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Noory B, Habib RR, Nuwayhid I. Exposure of Syrian refugee agricultural workers to pesticides in Lebanon: a socio-economic and political lens. Front Public Health 2024; 12:1402511. [PMID: 38993703 PMCID: PMC11236552 DOI: 10.3389/fpubh.2024.1402511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/17/2024] [Indexed: 07/13/2024] Open
Abstract
This article adopts a socio-economic and political lens to elucidate the interplay of factors that heighten the vulnerability of Syrian refugee agricultural workers and their exposure to pesticides in Lebanon. It provides a comprehensive understanding for the interconnected social, political and economic factors at the global, regional, national and local levels and how they increase the vulnerability of Syrian refugee agricultural workers, particularly their exposure to pesticides. The global factors highlight the shifts from colonialism to state-controlled economies to neoliberal policies. These changes have prioritized the interests of large agricultural schemes and multinationals at the expense of small and medium-sized agriculture. Consequently, there has been a boost in pesticides demand, coupled with weak regulations and less investment in agriculture in the countries of the Global South. The article explains how the dynamic interaction of climate change and conflicts in the Middle East and North Africa region has negatively impacted the agriculture sector and food production, which led to an increased potential for pesticide use. At the national and local levels, Lebanon's social, political and economic policies have resulted in the weakening of the agricultural sector, the overuse of pesticides, and the intensification of the Syrian refugee agricultural workers' vulnerability and exposure to pesticides. The article recommends that researchers, policymakers, and practitioners adopt a political-economic-social lens to analyze and address the full dynamic situation facing migrant and refugee workers in Lebanon and other countries and promote equity in the agricultural sector globally.
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Affiliation(s)
- Bandar Noory
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Rima R. Habib
- Department of Environmental Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Iman Nuwayhid
- Department of Environmental Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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2
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Mukiga AK, Boadu ES, Edson T. Perceived Public Participation and Health Delivery in Local Government Districts in Uganda. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:820. [PMID: 39063398 PMCID: PMC11276518 DOI: 10.3390/ijerph21070820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024]
Abstract
Citizen participation is a crucial aspect of the national health system, empowering individuals to contribute to improving local health services through Health Committees (HCs). HCs promote the participation of citizens in the delivery of primary healthcare services. The study explores the perceptions of citizen participation in the context of the Ruhama County Ntungamo local government area, Uganda. This study aims to understand the impact of HCs on healthcare service delivery. Using a qualitative approach of inquiry grounded in thematic analysis and rooted in principal-agent theory in a single case study, this study examined citizens' participation in the delivery of a local healthcare service. The study is based on interviews with 66 participants comprising health workers, patients, residents, health administrators, local councillors, and HC members. The findings reveal a notable absence of a health committee in healthcare delivery in Ruhama County. The absence is attributed to a need for a formalised citizen participation structure in managing health facilities and service delivery. It raises concerns about the limited influence of citizens in shaping healthcare policies and decision-making processes. The study recommends the incorporation of health committees into the local health systems to enhance participation and grant communities greater influence over the management of health facilities and service delivery. Incorporating health committees into local health systems strengthens citizen participation and leads to more effective and sustainable healthcare services aligned with people's needs and preferences. Integrating health committees within Itojo Hospital and similar facilities can grant citizens a meaningful role in shaping the future of their healthcare.
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Affiliation(s)
- Alex Kihehere Mukiga
- Centre for Development Support, University of Free State, Bloemfontein 9300, South Africa
| | - Evans Sakyi Boadu
- School of Governance, University of the Witwatersrand, Johannesburg 2050, South Africa;
- School of Sustainable Development, University of Environment and Sustainable Development (UESD), Somanya 00233, Ghana
| | - Tayebwa Edson
- Department of Surgery, Mbarara University of Science and Technology, Mbarara 1410, Uganda
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3
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Aivalli P, Gilmore B, Srinivas PN, De Brún A. Navigating intersectoral collaboration in nutrition programming: implementors' perspectives from Assam, India. Arch Public Health 2024; 82:82. [PMID: 38849925 PMCID: PMC11157891 DOI: 10.1186/s13690-024-01312-6] [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] [Received: 03/18/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND There is a growing interest in the use of intersectoral collaborative (ISC) approaches to address complex health-related issues. However, relatively little empirical research exists on the challenges of implementing, fostering and sustaining these approaches. Our study explores the perceptions and experiences of programme implementers regarding the implementation of an ISC approach, focusing on a case study of nutrition programming in Assam, India. METHODS We conducted qualitative semi-structured face-to-face in-depth interviews with eleven programme implementers from two selected districts of Assam, India. These participants were purposefully sampled to provide a comprehensive understanding of the experiences of implementing intersectoral collaboration. Following the interviews, an inductive thematic analysis was performed on the collected data. RESULTS The study identified three main themes: operationalisation of ISC in daily practice, facilitators of ISC, and barriers to effective ISC. These were further broken down into six subthemes: defined sectoral mandates, leadership dynamics, interpersonal relationships and engagement, collective vision and oversight, resource allocation, and power dynamics. These findings highlight the complexity of ISC, focusing on the important structural and relational aspects at the macro, meso, and micro levels. Interpersonal relationships and power dynamics among stakeholders substantially influenced ISC formation in both the districts. CONCLUSION Despite challenges, there is ongoing interest in establishing ISC in nutrition programming, supported by political development agendas. Success relies on clarifying sectoral roles, addressing power dynamics, and engaging stakeholders systematically. Actionable plans with measurable targets are crucial for promoting and sustaining ISC, ensuring positive programme outcomes. The insights from our study provide valuable guidance for global health practitioners and policymakers dealing with similar challenges, emphasising the urgent need for comprehensive research given the lack of universally recognised policies in the realm of ISC in global health practice.
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Affiliation(s)
- Praveenkumar Aivalli
- UCD Centre for Interdisciplinary Research Education and Innovation in Health Systems (UCD IRIS Centre), School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland.
- School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland.
- , Guwahati, India.
| | - Brynne Gilmore
- UCD Centre for Interdisciplinary Research Education and Innovation in Health Systems (UCD IRIS Centre), School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland
- School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | | | - Aoife De Brún
- UCD Centre for Interdisciplinary Research Education and Innovation in Health Systems (UCD IRIS Centre), School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland
- School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland
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Obol SJ, Nzedibe O. Critical perspective on infodemic and infodemic management in previous Ebola outbreaks in Uganda. Front Public Health 2024; 12:1375776. [PMID: 38532966 PMCID: PMC10963486 DOI: 10.3389/fpubh.2024.1375776] [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: 01/24/2024] [Accepted: 02/22/2024] [Indexed: 03/28/2024] Open
Abstract
This research investigates the complex dynamics of Uganda's recent Ebola outbreaks, emphasizing the interplay between disease spread, misinformation, and existing societal vulnerabilities. Highlighting poverty as a core element, it delves into how socioeconomic factors exacerbate health crises. The study scrutinizes the role of political economy, medical pluralism, health systems, and informal networks in spreading misinformation, further complicating response efforts. Through a comprehensive analysis, this study aims to shed light on the multifaceted challenges faced in combating epidemics in resource-limited settings. It calls for integrated strategies that address not only the biological aspects of the disease but also the socioeconomic and informational ecosystems that influence public health outcomes. This perspective research contributes to a better understanding of how poverty, medical pluralism, political economy, misinformation, and health emergencies intersect, offering insights for future preparedness and response initiatives.
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Affiliation(s)
| | - Okechi Nzedibe
- International Public Health, Euclid University, Bangui, Central African Republic
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Ecks S, Kulkarni V. 'Having the card makes us feel worthless': the negative value of government-funded health insurance in India. Anthropol Med 2023; 30:380-393. [PMID: 38299487 DOI: 10.1080/13648470.2023.2291738] [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: 09/27/2021] [Accepted: 04/28/2023] [Indexed: 02/02/2024]
Abstract
Since the 2000s, hundreds of government-funded health insurance (GFHI) schemes were introduced in India. These schemes are meant to prevent poorer households from incurring catastrophic health expenditures. Through GFHIs, policy-makers want to mobilize the decision-making powers of private consumers in a liberalized healthcare market. Patients are called upon to act as 'co-creators' of healthcare value by optimizing supply through demand. Based on long-term ethnographic fieldwork with insurance users in South India, we argue that GFHIs fail because people experience the value of insurance in drastically different ways that only partly overlap with how the policy assumes they value insurance. In addition, the hollow promises of health coverage can be experienced as so frustrating that signing up for health insurance actually makes people feel devalued.
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Boland ST, Balabanova D, Mayhew S. Examining the militarised hierarchy of Sierra Leone's Ebola response and implications for decision making during public health emergencies. Global Health 2023; 19:89. [PMID: 37993942 PMCID: PMC10664671 DOI: 10.1186/s12992-023-00995-w] [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: 06/08/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND In September, 2014, Médecins Sans Frontières (MSF) called for militarised assistance in response to the rapidly escalating West Africa Ebola Epidemic. Soon after, the United Kingdom deployed its military to Sierra Leone, which (among other contributions) helped to support the establishment of novel and military-led Ebola Virus Disease (Ebola) response centres throughout the country. To examine these civil-military structures and their effects, 110 semi-structured interviews with civilian and military Ebola Response Workers (ERWs) were conducted and analysed using neo-Durkheimian theory. RESULTS The hierarchical Ebola response centres were found to be spaces of 'conflict attenuation' for their use of 'rule-bound niches', 'neutral zones', 'co-dependence', and 'hybridity', thereby not only easing civil-military relationships (CMRel), but also increasing the efficiency of their application to Ebola response interventions. Furthermore, the hierarchical response centres were also found to be inclusive spaces that further increased efficiency through the decentralisation and localisation of these interventions and daily decision making, albeit for mostly privileged groups and in limited ways. CONCLUSIONS This demonstrates how hierarchy and localisation can (and perhaps should) go hand-in-hand during future public health emergency responses as a strategy for more robustly including typically marginalised local actors, while also improving necessary efficiency-in other words, an 'inclusive hierarchical coordination' that is both operationally viable and an ethical imperative.
