
Many health systems may host embedded researchers (ERs) and provide fiscal resources to encourage health service research. However, ERs may remain challenged to initiate research in these settings. This discussion examines how health system culture may impede research initiation, thereby exposing a paradox for embedded researchers immersed in research-ambivalent health systems. The discussion ultimately describes potential short-term and long-term strategies embedded researchers may employ to initiate scholarly inquiry in research-ambivalent health systems.
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Affiliation(s)
- Matthew F. Hudson
- Department of Medicine Prisma Health Cancer Institute Greenville South Carolina USA
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32
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Eisape A, Nogueira A. See Change: Overcoming Anti-Black Racism in Health Systems. Front Public Health 2022; 10:895684. [PMID: 35784218 PMCID: PMC9245034 DOI: 10.3389/fpubh.2022.895684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
Anti-Black racism embedded in contemporary health systems harms Black and Indigenous People of Color (BIPoC) in concert with various diseases. Seemingly unrelated at first, the COVID-19 pandemic is a recent example that reveals how the combined manifestations of anti-Black racism in disease governance, course, and burden exacerbate the historic and still present subjugation of Black people. Thus, such conditions highlight a biosocial network that intricately propagates and consolidates systems of oppression since the birth of the United States of America. In this article, we show how anti-Black racism in conjunction with past and ongoing epidemics exemplify intertwined conditions embodying and perpetuating racial inequities in the North American country. Through schematic visualizations and techniques of progressive disclosure, we situate disease governance, course, and burden as action spaces within a design model that alternates views of organizational strategies, operations, offerings, and people's experiences, supporting an action-oriented discussion in each of these spaces. We utilize insights from this analysis to recommend that public health moves forward, considering more holistic, solution-oriented questions that embrace systemic complexity and people-centered perspectives when seeking to improve health outcomes for all.
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Affiliation(s)
- Adedoyin Eisape
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - André Nogueira
- Design Laboratory, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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33
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Ssennyonjo A. Beyond "Lack of Political Will": Elaborating Political Economy Concepts to Advance "Thinking and Working Politically" Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective". Int J Health Policy Manag 2022; 12:7297. [PMID: 35643421 PMCID: PMC10125056 DOI: 10.34172/ijhpm.2022.7297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/11/2022] [Indexed: 11/09/2022] Open
Abstract
Political economy analysis (PEA) has been advanced as critical to understanding the political dimensions of policy change processes. However, political economy (PE) is not a theory on its own but draws on several concepts. Nannini et al, in concert with other scholars, emphasise that politics is characterised by conflict, contestation and negotiation over interests, ideas and power as various agents attempt to influence their context. This commentary reflects how Nannini et al wrestled with these PEA concepts - summarised in their conceptual framework used for PEA of the Ugandan case study on financial risk protection reforms. The central premise is that a common understanding of the PEA concepts (mainly structure-agency interactions, ideas, interests, institutions and power) forms a basis for strategies to advance thinking and working politically. Consequently, I generate several insights into how we can promote politically informed approaches to designing, implementing and evaluating policy reforms and development efforts.