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Affiliation(s)
- Samuel T Boland
- Centre for Universal Health, Chatham House, 10 St James's Square, London, SW1Y 4LE, UK.
| | - Dina Balabanova
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Square, London, WC1H 9SH, UK
| | - Susannah Mayhew
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Square, London, WC1H 9SH, UK
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Barthélemy EJ, Diouf SA, Silva ACV, Abu-Bonsrah N, de Souza IAS, Kanmounye US, Gabriel P, Sarpong K, Nduom EK, Lartigue JW, Esene I, Karekezi C. Historical determinants of neurosurgical inequities in Africa and the African diaspora: A review and analysis of coloniality. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001550. [PMID: 36962931 PMCID: PMC10021312 DOI: 10.1371/journal.pgph.0001550] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The movement to decolonize global health challenges clinicians and researchers of sub-disciplines, like global neurosurgery, to redefine their field. As an era of racial reckoning recentres the colonial roots of modern health disparities, reviewing the historical determinants of these disparities can constructively inform decolonization. This article presents a review and analysis of the historical determinants of neurosurgical inequities as understood by a group of scholars who share Sub-Saharan African descent. Vignettes profiling the colonial histories of Cape Verde, Rwanda, Cameroon, Ghana, Brazil, and Haiti illustrate the role of the colonial legacy in the currently unmet need for neurosurgical care in each of these nations. Following this review, a bibliographic lexical analysis of relevant terms then introduces a discussion of converging historical themes, and practical suggestions for transforming global neurosurgery through the decolonial humanism promulgated by anti-racist practices and the dialogic frameworks of conscientization.
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Affiliation(s)
- Ernest J. Barthélemy
- Global Neurosurgery Laboratory, Division of Neurosurgery, Department of Surgery, SUNY Downstate Health Sciences University, Brooklyn, New York, United States of America
- Society of Haitian Neuroscientists, Inc., New York, New York, United States of America
| | - Sylviane A. Diouf
- Center for the Study of Slavery & Justice, Brown University, Providence, Rhode Island, United States of America
| | | | - Nancy Abu-Bonsrah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Research Department, Association of Future African Neurosurgeons, Yaoundé, Cameroon
| | | | - Ulrick Sidney Kanmounye
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Phabinly Gabriel
- Society of Haitian Neuroscientists, Inc., New York, New York, United States of America
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Kwadwo Sarpong
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Edjah K. Nduom
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Jean Wilguens Lartigue
- Society of Haitian Neuroscientists, Inc., New York, New York, United States of America
- Department of Surgery, Mirebalais University Hospital, Zanmi Lasante, Mirebalais, Haiti
| | - Ignatius Esene
- Department of Neurosurgery, Division of Neurosurgery, Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon
| | - Claire Karekezi
- Neurosurgery Unit, Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda
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Kehr J. The moral economy of universal public healthcare. On healthcare activism in austerity Spain. Soc Sci Med 2023; 319:115363. [PMID: 36443121 DOI: 10.1016/j.socscimed.2022.115363] [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: 11/30/2021] [Revised: 07/06/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022]
Abstract
Spain has a national health service, universal in access and free at the point of use. The global economic crisis of 2008, with its subsequent austerity policies, has put the universality of public healthcare at risk. This has led to an increase in healthcare activism, whose aim is to fight healthcare cuts and privatization to safeguard the national health service for all. This article addresses such healthcare activism. Drawing on long-term fieldwork with a heterogeneous set of actors ranging from individual activists and unions to ad hoc activist collectives, I will analyze the moral economy of healthcare activists in Madrid, to understand why and in which terms they defend universal healthcare as a common good and challenge its marketization. In Spain, since the democratic transition, struggles around what constitutes a common weal have been highly politicized and affect-laden. The national health system stands as one example here, as it is closely linked to the emergence of the democratic welfare state in the late 1970s, following decades of Franco's dictatorship. This makes Spain a particularly interesting case, as the widely acknowledged understanding of public healthcare as a public and social good is intimately linked to democratization and welfare. Therefore, struggles over the nature of health systems are also struggles over the political, moral and economic organization of society, over (il)legitimate forms of power and over ways of caring for each other. In such struggles, visions of the public, the state and the political economy come to the fore. In Spain, there is ambivalence about the state's role as both protector and provider of the public good, but also as facilitator of capitalism, which this article will address.
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Affiliation(s)
- Janina Kehr
- University of Vienna, Department of Social and Cultural Anthropology, Universitätsstraße 7, 1010, Wien, Austria.
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Gorsky M, Manton J. The political economy of 'strengthening health services': The view from WHO AFRO, 1951-c.1985. Soc Sci Med 2023; 319:115412. [PMID: 36566115 DOI: 10.1016/j.socscimed.2022.115412] [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: 11/28/2021] [Revised: 08/02/2022] [Accepted: 09/27/2022] [Indexed: 11/19/2022]
Abstract
Our contribution to this special issue examines the early history of international striving for universal health care, from the perspective of the World Health Organisation's (WHO's) Regional Office for Africa (AFRO). The aspiration was repeatedly reframed, from 'strengthening health services' in the 1948 constitution of the World Health Organisation (WHO), to 'Health For All' through primary health care (PHC) in the 1970s, to today's articulations of universal coverage and 'health systems strengthening'. We aim to establish how AFRO supported member states in implementing these policies up to the mid-1980s, and with what degree of success. We also compare AFRO's experience to the established historiographical narrative of global health, as over-fixated on vertical interventions, save for the transitory impact of the PHC movement. Using the archives of WHO in Geneva and AFRO in Brazzaville, we first analyse AFRO's influence and capacity through quantitative financial data. The AFRO nations were net recipients of WHO resources, raising questions about their relative autonomy and voice in the organisation. We then examine AFRO's expenditure, showing that though circumscribed by funds with allocated purposes, there was nonetheless a significant proportion committed to services from the early 1960s, specifically capacity for planning and administration and the nursing, maternal and child health workforce. Counter to expectations though, there was no significant boost to these areas, nor to funding PHC projects, in the 1970s/early 1980s, when disease-specific interventions obtained a larger share. Qualitative sources show that despite its slender resources AFRO accomplished much with respect to training, capacity building and supporting innovative service-delivery, while insisting on African policy input into design and implementation. However country level system-wide planning in health was persistently vulnerable, and the bureaucratic capacity of post-colonial states often weak. Thus AFRO's overall impact was decisively bounded by the global structural inequalities in which it operated.
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Affiliation(s)
- Martin Gorsky
- Centre for History in Public Health, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, UK.
| | - John Manton
- Centre for History in Public Health, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, UK.
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Bannister D. Whose public, whose goods? Generations of patients and visions of fairness in Ghanaian health. Soc Sci Med 2023; 319:115393. [PMID: 36411126 DOI: 10.1016/j.socscimed.2022.115393] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 08/02/2022] [Accepted: 09/22/2022] [Indexed: 10/14/2022]
Abstract
Since Ghana's independence in 1957, the country has seen an ebb and flow of reforms intended to expand and fund state healthcare, informed by diverse notions of affordability and adequate provision. Cycles of attempted health reforms have emerged from disparate political and economic ideologies, themselves a product of broader global histories and specific national experiences. Based on group interviews with people across most administrative regions of Ghana, this paper examines how the formative historical experiences of different generations gives rise to a multiplicity of understandings of what constitutes a 'fair' distribution of national health resources. It discusses the forms and contents of arguments that people of different ages raised in both rural and urban settings in the course of the study - with particular reference to the operation of Ghana's current National Health Insurance Scheme, and in light of their perceptions of the justice or injustice of present day healthcare in relation to earlier periods.
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Affiliation(s)
- David Bannister
- The Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway.
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Kehr J, Muinde JVS, Prince RJ. Health for all? Pasts, presents and futures of aspirations for universal healthcare. Soc Sci Med 2023; 319:115660. [PMID: 36697329 DOI: 10.1016/j.socscimed.2023.115660] [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] [Indexed: 01/07/2023]
Abstract
In this special issue, we bring together anthropological and historical work that considers successive aspirations towards 'health for all': their pasts, their futures, and their diverse meanings and iterations. Across the world, hopes for providing 'health for all' were central to nation building in the long 20th century, and for international relations, particularly after the second world war and the establishment of the WHO. Health became seen as a fundamental good by citizens of North and South and has remained a central force shaping global and national politics until today. But what does 'health for all' actually mean, and how did it come to matter? In this introduction we approach 'health for all as a situated, multi-faceted phenomenon, that - while having a shared aspiration towards universality of access and equality of care - comes into focus in partial, diverse and contentious policies, programmes, projects and practices. Beyond homogenising narratives that frame 'health for all' in terms of either success or failure, the special issue highlights the diverse iterations that 'health for all' has taken on the ground for different subjects and groups of people, exploring exclusions and limitations as well as dreams and aspirations.
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Affiliation(s)
- Janina Kehr
- Institute for Social and Cultural Anthropology, University of Vienna, Austria
| | - Jacinta Victoria Syombua Muinde
- University of Oslo, Institute of Health and Society, P O Box 1130, Blindern, Oslo, 0317, Norway; Department of Social Anthropology, University of Oslo, Norway
| | - Ruth J Prince
- University of Oslo, Institute of Health and Society, P O Box 1130, Blindern, Oslo, 0317, Norway.
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Wintrup J. Health by the people, again? The lost lessons of Alma-Ata in a community health worker programme in Zambia. Soc Sci Med 2023; 319:115257. [PMID: 36115730 DOI: 10.1016/j.socscimed.2022.115257] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 05/24/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
National community health worker (CHW) programmes were central to the vision of primary health care that emerged from the Alma-Ata declaration of 1978. CHWs were identified as agents who could offer basic medical treatment and promote community participation and empowerment. Despite the ambitions of this era, many national CHW programmes were neglected, starved of funding, or discontinued in the decades that followed. These programmes were difficult to sustain in a context of rising debt and structural adjustment, but they also suffered due to poor implementation and a lack of clarity about the role and identity of CHWs. Nevertheless, national CHW programmes have returned to the policy agenda in the past fifteen years and key figures and organisations within global health have begun to argue that they offer a way of strengthening health systems and achieving universal health coverage (UHC). Based on ethnographic research conducted between 2019 and 2020, this article examines a new national CHW programme that has been introduced in Zambia. However, as I show in this article, Zambia's new CHW programme has suffered from many of the same key problems that affected the programmes of the Alma-Ata era: insufficient funding, poor implementation, and a lack of clarity about the role of CHWs. This article shows how these mistakes have been repeated and asks why the lessons of the Alma-Ata era have been lost. Three central problems are identified: national CHW programmes continue to be underfunded and regarded as a "cheap" solution; global health organisations and actors today prioritise technical and quantitative approaches when they design and implement these programmes and therefore overlook the historical experiences and qualitative research of the past thirty years; and, finally, policymakers continue to gloss over the tensions and contradictions within the idea of the "community health worker" itself, creating unclear and unrealistic expectations for CHWs.
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Affiliation(s)
- James Wintrup
- Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway.
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Muinde JVS, Prince RJ. A new universalism? Universal health coverage and debates about rights, solidarity and inequality in Kenya. Soc Sci Med 2023; 319:115258. [PMID: 36307339 DOI: 10.1016/j.socscimed.2022.115258] [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: 11/30/2021] [Revised: 05/23/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
The rise of universal health coverage (UHC) as a global policy endorsed in the Sustainable Development Goals (SGDs) appears to signal new directions in global health as it introduces a progressive language of inclusion, solidarity and social justice and advocates the right of 'everyone' to access the healthcare they need 'without financial hardship'. Since 2018 the Kenyan government has attempted to widen access to healthcare by experimenting with free health care services and expanding health insurance coverage. Such progressive moves are, however, layered onto histories of healthcare, citizenship and state responsibility that in Kenya have been dominated by forms of exclusion, differentiation, a politics of patronage, and class inequality, all of which work against universal access. In this paper, we follow recent attempts to increase access to healthcare, paying particular attention to how a language of rights and inclusion circulated among "ordinary citizens" as well as among the health workers and government officials tasked with implementing reforms. Despite being clothed in a language of universalism, solidarity and inclusion, Kenya's UHC reforms feed into an already fragmented and struggling healthcare system, reinforcing differentiated, limited and uneven access to healthcare services and reproducing inequity and exclusions. In this context, reforms for universal health coverage that promise a form of substantial citizenship are in tension with Kenyans' experiences of accessing healthcare. We explore how, amid vocal concerns about healthcare costs and state neglect, the promises and expectations surrounding universal health coverage reforms shaped the claims people made to accessing care. While our informants were cynical about these promises, they were also hopeful. The language of universality and inclusion drew people's attention to entrenched forms of inequality and difference, the limits of solidarity and the gaps between promises and realities, but it also generated expectations and a sense of new possibilities.
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Affiliation(s)
- Jacinta Victoria S Muinde
- University of Oslo, Department of Social Anthropology, Norway; University of Oslo, Institute of Health and Society, Norway.
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Chary AN, Nandi M, Flood D, Tschida S, Wilcox K, Kurschner S, Garcia P, Rohloff P. Qualitative study of pathways to care among adults with diabetes in rural Guatemala. BMJ Open 2023; 13:e056913. [PMID: 36609334 PMCID: PMC9827254 DOI: 10.1136/bmjopen-2021-056913] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE The burden of diabetes mellitus is increasing in low-income and middle-income countries (LMICs). Few studies have explored pathways to care among individuals with diabetes in LMICs. This study evaluates care trajectories among adults with diabetes in rural Guatemala. DESIGN A qualitative investigation was conducted as part of a population-based study assessing incidence and risk factors for chronic kidney disease in two rural sites in Guatemala. A random sample of 807 individuals had haemoglobin A1c (HbA1c) screening for diabetes in both sites. Based on results from the first 6 months of the population study, semistructured interviews were performed with 29 adults found to have an HbA1c≥6.5% and who reported a previous diagnosis of diabetes. Interviews explored pathways to and experiences of diabetes care. Detailed interview notes were coded using NVivo and used to construct diagrams depicting each participant's pathway to care and use of distinct healthcare sectors. RESULTS Participants experienced fragmented care across multiple health sectors (97%), including government, private and non-governmental sectors. The majority of participants sought care with multiple providers for diabetes (90%), at times simultaneously and at times sequentially, and did not have longitudinal continuity of care with a single provider. Many participants experienced financial burden from out-of-pocket costs associated with diabetes care (66%) despite availability of free government sector care. Participants perceived government diabetes care as low-quality due to resource limitations and poor communication with providers, leading some to seek care in other health sectors. CONCLUSIONS This study highlights the fragmented, discontinuous nature of diabetes care in Guatemala across public, private and non-governmental health sectors. Strategies to improve diabetes care access in Guatemala and other LMICs should be multisectorial and occur through strengthened government primary care and innovative private and non-governmental organisation care models.
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Affiliation(s)
- Anita Nandkumar Chary
- Medicine & Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
| | - Meghna Nandi
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Family Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - David Flood
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott Tschida
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
| | - Katharine Wilcox
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Family Medicine, University of Illinois Medical Center at Chicago, Chicago, Illinois, USA
| | - Sophie Kurschner
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Pablo Garcia
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Nephrology, Stanford University School of Medicine, Stanford, California, USA
| | - Peter Rohloff
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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15
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Louvel S, Soulier A. Biological embedding vs. embodiment of social experiences: How these two concepts form distinct thought styles around the social production of health inequalities. Soc Sci Med 2022; 314:115470. [PMID: 36327636 DOI: 10.1016/j.socscimed.2022.115470] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/10/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES This article compares research on biological embedding and the embodiment of social experiences, two concepts proposed in the 1990s to introduce a new perspective on the social production of health inequalities. We draw on Ludwig Fleck's concept of 'thought style' (1935/2008) to question the possible emergence of a common research program around the processes by which the social becomes biological. METHODS We compiled a corpus of 322 articles referring to either biological embedding or to the embodiment of social experiences, identified in the Web of Science core collection and published from 1990 to 2021. We analyzed the articles' use of these concepts using scientometric indicators and qualitative content analysis. RESULTS Initial differences between the research agendas associated with biological embedding and embodiment are strengthened as both concepts circulate around scientific communities studying the social production of health inequalities. Thought styles formed around embedding and embodiment differ significantly in terms of shared references, sets of methods and research questions, and policy recommendations. Research on biological embedding forms a thought style shared by researchers in the biomedical and public health sciences. Conversely, the concept of embodiment of social experiences connects perspectives from biomedical, public health, human and social sciences, and gathers three thought styles, one identical to that of biological embedding and two formed in social epidemiology and in medical anthropology. CONCLUSIONS Acknowledging the differences between the concepts and divergences in their evolution provides an opportunity for identification of topics where thought styles are either complementary or in tension.
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Affiliation(s)
- Séverine Louvel
- PACTE - Sciences Po Grenoble, 1030 Avenue Centrale, Domaine Universitaire, 38040 Grenoble Cedex 09, France.
| | - Alexandra Soulier
- IHPST - Institut D'histoire et de Philosophie des Sciences et des Techniques (UMR 8590), Maison de La Philosophie - Marin Mersenne, 13, Rue Du Four, 75006 Paris, France.
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16
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Chapman RR, Raige H, Abdulahi A, Mohamed S, Osman M. Decolonising the global to local movement: Time for a new paradigm. Glob Public Health 2022; 17:3076-3089. [PMID: 34788558 DOI: 10.1080/17441692.2021.1986736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Mama Amaan Project (MAP) delivered perinatal education and doula services to underserved refugee and immigrant communities in Seattle, Washington. MAP presented at a 'global to local (glocal)' workshop for US-based global health agencies redirecting their experience and resources to address domestic health crises. Glocal models reference Global South anti-colonial social transformations through Primary Health Care (PHC) - 'health for all as a right' and investment in strong public sectors. As Black women working in our communities, we resisted labelling MAP glocal. Western donors and NGOs appropriate PHC's community participation narratives, meanwhile implementing World Bank/IMF economic structural adjustment health system cuts - thereby shifting austerity-related resource shortfalls to communities. In US contexts of neoliberal shrinking social safety nets and workers' rights, similar strategies to address austerity-related health disparities are promoted as 'global to local'. Projects like MAP cannot substitute quality public services. They expose gaps and build community empowerment to demand quality healthcare. Drawing on MAP and 'global health' experience in Mozambique, we call for re-embracing PHC's activist values - agitating for health as a universal human right for all, rather than putting the burden and blame on underserved communities. We propose decolonising the 'glocal' paradigm by embracing 'transnationality', 'relationality' and 'mutuality'.