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Affiliation(s)
- Aloysius Ssennyonjo
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Institute of Development Policy (IOB), University of Antwerp, Antwerp, Belgium
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Koduah A, Baatiema L, Kretchy IA, Agyepong IA, Danso-Appiah A, de Chavez AC, Ensor T, Mirzoev T. Powers, engagements and resultant influences over the design and implementation of medicine pricing policies in Ghana. BMJ Glob Health 2022; 7:bmjgh-2021-008225. [PMID: 35589156 PMCID: PMC9121428 DOI: 10.1136/bmjgh-2021-008225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Universal availability and affordability of essential medicines are determined by effective design and implementation of relevant policies, typically involving multiple stakeholders. This paper examined stakeholder engagements, powers and resultant influences over design and implementation of four medicines pricing policies in Ghana: Health Commodity Supply Chain Master Plan, framework contracting for high demand medicines, Value Added Tax (VAT) exemptions for selected essential medicines, and ring-fencing medicines for local manufacturing. Methods Data were collected using reviews of policy documentation (n=16), consultative meetings with key policy actors (n=5) and in-depth interviews (n=29) with purposefully identified national-level policymakers, public and private health professionals including members of the National Medicine Pricing Committee, pharmaceutical wholesalers and importers. Data were analysed using thematic framework. Results A total of 46 stakeholders were identified, including representatives from the Ministry of Health, other government agencies, development partners, pharmaceutical industry and professional bodies. The Ministry of Health coordinated policy processes, utilising its bureaucratic mandate and exerted high influences over each policy. Most stakeholders were highly engaged in policy processes. Whereas some led or coproduced the policies in the design stage and participated in policy implementation, others were consulted for their inputs, views and opinions. Stakeholder powers reflected their expertise, bureaucratic mandates and through participation in national level consultation meetings, influences policy contents and implementation. A wider range of stakeholders were involved in the VAT exemption policies, reflecting their multisectoral nature. A minority of stakeholders, such as service providers were not engaged despite their interest in medicines pricing, and consequently did not influence policies. Conclusions Stakeholder powers were central to their engagements in, and resultant influences over medicine pricing policy processes. Effective leadership is important for inclusive and participatory policymaking, and one should be cognisant of the nature of policy issues and approaches to policy design and implementation.
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Affiliation(s)
- Augustina Koduah
- Pharmacy Practice and Clinical Pharmacy, University of Ghana School of Pharmacy, Legon, Accra, Ghana
| | - Leonard Baatiema
- Health Policy, Planning & Management, University of Ghana School of Public Health, Legon, Accra, Ghana
| | - Irene A Kretchy
- Pharmacy Practice and Clinical Pharmacy, University of Ghana School of Pharmacy, Legon, Accra, Ghana
| | - Irene Akua Agyepong
- Dodowa Health Research Centre, Ghana Health Service, Accra, Greater Accra, Ghana.,Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Greater Accra, Ghana
| | - Anthony Danso-Appiah
- Epidemiology and Disease Control, University of Ghana School of Public Health, Legon, Accra, Ghana
| | - Anna Cronin de Chavez
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, London, UK
| | - Timothy Ensor
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Tolib Mirzoev
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, London, UK
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Hernandez A, Hurtig AK, San Sebastian M, Jerez F, Flores W. 'History obligates us to do it': political capabilities of Indigenous grassroots leaders of health accountability initiatives in rural Guatemala. BMJ Glob Health 2022; 7:e008530. [PMID: 35508334 PMCID: PMC9073391 DOI: 10.1136/bmjgh-2022-008530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/13/2022] [Indexed: 11/23/2022] Open
Abstract
Growing interest in how marginalised citizens can leverage countervailing power to make health systems more inclusive and equitable points to the need for politicised frameworks for examining bottom-up accountability initiatives. This study explores how political capabilities are manifested in the actions and strategies of Indigenous grassroots leaders of health accountability initiatives in rural Guatemala. Qualitative data were gathered through group discussions and interviews with initiative leaders (called defenders of the right to health) and initiative collaborators in three municipalities. Analysis was oriented by three dimensions of political capabilities proposed for evaluating the longer-term value of participatory development initiatives: political learning, reshaping networks and patterns of representation. Our findings indicated that the defenders' political learning began with actionable knowledge about defending the right to health and citizen participation. The defenders used their understanding of local norms to build trust with remote Indigenous communities and influence them to participate in monitoring to attempt to hold the state accountable for the discriminatory and deficient healthcare they received. Network reshaping was focused on broadening their base of support. Their leadership strategies enabled them to work with other grassroots leaders and access resources that would expand their reach in collective action and lend them more influence representing their problems beyond the local level. Patterns of representing their interests with a range of local and regional authorities indicated they had gained confidence and credibility through their evolving capability to navigate the political landscape and seek the right authority based on the situation. Our results affirm the critical importance of sustained, long-term processes of engagement with marginalised communities and representatives of the state to enable grassroots leaders of accountability initiatives to develop the capabilities needed to mobilise collective action, shift the terms of interaction with the state and build more equitable health systems.