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Affiliation(s)
- Rachel R Chapman
- Department of Anthropology, University of Washington, Seattle, WA, USA
| | | | | | - Sumaya Mohamed
- Department of Anthropology, University of Washington, Seattle, WA, USA.,Mama Amaan, Seattle, WA, USA
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17
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Glynn EH. Corruption in the health sector: A problem in need of a systems-thinking approach. Front Public Health 2022; 10:910073. [PMID: 36091569 PMCID: PMC9449116 DOI: 10.3389/fpubh.2022.910073] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/27/2022] [Indexed: 01/22/2023] Open
Abstract
Health systems are comprised of complex interactions between multiple different actors with differential knowledge and understanding of the subject and system. It is exactly this complexity that makes it particularly vulnerable to corruption, which has a deleterious impact on the functioning of health systems and the health of populations. Consequently, reducing corruption in the health sector is imperative to strengthening health systems and advancing health equity, particularly in low- and middle-income countries (LMICs). Although health sector corruption is a global problem, there are key differences in the forms of and motivations underlying corruption in health systems in LMICs and high-income countries (HICs). Recognizing these differences and understanding the underlying system structures that enable corruption are essential to developing anti-corruption interventions. Consequently, health sector corruption is a problem in need of a systems-thinking approach. Anti-corruption strategies that are devised without this understanding of the system may have unintended consequences that waste limited resources, exacerbate corruption, and/or further weaken health systems. A systems-thinking approach is important to developing and successfully implementing corruption mitigation strategies that result in sustainable improvements in health systems and consequently, the health of populations.
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Affiliation(s)
- Emily H. Glynn
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
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18
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Ameso EA, Prince RJ. Striking health workers: Precarity and healthcare in neoliberal Kenya. ANTHROPOLOGY TODAY 2022. [DOI: 10.1111/1467-8322.12742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Thulin EJ, McLean KE, Sevalie S, Akinsulure-Smith AM, Betancourt TS. Mental health problems among children in Sierra Leone: Assessing cultural concepts of distress. Transcult Psychiatry 2022; 59:461-478. [PMID: 32316867 DOI: 10.1177/1363461520916695] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Globally, over 13% of children and adolescents are affected by mental disorders, yet relatively little scholarship addresses how risk factors, symptoms, and nosology vary by culture and context, especially in young children living in post-conflict and low-resource settings. To address this gap, we conducted a qualitative study to identify and describe the most salient mental health problems facing children aged 6 to 10 years in Sierra Leone, as well as the thoughts, feelings, and behaviors related to these problems. Free list interviews (N = 200) and semi-structured interviews (N = 66) were conducted among caregivers, children, and other relevant key informants to explore risk factors and locally meaningful concepts of distress. Our findings indicate that children are faced with a variety of challenges in their social environments that contribute to distress, including hunger, unmet material needs, and excessive work. Our research identifies five contextually defined mental health problems faced by young children: gbos gbos (angry, destructive behavior), poil at (sad, disruptive behavior), diskoraj (sad, withdrawn), wondri (excessive worry), and fred fred (abnormal fear). The manifestations of these distress concepts are described in detail and contextualized according to Sierra Leone's history of war and current backdrop of poverty and insecurity. Implications are discussed for locally relevant diagnosis and treatment as well as for the wider literature on global child mental health.
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Affiliation(s)
- Elyse J Thulin
- Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA
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20
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Khanakwa S, Mbonigaba J. Institutional Arrangements for Providing HIV and AIDS Services in Uganda: A Transaction Cost Economics Analysis. Health Serv Insights 2022; 15:11786329221096046. [PMID: 35571583 PMCID: PMC9092571 DOI: 10.1177/11786329221096046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
Transaction cost economics (TCE) theory predicts that features of institutional arrangements determine the intensity of their governance instruments. Consequently, institutional features link to transaction costs, but the linkages have received little attention in the public health literature. This study sought to address this gap. It examined the governance features of institutional arrangements and their transaction cost implications for providing HIV prevention and social support services in Uganda. The analysis was based on 4 proposed TCE governance instruments: administrative controls, adaptation, incentives and contract laws. These governance instruments were assessed in 3 modes of delivery( institutional arrangments) for HIV and AIDS Services in Uganda: Contracting-Out – the case of DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe); a Public-Non-Governmental Organisation (NGO) partnership – the case of the CHAI (Community-led HIV/AIDS Initiative); and direct Public Sector Delivery. These assessed delivery modes follow Williamson’s TCE framework of 3 institutional arrangements to deliver goods and services, notably market, hybrid (partnership) and internal (hierarchy) delivery, with related governance features. Within this framework, the discriminating alignment hypothesis guided the analysis. According to the hypothesis, the delivery modes of goods and services result in smaller transaction costs when their governance features are as predicted by TCE. The hypothesis was assessed by analysing, with qualitative methods, the differences in HIV and AIDS services characteristics across the 3 arrangements and their differences with theory prediction, and hence the difference in transaction cost implications. The study found that the delivery arrangements that minimised cost are those whose HIV and AIDS services were aligned with the TCE theory prediction. The aligned ‘public-NGO partnership’ arrangement (CHAI) had fewer sources of transactional costs than the misaligned arrangements – ‘contracting-out’ (DREAMS) and ‘public sector’. The analysis revealed that the DREAMS and public sector delivery models suffered some flaws in efficiencies. DREAMS had high administrative controls, high-powered tangible incentive intensity and intensive monitoring mechanisms for performance adaptation due to the lack of ‘trust’ on the part of the financing agency, contrary to the TCE prediction. In contrast with the TCE prediction, low administrative controls in the public sector arose from the failure to invest in performance monitoring systems. The high-powered incentive intensity and low administrative controls observed in the CHAI arrangement primarily stemmed from the reliance on informal institutions (trust, social expectations and reputation) rather than principal-agent arms-length sanctions. These results suggest that the level of transaction costs is associated with features of institutional arrangements. The valuable insights from TCE could contribute to policymaking during the design of institutional arrangements to efficiently deliver HIV and AIDS services.
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Affiliation(s)
- Sarah Khanakwa
- Health Economics and HIV/AIDS Research Division, Westville Campus, University of KwaZulu-Natal, Durban, South Africa, and Uganda AIDS Commission
| | - Josue Mbonigaba
- School of Accounting, Economics, and Finance, Westville Campus, University of KwaZulu-Natal, Durban, South Africa
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21
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Moore EV, Nambi R, Isabirye D, Nakyanjo N, Nalugoda F, Santelli JS, Hirsch JS. When Coffee Collapsed: An Economic History of HIV in Uganda. Med Anthropol 2022; 41:49-66. [PMID: 34383575 PMCID: PMC8816880 DOI: 10.1080/01459740.2021.1961249] [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] [Indexed: 01/03/2023]
Abstract
In some Ugandan fishing communities, almost half the population lives with HIV. Researchers designate these communities "HIV hotspots" and attribute disproportionate disease burdens to "sex-for-fish" relationships endemic to the lakeshores. In this article, we trace the emergence of Uganda's HIV hotspots to structural adjustment. We show how global economic policies negotiated in the 1990s precipitated the collapse of Uganda's coffee sector, causing mass economic dislocation among women workers, who migrated to the lake. There, they entered overt forms of sex work or marriages they may have otherwise avoided, intimate economic arrangements that helped to "engineer the spread of HIV," as one respondent recounted.
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Affiliation(s)
- Erin V Moore
- Department of Anthropology, Ohio State University, Columbus, Ohio, USA
| | - Rodah Nambi
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | | | | | - John S Santelli
- Heilbrunn Department of Population and Family Health Columbia University, New York, New York, USA
| | - Jennifer S Hirsch
- Department of Sociomedical Sciences and The Columbia Population Research Center New York, New York, USA
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22
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Virhia J. Contextualising health seeking behaviours for febrile illness: Lived experiences of farmers in northern Tanzania. Health Place 2021; 73:102710. [PMID: 34801785 DOI: 10.1016/j.healthplace.2021.102710] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 01/09/2023]
Abstract
Understanding how people seek treatment for febrile illness can provide important insights into when care is sought and under what circumstances. This is includes examining how people engage with health facilities and the barriers to care they experience. However, a focus on individual actions runs the risk of overemphasising the agency of individuals to make apt health decisions while underestimating the ways which health behaviours are circumscribed by their place-specific social, historic and political contexts. Drawing on the experiences of approximately 100 farmers in a small livestock keeping community in northern Tanzania, this study uses biosocial theory of health to better understand how febrile illness is managed among individuals. The paper draws attention to the ways in which health decisions are mediated by individual, intrinsic and extrinsic health system factors. Some extrinsic factors (such as hospital user fees) are legacies of neoliberal healthcare reform policies which continue to have consequences for how people manage febrile illness in Tanzania. The findings highlight the need for considerations of health behaviours to look beyond the individual and to appreciate the role of the wider health landscape in influencing individual choice and agency when seeking treatment for illness.
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Affiliation(s)
- Jennika Virhia
- Institute of Health & Wellbeing/School of Social & Political Sciences, 27 Bute Gardens, University of Glasgow, G12 8RS, UK.
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23
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Wells JCK, Marphatia AA, Amable G, Siervo M, Friis H, Miranda JJ, Haisma HH, Raubenheimer D. The future of human malnutrition: rebalancing agency for better nutritional health. Global Health 2021; 17:119. [PMID: 34627303 PMCID: PMC8500827 DOI: 10.1186/s12992-021-00767-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 09/15/2021] [Indexed: 01/11/2023] Open
Abstract
The major threat to human societies posed by undernutrition has been recognised for millennia. Despite substantial economic development and scientific innovation, however, progress in addressing this global challenge has been inadequate. Paradoxically, the last half-century also saw the rapid emergence of obesity, first in high-income countries but now also in low- and middle-income countries. Traditionally, these problems were approached separately, but there is increasing recognition that they have common drivers and need integrated responses. The new nutrition reality comprises a global ‘double burden’ of malnutrition, where the challenges of food insecurity, nutritional deficiencies and undernutrition coexist and interact with obesity, sedentary behaviour, unhealthy diets and environments that foster unhealthy behaviour. Beyond immediate efforts to prevent and treat malnutrition, what must change in order to reduce the future burden? Here, we present a conceptual framework that focuses on the deeper structural drivers of malnutrition embedded in society, and their interaction with biological mechanisms of appetite regulation and physiological homeostasis. Building on a review of malnutrition in past societies, our framework brings to the fore the power dynamics that characterise contemporary human food systems at many levels. We focus on the concept of agency, the ability of individuals or organisations to pursue their goals. In globalized food systems, the agency of individuals is directly confronted by the agency of several other types of actor, including corporations, governments and supranational institutions. The intakes of energy and nutrients by individuals are powerfully shaped by this ‘competition of agency’, and we therefore argue that the greatest opportunities to reduce malnutrition lie in rebalancing agency across the competing actors. The effect of the COVID-19 pandemic on food systems and individuals illustrates our conceptual framework. Efforts to improve agency must both drive and respond to complementary efforts to promote and maintain equitable societies and planetary health.
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Affiliation(s)
- Jonathan C K Wells
- Childhood Nutrition Research Centre, Population Policy and Practice Research and Teaching Programme, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
| | | | - Gabriel Amable
- Department of Geography, University of Cambridge, Cambridge, UK
| | - Mario Siervo
- School of Life Sciences, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, UK
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - J Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Hinke H Haisma
- Population Research Centre, Department of Demography, University of Groningen, Groningen, the Netherlands
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24
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Faure MC, Munung NS, Ntusi NAB, Pratt B, de Vries J. Considering equity in global health collaborations: A qualitative study on experiences of equity. PLoS One 2021; 16:e0258286. [PMID: 34618864 PMCID: PMC8496851 DOI: 10.1371/journal.pone.0258286] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/24/2021] [Indexed: 12/19/2022] Open
Abstract
International collaborations have become the standard model for global health research and often include researchers and institutions from high income countries (HICs) and low- and middle-income countries (LMICs). While such collaborations are important for generating new knowledge that will help address global health inequities, there is evidence to suggest that current forms of collaboration may reproduce unequal power relations. Therefore, we conducted a qualitative study with scientists, researchers and those involved in research management, working in international health collaborations. Interviews were conducted between October 2019 and March 2020. We conducted 13 interviews with 15 participants. From our findings, we derive three major themes. First, our results reflect characteristics of equitable, collaborative research relationships. Here we find both relational features, specifically trust and belonging, and structural features, including clear contractual agreements, capacity building, inclusive divisions of labour, and the involvement of local communities. Second, we discuss obstacles to develop equitable collaborations. These include exclusionary labour practices, donor-driven research agendas, overall research culture, lack of accountability and finally, the inadequate financing of indirect costs for LMIC institutions. Third, we discuss the responsibilities for promoting science equity of funders, LMIC researchers, LMIC institutions, and LMIC governments. While other empirical studies have suggested similar features of equity, our findings extend these features to include local communities as collaborators in research projects and not only as beneficiaries. We also suggest the importance of funders paying for indirect costs, without which the capacity of LMIC institutions will continually erode. And finally, our study shows the responsibilities of LMIC actors in developing equitable collaborations, which have largely been absent from the literature.
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Affiliation(s)
- Marlyn C. Faure
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Nchangwi S. Munung
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ntobeko A. B. Ntusi
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Bridget Pratt
- Centre for Health Equity, School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Jantina de Vries
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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25
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Wintrup J. Promising careers? A critical analysis of a randomised control trial in community health worker recruitment in Zambia. Soc Sci Med 2021; 299:114412. [PMID: 34627636 DOI: 10.1016/j.socscimed.2021.114412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 09/12/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
This paper examines an influential randomised control trial (RCT) that aimed to identify how to recruit the best community health workers (CHWs) in Zambia. The economists who designed the RCT found that when they used job advertisement posters that emphasised future career prospects, they attracted applicants who were more "effective" health workers (according to various quantitative measures). The Zambian government accepted this policy advice and recruited thousands of new CHWs using posters that highlighted the career path available. However, since rolling out the programme nationally, the Zambian government has not built a career ladder into this position and the recruitment process has offered false hope to those who were selected. While acknowledging the responsibility of the Zambian government, this paper analyses the role of the RCT in this outcome. Drawing on ethnographic research and interviews conducted between 2019 and 2020, the paper shows how the RCT was flawed. The economists who designed the RCT framed it as a study of "bureaucrats" and "civil servants" and therefore overlooked crucial academic and policy debates about the distinctive role of CHWs - including the well-documented reluctance of governments to offer them careers. By failing to consider the political context of the CHW programme, the economists who designed the RCT provided policy advice that "worked" for the Zambian government in the short-term but which has ultimately been harmful to CHWs. Drawing on this case study, the paper contributes to the growing critical scholarship on RCTs and raises questions about whether these studies objectively improve policymaking, as many of their proponents claim.
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Affiliation(s)
- James Wintrup
- Institute of Health and Society, University of Oslo, Norway.
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26
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Tichenor M, Winters J, Storeng KT, Bump J, Gaudillière JP, Gorsky M, Hellowell M, Kadama P, Kenny K, Shawar YR, Songane F, Walker A, Whitacre R, Asthana S, Fernandes G, Stein F, Sridhar D. Interrogating the World Bank's role in global health knowledge production, governance, and finance. Global Health 2021; 17:110. [PMID: 34538254 PMCID: PMC8449994 DOI: 10.1186/s12992-021-00761-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 08/31/2021] [Indexed: 12/03/2022] Open
Abstract
Background In the nearly half century since it began lending for population projects, the World Bank has become one of the largest financiers of global health projects and programs, a powerful voice in shaping health agendas in global governance spaces, and a mass producer of evidentiary knowledge for its preferred global health interventions. How can social scientists interrogate the role of the World Bank in shaping ‘global health’ in the current era? Main body As a group of historians, social scientists, and public health officials with experience studying the effects of the institution’s investment in health, we identify three challenges to this research. First, a future research agenda requires recognizing that the Bank is not a monolith, but rather has distinct inter-organizational groups that have shaped investment and discourse in complicated, and sometimes contradictory, ways. Second, we must consider how its influence on health policy and investment has changed significantly over time. Third, we must analyze its modes of engagement with other institutions within the global health landscape, and with the private sector. The unique relationships between Bank entities and countries that shape health policy, and the Bank’s position as a center of research, permit it to have a formative influence on health economics as applied to international development. Addressing these challenges, we propose a future research agenda for the Bank’s influence on global health through three overlapping objects of and domains for study: knowledge-based (shaping health policy knowledge), governance-based (shaping health governance), and finance-based (shaping health financing). We provide a review of case studies in each of these categories to inform this research agenda. Conclusions As the COVID-19 pandemic continues to rage, and as state and non-state actors work to build more inclusive and robust health systems around the world, it is more important than ever to consider how to best document and analyze the impacts of Bank’s financial and technical investments in the Global South. Supplementary Information The online version contains supplementary material available at 10.1186/s12992-021-00761-w.
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Affiliation(s)
- Marlee Tichenor
- Department of Anthropology, Durham University, Dawson Building South Road, Durham, DH1 3LE, UK.