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Affiliation(s)
- Alison Hernandez
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Ciudad de Guatemala, Guatemala
- Epidemiology and Global Health, Umea University, Umea, Sweden
| | | | | | - Fernando Jerez
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Ciudad de Guatemala, Guatemala
| | - Walter Flores
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Ciudad de Guatemala, Guatemala
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Miranda JJ, Beran D, Diez-Canseco F, Buse K, Mendoza W, Peiris D. [How does research influence health policies?]. GACETA SANITARIA 2022; 36:201-203. [PMID: 34998573 DOI: 10.1016/j.gaceta.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 11/04/2022]
Affiliation(s)
- J Jaime Miranda
- CRONICAS Centro de Excelencia en Enfermedades Crónicas, Universidad Peruana Cayetano Heredia, Lima, Perú; Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Perú; The George Institute for Global Health, University of New South Wales, Sidney, Australia; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Londres, Reino Unido.
| | - David Beran
- Division of Tropical and Humanitarian Medicine, University of Geneva, and Geneva University Hospitals, Ginebra, Suiza
| | - Francisco Diez-Canseco
- CRONICAS Centro de Excelencia en Enfermedades Crónicas, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Kent Buse
- The George Institute for Global Health, Imperial College London, Londres, Reino Unido. https://twitter.com/kentbuse
| | - Walter Mendoza
- Fondo de Población de las Naciones Unidas (UNFPA), Lima, Perú
| | - David Peiris
- The George Institute for Global Health, University of New South Wales, Sidney, Australia. https://twitter.com/davidpeiris
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Palfreyman A, Riyaz S, Rizwan Z, Vijayaraj K, Chathuranga IPR, Daluwatte R, Devindi WAT, Eranda BS, Jayalath V, Junaid A, Kamal A, Kannangara SK, Madushani KMGP, Mathanakumar L, Mubarak SI, Nagalingam V, Palihawadana S, Pathirana R, Sampath VGS, Shanmuganathan L, Thrimawithana T, Vijayaratnam P, Vithanage SL, Wathsala RKKAS, Yalini RM. Cultivating capacities in community-based researchers in low-resource settings: Lessons from a participatory study on violence and mental health in Sri Lanka. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000899. [PMID: 36962631 PMCID: PMC10021324 DOI: 10.1371/journal.pgph.0000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/17/2022] [Indexed: 11/07/2022]
Abstract
Participatory methods, which rely heavily on community-based data collectors, are growing in popularity to deliver much-needed evidence on violence and mental health in low- and middle-income countries. These settings, along with local researchers, encounter the highest burden of violence and mental ill-health, with the fewest resources to respond. Despite increased focus on wellbeing for research participants and, to a lesser degree, professional researchers in such studies, the role-specific needs of community-based researchers receive scant attention. This co-produced paper draws insights from one group's experience to identify rewards, challenges, and recommendations for supporting wellbeing and development of community-based researchers in sensitive participatory projects in low-resource settings. Twenty-one community-based researchers supporting a mixed-methods study on youth, violence and mental health in Sri Lanka submitted 63 reflexive structured journal entries across three rounds of data collection. We applied Attride-Stirling's method for thematic analysis to explore peer researchers' learning about research, violence and mental health; personal-professional boundaries; challenges in sensitive research; and experiences of support from the core team. Sri Lanka's first study capturing experiences of diverse community-based researchers aims to inform the growing number of global health and development actors relying on such talent to deliver sensitive and emotionally difficult work in resource-limited and potentially volatile settings. Viewing participatory research as an opportunity for mutual learning among both community-based and professional researchers, we identify practice gaps and opportunities to foster respectful team dynamics and create generative and safe co-production projects for all parties. Intentional choices around communication, training, human and consumable resources, project design, and navigating instable research conditions can strengthen numerous personal and professional capacities across teams. Such individual and collective growth holds potential to benefit short- and long-term quality of evidence and inform action on critical issues, including violence and mental health, facing high-burden, low-resource contexts.