| | - Janelle Winters
- Global Health Studies, Department of History, University of Iowa, 280 Schaeffer Hall, Iowa, 52242, USA
| | - Katerini T Storeng
- Center for Development and Environment, University of Oslo, Norway, Postboks 1116, Blindern, 0317, Oslo, Norway
| | - Jesse Bump
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, 665 Huntington Avenue, Building 1, Room 1205, Boston, MA, 02115, USA
| | - Jean-Paul Gaudillière
- Centre de recherche médecine, science, santé et société (CERMES3), Ecole des Hautes Etudes en Sciences Sociales, 7, rue Guy Môquet, 8 - 94801, Villejuif Cedex, BP, France
| | - Martin Gorsky
- Centre for History in Public Health, London School of Hygiene and Tropical Medicine, UK, Room S12, LSHTM, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Mark Hellowell
- Global Health Policy Unit, Social Policy, University of Edinburgh, Chrystal Macmillan Building, 15A George Square, Edinburgh, EH8 9LD, UK
| | - Patrick Kadama
- African Center for Global Health and Social Formation, Plot 13 B Acacia Avenue, Kololo, P.O. Box 9974, Kampala, Uganda
| | - Katherine Kenny
- Department of Sociology and Social Policy, University of Sydney, Australia, A02 - Social Sciences Building, Camperdown, NSW, 2006, Australia
| | - Yusra Ribhi Shawar
- Bloomberg School of Public Health and Paul H. Nitze School of Advanced International Studies, Johns Hopkins University, 615 N. Wolfe Street Room E8132, Baltimore, MD, 21205, USA
| | - Francisco Songane
- Africa Public Health Foundation, 5th Floor, The Atrium Kilimani, Nairobi, Kenya
| | - Alexis Walker
- Columbia University Irving Medical Center, 630 W. 168th St., New York, NY, 10032, USA
| | - Ryan Whitacre
- Global Health Centre, Graduate Institute of International and Development Studies, Case postale 1672, 1211, Genève 1, Switzerland
| | - Sumegha Asthana
- Center of Social Medicine and Community Health, Jawaharlal Nehru University, New Mehrauli Road, New Delhi, 110067, India
| | - Genevie Fernandes
- Usher Institute, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Felix Stein
- Centre for Development and the Environment, University of Oslo, Postboks 1116 Blindern, 0317, Oslo, Norway
| | - Devi Sridhar
- Usher Institute, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
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Vorhölter J. A pioneer of psy: The first Ugandan psychiatric nurse and her (different) tale of psychiatry in Uganda. Transcult Psychiatry 2021; 58:460-470. [PMID: 32102620 DOI: 10.1177/1363461520901642] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In Africa, the emergence of a "modern" mental health regime centered on psychiatry is often portrayed as a unidirectional intervention by "the West." Analyses ranging from medical histories of colonial psychiatry to more recent studies of Global Mental Health focus mostly on the role of external actors and the ways their actions impact(ed) on local populations. Uncritical studies simply reduce the complexity of African therapeutic landscapes to a "treatment gap" and see the introduction of "science-based" mental health approaches as necessary "civilizing" missions. Critical studies emphasize the harms of psychiatric interventions and celebrate local healing practices instead. Both approaches are problematic: they ignore the many interconnections between highly dynamic treatment regimes that cannot be neatly designated as African or western, portray local populations as largely passive, and neglect the multiple ways in which psychiatry has been embraced, adapted, and disrupted by Africans themselves. This article challenges simplistic depictions of "western" psychiatry in Africa by providing a portrait of Rwashana Selina, the first Ugandan psychiatric nurse who-after being sent to the UK in the 1950s for training-became a central figure in Ugandan psychiatry. Based on interview material, I recount her life story and discuss her formative role in the development of psychiatric care in the colonial and postcolonial era. Rwashana's tale of Ugandan psychiatry emphasizes co-operation, mutual acknowledgments and pluralistic leadership and thus breaks with typical images of and dichotomies between white doctors and supposedly inferior African medical staff.
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Zhou A. Limits of neoliberalism: HIV, COVID-19, and the importance of healthcare systems in Malawi. Glob Public Health 2021; 16:1346-1363. [PMID: 34148531 DOI: 10.1080/17441692.2021.1940237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Countries in sub-Saharan Africa have been seriously affected by HIV and now face a new pandemic - COVID-19. How have prior experiences with managing HIV prepared countries for COVID-19? To what extent has the structure of the global health field enabled or constrained countries' ability to respond? Drawing on qualitative methods, this article examines the impact of HIV interventions on the healthcare system in Malawi and its implications for addressing COVID-19. I argue that the historical and continued influence of neoliberalism in global health manifests in the structures and routines of clinical practice. In Malawi's health centres, a parallel NGO system of care has become grafted onto state healthcare, with NGOs managing HIV commodities and providing care to HIV patients. While HIV NGOs do support the work of government providers, it is limited to tasks that align with their programmatic goals. Outside of donor priorities, the conditions of public healthcare are left behind, and government providers struggle with shortages of staff, medical resources, and basic infrastructure. In the context of COVID-19, risks are compounded as public healthcare facilities not only struggle with resources to treat patients, but also become a site of risk itself for COVID-19 infection.
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Affiliation(s)
- Amy Zhou
- Department of Sociology, Barnard College, Columbia University, New York, NY, USA
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Wintrup J. Who alone can ‘see’? Christian humanitarianism, aspect-perception and political critique. CRITIQUE OF ANTHROPOLOGY 2021. [DOI: 10.1177/0308275x211021658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article offers a critique of Christian humanitarianism in Zambia. But it does so by engaging with the arguments of anthropologists who have begun to question the status of political critique within the discipline. These anthropologists argue that critique often undermines ethnographic understanding because it problematically positions the anthropologist as an actor who is able to ‘uncover’ political realities that remain invisible to others. In this article, I take these concerns seriously and attempt to reconsider the practice of critique by drawing on an ethnographic description of the work of Christian medical missionaries in Zambia. Focusing on how these missionaries encouraged one another to ‘see’ their Zambian patients as ‘Christ-like’ and ‘faithful’ in moments of suffering, I argue that these practices of ‘seeing’ and ‘showing’ resemble certain forms of political critique. Rather than an exercise in ‘uncovering’ hidden realities, critique can also be understood as an act of ‘aspect-showing’ – the aim of which is to encourage others to ‘see’ the same things in a different light. The critique of Christian humanitarianism I offer here is therefore itself an act of aspect-showing that partially resembles that which missionaries themselves engaged in.
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Abstract
In India, most healthcare expenses are patients' out-of-pocket payments to private sector providers. Catastrophic health expenditures drive millions of families deeper into poverty. To save poorer households, hundreds of government-funded health insurance schemes have been introduced since the 2000s. These "demand side" schemes suggest that treatments in the private sector will be fully reimbursed. Fieldwork in one of India's largest hospitals shows that GFHIs overpromise. GFHIs are designed to turn patients into co-creators of healthcare value, but instead they deepen individuals' lack of market transparency. Poor patients pay the price for the state's lack of trust in them.
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Affiliation(s)
- Stefan Ecks
- Social Anthropology, University of Edinburgh
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Suh S. A Stalled Revolution? Misoprostol and the Pharmaceuticalization of Reproductive Health in Francophone Africa. FRONTIERS IN SOCIOLOGY 2021; 6:590556. [PMID: 33954164 PMCID: PMC8091168 DOI: 10.3389/fsoc.2021.590556] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 01/14/2021] [Indexed: 06/12/2023]
Abstract
Misoprostol entered the global market under the name Cytotec in the mid-1980s for the treatment of gastric ulcers. Decades of research have since demonstrated the safety and effectiveness of off-label use of misoprostol as a uterotonic in pregnant women to prevent and treat post-partum hemorrhage, treat incomplete abortion, or terminate first-trimester pregnancy. Global health experts emphasize misoprostol's potential to revolutionize access to reproductive health care in developing countries. Misoprostol does not require refrigeration, can be self-administered or with the aid of a non-physician, and is relatively inexpensive. It holds particular promise for improving reproductive health in sub-Saharan Africa, where most global maternal mortality related to post-partum hemorrhage and unsafe abortion occurs. Although misoprostol has been widely recognized as an essential obstetric medication, its application remains highly contested precisely because it disrupts medical and legal authority over pregnancy, delivery, and abortion. I draw on fieldwork in Francophone Africa to explore how global health organizations have negotiated misoprostol's abortifacient qualities in their reproductive health work. I focus on this region not only because it has some of the world's highest rates of maternal mortality, but also fertility, thereby situating misoprostol in a longer history of family planning programs in a region designated as a zone of overpopulation since the 1980s. Findings suggest that stakeholders adopt strategies that directly address safe abortion on the one hand, and integrate misoprostol into existing clinical protocols and pharmaceutical supply systems for legal obstetric indications on the other. Although misoprostol has generated important partnerships among regional stakeholders invested in reducing fertility and maternal mortality, the stigma of abortion stalls its integration into routine obstetric care and availability to the public. I demonstrate the promises and pitfalls of pharmaceuticalizing reproductive health: despite the availability of misoprostol in some health facilities and pharmacies, low-income and rural women continue to lack access not only to the drug, but to quality reproductive health care more generally.
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Affiliation(s)
- Siri Suh
- Brandeis University, Waltham, MA, United States
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32
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Meghani Z. The impact of vertical public health initiatives on gendered familial care work: public health and ethical issues. CRITICAL PUBLIC HEALTH 2021. [DOI: 10.1080/09581596.2021.1908960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Zahra Meghani
- Philosophy Department, University of Rhode Island, Kingston, RI, USA
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Abstract
As a result of reforms aimed at adjusting it to the market economy, the Polish health care system has become a complicated mix of public and private services. Using as an example maternity services, I show how private services allow a subtle process of patient selection to emerge, contributing to the fragmentation of public care. The process of selection is based on social relations formed between health care providers and patients through the use of private services. This has a negative impact on women who do not have the social or financial resources to engage in private services.W wyniku reform mających na celu dostosowanie do gospodarki rynkowej, opieka zdrowotna w Polsce przekształcona została w skomplikowaną mieszaninę usług publicznych i prywatnych. Na podstawie świadczeń położniczych, pokazuję, w jaki sposób prywatne usługi zdrowotne stały się "oknami" pozwalającymi na subtelną selekcję pacjentów. Selekcja ta oparta jest na relacjach społecznych nawiązywanych pomiędzy lekarzem/położną a pacjentką przy okazji korzystania z prywatnych usług i prowadzi do fragmentaryzacji opieki publicznej. Proces ten szczególnie negatywnie wpływa na kobiety, których zasoby społeczne i finansowe nie pozwalają na korzystanie z prywatnych usług zdrowotnych.
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Affiliation(s)
- Maria Węgrzynowska
- Department of Midwifery, Centre for Postgraduate Medical Education, Warsaw, Poland
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Munala L, Welle E, Okunna N, Hohenshell E. The Impact of Macroeconomic Policies on Healthcare Delivery in Kenya: An Analysis of the National Sexual Violence Prevention and Care Response. INTERNATIONAL QUARTERLY OF COMMUNITY HEALTH EDUCATION 2020; 42:73-83. [PMID: 33356913 DOI: 10.1177/0272684x20982596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sexual violence is one of the most common forms of violence against women in Kenya. This study documents the care of sexual violence survivors from the perspective of health care practitioners based on an analytic framework developed in studies of the political-economy of health to examine the effects of International Financial Institutions' conditionalities on the allocation of national fiscal resources. The study documented the working conditions of practitioners and myriad challenges that they experience in providing quality services to sexual violence survivors. The issues reflected in the results are grounded in social structural inequities driven by the global political economic policies that perpetuate poverty and dependency throughout Africa and the developing world. Macro-level variables associated with health care provision are assessed with a focus on global macroeconomic policies established by the International Monetary Fund and World Bank, their impact on Kenya's health economy and their ultimate impact on the capacity of the health system to meet the complex needs of survivors of sexual violence. In this paper, study results are analysed within the context of these macroeconomic policies and their legacy.
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Affiliation(s)
- Leso Munala
- Department of Public Health, St. Catherine University, St. Paul, Minnesota, United States
| | - Emily Welle
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, United States
| | - Nene Okunna
- Department of Health Studies Saint Joseph's University, Philadelphia, Pennsylvania, United States
| | - Emily Hohenshell
- Department of Public Health, St. Catherine University, St. Paul, Minnesota, United States
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Harvey M, Neff J, Knight KR, Mukherjee JS, Shamasunder S, Le PV, Tittle R, Jain Y, Carrasco H, Bernal-Serrano D, Goronga T, Holmes SM. Structural competency and global health education. Glob Public Health 2020; 17:341-362. [PMID: 33351721 DOI: 10.1080/17441692.2020.1864751] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Structural competency is a new curricular framework for training health professionals to recognise and respond to disease and its unequal distribution as the outcome of social structures, such as economic and legal systems, healthcare and taxation policies, and international institutions. While extensive global health research has linked social structures to the disproportionate burden of disease in the Global South, formal attempts to incorporate the structural competency framework into US-based global health education have not been described in the literature. This paper fills this gap by articulating five sub-competencies for structurally competent global health instruction. Authors drew on their experiences developing global health and structural competency curricula-and consulted relevant structural competency, global health, social science, social theory, and social determinants of health literatures. The five sub-competencies include: (1) Describe the role of social structures in producing and maintaining health inequities globally, (2) Identify the ways that structural inequalities are naturalised within the field of global health, (3) Discuss the impact of structures on the practice of global health, (4) Recognise structural interventions for addressing global health inequities, and (5) Apply the concept of structural humility in the context of global health.
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Affiliation(s)
- Michael Harvey
- College of Public Health, Temple University, Philadelphia, PA, USA
| | - Joshua Neff
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Kelly R Knight
- School of Medicine, University of California, San Francisco, CA, USA
| | - Joia S Mukherjee
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Sriram Shamasunder
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Phuoc V Le
- School of Medicine, University of California, San Francisco, CA, USA.,School of Public Health, University of California, Berkeley, CA, USA
| | - Robin Tittle
- Division of Hospital and Specialty Medicine, Portland VA Medical Center, Oregon Health and Sciences University, Portland, OR, USA
| | | | - Héctor Carrasco
- School of Medicine and Health Sciences, Tecnológico de Monterrey, Mexico City Campus, Mexico
| | - Daniel Bernal-Serrano
- School of Medicine and Health Sciences, Tecnológico de Monterrey, Mexico City Campus, Mexico
| | | | - Seth M Holmes
- Division of Society and Environment, Department of Environmental Science, Policy, and Management, University of California, Berkeley, CA, USA
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Flynn MB. Global capitalism as a societal determinant of health: A conceptual framework. Soc Sci Med 2020; 268:113530. [PMID: 33288355 DOI: 10.1016/j.socscimed.2020.113530] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/03/2020] [Accepted: 11/12/2020] [Indexed: 01/24/2023]
Abstract
Recent scholarship has sought to distinguish between the deeper societal factors that shape the more proximate social determinants of health. One of these socio-structural institutions is global capitalism. While critical scholarship has advanced our understanding of the relationships between capitalist globalization and health, more work is needed to understand the transnational economic, political, and cultural practices that affect various global health issues. This paper argues that the theory of global capitalism provides an important, critical perspective for understanding different phenomena associated with global health. The theory's key concepts of transnational corporations, financialization, consumerism, transnational social classes, and transnational state comprise the conceptual framework. When applied to various global health topics, the theory advances our understanding of the health-related institutional structures of today's global economy, provides a holistic view that integrates various strands of health research, highlights various forms of health activism, and offers new questions for addressing persistent health injustice across the world.
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Affiliation(s)
- Matthew B Flynn
- Georgia Southern University, PO Box 8051, Statesboro, GA 30460, USA.
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Noory B, Hassanain SA, Lindskog BV, Elsony A, Bjune GA. Exploring the consequences of decentralization: has privatization of health services been the perceived effect of decentralization in Khartoum locality, Sudan? BMC Health Serv Res 2020; 20:669. [PMID: 32690003 PMCID: PMC7370464 DOI: 10.1186/s12913-020-05511-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/05/2020] [Indexed: 12/04/2022] Open
Abstract
Background The health system of Sudan has experienced several forms of decentralization, as well as, a radical reform. Authority and governance of secondary and tertiary health facilities have been shifted from federal to state levels. Moreover, the provision of health care services have been moved from large federal tertiary level hospitals such as Khartoum Teaching Hospital (KTH) and Jafaar Ibnoaf Hospital (JIH), located in the center of Khartoum, to smaller district secondary hospitals like Ibrahim Malik (IBMH), which is located in the southern part of Khartoum. Exploring stakeholders’ perceptions on this decentralisation implementation and its relevant consequences is vital in building an empirical benchmark for the improvement of health systems. Methods This study utilised a qualitative design which is comprised of in-depth interviews and qualitative content analysis with an inductive approach. The study was conducted between July and December 2015, and aimed at understanding the personal experiences and perceptions of stakeholders towards decentralisation enforcement and the implications on public health services, with a particular focus on the Khartoum locality. It involved community members residing in the Khartoum Locality, specifically in catchments area where hospital decentralisation was implemented, as well as, affiliated health workers and policymakers. Results The major finding suggested that privatisation of health services occurred after decentralisation. The study participants also highlighted that scrutiny and reduction of budgets allocated to health services led to an instantaneous enforcement of cost recovery user fee. Devolving KTH Khartoum Teaching and Jafar Ibnoaf Hospitals into peripherals with less. Capacity, was considered to be a plan to weaken public health services and outsource services to private sector. Another theme that was highlighted in hospitals included the profit-making aspect of the governmental sector in the form of drug supplying and profit-making retail. Conclusions A change in health services after the enforcement of decentralisation was illustrated. Moreover, the incapacitation of public health systems and empowerment of the privatisation concept was the prevailing perception among stakeholders. Having contextualised in-depth studies and policy analysis in line with the global liberalisation and adjustment programmes is crucial for any health sector reform in Sudan.
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Affiliation(s)
- Bandar Noory
- The Epidemiological Laboratory, Khartoum, Sudan. .,International Community Health, University of Oslo, Oslo, Norway.
| | | | | | - Asma Elsony
- The Epidemiological Laboratory, Khartoum, Sudan
| | - Gunnar Aksel Bjune
- Department of Community Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
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Alhassan JAK, Wariri O, Onuwabuchi E, Mark G, Kwarshak Y, Dase E. Access to skilled attendant at birth and the coverage of the third dose of diphtheria-tetanus-pertussis vaccine across 14 West African countries - an equity analysis. Int J Equity Health 2020; 19:78. [PMID: 32487158 PMCID: PMC7268225 DOI: 10.1186/s12939-020-01204-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Universal Health Coverage (UHC) remains a critical public health goal that continues to elude many countries of the global south. As countries strive for its attainment, it is important to track progress in various subregions of the world to understand current levels and mechanisms of progress for shared learning. Our aim was to compare multidimensional equity gaps in access to skilled attendant at birth (SAB) and coverage of the third dose of Diphtheria-Tetanus-Pertussis (DTP3) across 14 West African countries. METHODS The study was a cross sectional comparative analysis that used publicly available, nationally representative health surveys. We extracted data from Demographic and Health Surveys, and Multiple Indicator Cluster Surveys conducted between 2010 and 2017 in Benin, Burkina Faso, Cote d' Ivoire, The Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone and Togo. The World Health Organization's Health Equity Assessment Toolkit (HEAT Plus) software was used to evaluate current levels of intra-country equity in access to SAB and DTP3 coverage across four equity dimensions (maternal education, location of residence, region within a country and family wealth status). RESULTS There was a general trend of higher levels of coverage for DTP3 compared to access to SAB in the subregion. Across the various dimensions of equity, more gaps appear to have been closed in the subregion for DTP3 compared to SAB. The analysis revealed that countries such as Sierra Leone, Liberia and Ghana have made substantial progress towards equitable access for the two outcomes compared to others such as Nigeria, Niger and Guinea. CONCLUSION In the race towards UHC, equity should remain a priority and comparative progress should be consistently tracked to enable the sharing of lessons. The West African subregion requires adequate government financing and continued commitment to move toward UHC and close health equity gaps.