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Affiliation(s)
- Alexis Palfreyman
- Institute for Global Health, University College London, London, United Kingdom
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Bellerose M, Gogoi A, Rauf R, Sacks E. Deterministic, not tokenistic: placing women's demands at the centre of health policies and programmes. Sex Reprod Health Matters 2022; 29:2105293. [PMID: 36017910 PMCID: PMC9423829 DOI: 10.1080/26410397.2022.2105293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Meghan Bellerose
- MPH Student, Department of Population and Family Health, Columbia University Mailman School of Public Health, New York City, NY, USA
| | - Aparajita Gogoi
- National Coordinator, White Ribbon Alliance, New Delhi, India
| | - Rafia Rauf
- National Coordinator, White Ribbon Alliance, Islamabad, Pakistan. Correspondence:
| | - Emma Sacks
- Associate Faculty, Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
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Majumdar P, Gupta SD, Mangal DK, Sharma N, Kalbarczyk A. Understanding the role of power and its relationship to the implementation of the polio eradication initiative in india. FRONTIERS IN HEALTH SERVICES 2022; 2:896508. [PMID: 36925767 PMCID: PMC10012611 DOI: 10.3389/frhs.2022.896508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022]
Abstract
Background Power is exercised everywhere in global health, although its presence may be more apparent in some instances than others. Studying power is thus a core concern of researchers and practitioners working in health policy and systems research (HPSR), an interdisciplinary, problem-driven field focused on understanding and strengthening multilevel systems and policies. This paper aims to conduct a power analysis as mobilized by the actors involved in implementation of the polio program. It will also reflect how different power categories are exerted by actors and embedded in strategies to combat program implementation challenges while planning and executing the Global Polio Eradication Initiative. Methods We collected quantitative and qualitative data from stakeholders who were part of the Polio universe as a part of Synthesis and Translation of Research and Innovations from the Polio Eradication Project. Key informants were main actors of the polio eradication program, both at the national and sub-national levels. Research tools were designed to explore the challenges, strategies and unintended consequences in implementing the polio eradication program in India. We utilized Moon's expanded typology of power in global governance to analyze the implementation of the polio eradication programme in India. Results We collected 517 survey responses and conducted 25 key informant interviews. Understanding power is increasingly recognized as an essential parameter to understand global governance and health. Stakeholders involved during polio program implementation have exerted different kinds of power from structural to discursive, moral power wielded by religious leaders to institutional power, expert power used by professional doctors to commoners like female vaccinators, and network power exercised by community influencers. Hidden power was also demonstrated by powerless actors like children bringing mothers to polio booths. Conclusion Power is not a finite resource, and it can be used, shared, or created by stakeholders and networks in multiple ways. Those people who seem to be powerless possess invisible power that can influence decision making. Moreover, these power categories are not mutually exclusive and may be deeply interconnected with each other; one type of power can be transformed into another. Power and relations play an important role in influencing the decision-making of the community and individuals. Mid-range theories of core implementation science like PARIHAS and CFIR can also add an important variable of power in their construct necessary for implementation success of any health program.
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Affiliation(s)
- Piyusha Majumdar
- SD Gupta School of Public Health, IIHMR University, Jaipur, Rajasthan, India
| | - S D Gupta
- Indian Institute of Health Management Research, Jaipur, Rajasthan, India
| | - D K Mangal
- IIHMR University, Jaipur, Rajasthan, India
| | - Neeraj Sharma
- SD Gupta School of Public Health, IIHMR University, Jaipur, Rajasthan, India
| | - Anna Kalbarczyk
- International Health, Bloomberg School of Public Health, Baltimore, MD, United States
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Ridde V, Hane F. Universal health coverage: the roof has been leaking for far too long. BMJ Glob Health 2021; 6:bmjgh-2021-008152. [PMID: 34896981 PMCID: PMC8663104 DOI: 10.1136/bmjgh-2021-008152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 01/10/2023] Open
Affiliation(s)
- Valéry Ridde
- Université de Paris, IRD, INSERM, Ceped, IRD, Paris, France .,Institut de Santé et Développement (ISED), Université Cheikh Anta Diop, Dakar, Senegal
| | - Fatoumata Hane
- Département de sociologie, Université Assane Seck, Ziguinchor, Senegal
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