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Affiliation(s)
- Jacob Albin Korem Alhassan
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Canada
- African Population and Health Policy Initiative, Gombe, Nigeria
| | - Oghenebrume Wariri
- African Population and Health Policy Initiative, Gombe, Nigeria
- Medical Research Council (MRC) Unit The Gambia, London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Egwu Onuwabuchi
- African Population and Health Policy Initiative, Gombe, Nigeria
- Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Gombe, Nigeria
| | - Godwin Mark
- Department of One Health, The University of Edinburgh, Royal (Dick) School of Veterinary Studies, Edinburgh, Scotland UK
| | - Yakubu Kwarshak
- Department of Global Health and Management, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland UK
| | - Eseoghene Dase
- African Population and Health Policy Initiative, Gombe, Nigeria
- Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Gombe, Nigeria
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Suarez M. ‘The Best Investment of Your Life’: Mortgage Lending and Transnational Care among Ecuadorian Migrant Women in Barcelona. ETHNOS 2020. [DOI: 10.1080/00141844.2019.1687539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Maka Suarez
- Centre for Interdisciplinary Ethnography-Kaleidos, University of Cuenca & FLACSO-Ecuador, Ecuador
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Vasquez EE, Perez-Brumer A, Parker RG. Social inequities and contemporary struggles for collective health in Latin America. Glob Public Health 2020; 14:777-790. [PMID: 31104588 DOI: 10.1080/17441692.2019.1601752] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
As part of a planned series from Global Public Health aimed at exploring both the epistemological and political differences in diverse public health approaches across different geographic and cultural regions, this special issue assembles papers that consider the legacy of the Latin American Social Medicine and Collective Health (LASM-CH) movements, as well as additional examples of contemporary social action for collective health from the region. In this introduction, we review the historical roots of LASM-CH and the movement's primary contributions to research, activism and policy-making over the latter-half of the twentieth century. We also introduce the special issue's contents. Spanning 19 papers, the articles in this special issue offer critical insight into efforts to create more equitable, participatory health regimes in the context of significant social and political change that many of the countries in the region have experienced in recent decades. We argue that as global health worldwide has been pushed to adopt increasingly conservative agendas, recognition of and attention to the legacies of Latin America's epistemological innovations and social movement action in the domain of public health are especially warranted.
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Affiliation(s)
- Emily E Vasquez
- a Department of Sociomedical Sciences , Columbia University , New York , NY , USA
| | - Amaya Perez-Brumer
- a Department of Sociomedical Sciences , Columbia University , New York , NY , USA
| | - Richard G Parker
- a Department of Sociomedical Sciences , Columbia University , New York , NY , USA.,b Institute for the Study of Collective Health (IESC) , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil.,c ABIA (Brazilian Interdisciplinary AIDS Association) , Rio de Janeiro , Brazil
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Beneduce R. "Madness and Despair are a Force": Global Mental Health, and How People and Cultures Challenge the Hegemony of Western Psychiatry. Cult Med Psychiatry 2019; 43:710-723. [PMID: 31729692 DOI: 10.1007/s11013-019-09658-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The author suggests to consider some important hidden connections in Global Mental Health (GMH) discourse and interventions, above all the political meaning of suffering and symptoms, the power of psychiatric diagnostic categories (both Western and traditional) to name and to occult at once other conflicts, and the implicit criticism expressed by so-called local healing knowledge and its epistemologies. These issues, by emphasizing the importance to explore other ontologies, help to understand the perplexity and resistance that GMH and its agenda meet among many scholars and professionals, who denounce the risks of reproducing and globalizing Western hegemonic values concerning health, illness, and healing.
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Affiliation(s)
- Roberto Beneduce
- Department of Cultures, Politics, and Society, University of Turin, Lungo Dora Siena 100, Turin, 10153, Italy.
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Marten MG, Sullivan N. Hospital side hustles: Funding conundrums and perverse incentives in Tanzania's publicly-funded health sector. Soc Sci Med 2019; 244:112662. [PMID: 31726268 DOI: 10.1016/j.socscimed.2019.112662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 11/16/2022]
Abstract
Following three decades of international financial institutions implementing austerity measures in sub-Saharan Africa, many health systems remain chronically underfinanced. During this period, countries like Tanzania have moved from a post-independence vision of a strong social sector providing free care for citizens, to a model of increased privatization of public health facilities, shifting the burden of self-financing to individual health facilities and the constituents they serve. Drawing on longitudinal ethnographic research and document analysis undertaken between 2008 and 2017 within three publicly-funded hospitals in north-central Tanzania, this article examines the actions and perspectives of administrators to explore how novel shifts towards semi-privatization of public facilities are perceived as taken-for-granted solutions to funding shortfalls. Specifically, hospital administrators used "side hustle" strategies of projectification and market-based income generating activities to narrow the gap between inadequate state financing and necessary recurrent expenditures. Examples from publicly-funded hospitals in Tanzania demonstrate that employing side hustles to address funding conundrums derives from perverse incentives: while these strategies are supposed to generate revenues to sustain or bolster services to poor clients, in practice these market-based approaches erode the ability of publicly-funded hospitals to meet their obligations to the poorest. These cases show that neoliberal ideas promoting health financing through public-private initiatives offer little opportunity in practice for strengthening health systems in low income countries, undermining those health systems' ability to achieve the goal of universal health care.
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Affiliation(s)
- Meredith G Marten
- Department of Anthropology, University of West Florida, 11000 University Pkwy, Pensacola FL 32514, USA
| | - Noelle Sullivan
- Program in Global Health Studies, Northwestern University, 1800 Sherman, Suite 1-200, Evanston, IL 60208, USA.
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43
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On the limitations of barriers: Social visibility and weight management in Cuba and Samoa. Soc Sci Med 2019; 239:112501. [DOI: 10.1016/j.socscimed.2019.112501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
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Forster T, Kentikelenis AE, Stubbs TH, King LP. Globalization and health equity: The impact of structural adjustment programs on developing countries. Soc Sci Med 2019; 267:112496. [PMID: 31515082 DOI: 10.1016/j.socscimed.2019.112496] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/15/2019] [Accepted: 08/15/2019] [Indexed: 11/26/2022]
Abstract
Among the many drivers of health inequities, this article focuses on important, yet insufficiently understood, international-level determinants: economic globalization and the organizations that spread market-oriented policies to the developing world. One such organization is the International Monetary Fund (IMF), which provides financial assistance to countries in economic trouble in exchange for policy reforms. Through its 'structural adjustment programs,' countries around the world have liberalized and deregulated their economies. We examine how policy reforms prescribed in structural adjustment programs explain variation in health equity between nations-approximated by health system access and neonatal mortality. Our empirical analysis uses an original dataset of IMF-mandated policy reforms for a panel of up to 137 developing countries between 1980 and 2014. We employ regression analysis to evaluate the relationship between these reforms and health equity, taking into account the non-random selection and design of IMF programs. We find that structural adjustment reforms lower health system access and increase neonatal mortality. Additional analyses show that labor market reforms drive these deleterious effects. Overall, our evidence suggests that structural adjustment programs endanger the attainment of Sustainable Development Goals in developing countries.
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Affiliation(s)
- Timon Forster
- Berlin Graduate School for Global and Transregional Studies, Free University Berlin, Berlin, Germany
| | - Alexander E Kentikelenis
- Centre for Global Health Inequalities Research, Norwegian University of Science and Technology, Trondheim, Norway; Department of Social and Political Sciences, Bocconi University, Milan, Italy.
| | - Thomas H Stubbs
- Centre for Business Research, University of Cambridge, Cambridge, UK; Department of Politics and International Relations, Royal Holloway, University of London, London, UK
| | - Lawrence P King
- Department of Economics, University of Massachusetts Amherst, Amherst, USA
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Gainty C. A Historical View on Health Care: A New View on Austerity? HEALTH CARE ANALYSIS 2019; 27:220-230. [PMID: 31250325 DOI: 10.1007/s10728-019-00375-9] [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] [Indexed: 11/26/2022]
Abstract
It is an axiom of contemporary conversations about austerity and health care that the relationship between the two is essentially direct. Cutting funds damages health care systems and hurts the health of individuals who rely on them. Though this premise has provoked necessary discussion about global politics, the global economy and their impact on individual well-being, it is nonetheless intrinsically problematic. Assigning health and health care as objects of austerity not only obscures the complexity of health care systems and the opacity of health's definitional borders, but also misunderstands austerity, its manifestations and its significance. The ambition of this essay is to bring health care back into the debate, in order to establish the greater dynamism of the contemporary austerity and health care relationship. This historical reconstruction will challenge the significance of our current situating of austerity as health care's bogeyman, press for a reconsideration of our contemporary definitions of the key factors involved here (health, health care and austerity) and finally conclude with some thoughts on how we might more productively approach the problem of health now.
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Walker A. Into the Machine: Economic Tools, Sovereignty, and Joy in a Global Health Institution. Med Anthropol Q 2019; 33:539-556. [PMID: 31134634 DOI: 10.1111/maq.12529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 03/22/2019] [Accepted: 05/03/2019] [Indexed: 11/30/2022]
Abstract
Since the early 1990s, the World Bank and Inter-American Development Bank have led efforts advocating the use of economic tools in setting priorities for health spending in poor countries. But while these powerful global health institutions present economic management as the key to improving health, they often fail to implement even their own policies requiring the use of economic tools for health project planning. In these institutions, economic tools operate beyond application for decision-making, becoming simultaneously a site of tensions regarding sovereignty and sites of enjoyment for economists at development bank headquarters. This article traces the ways that economic tools are both deployed and left aside across development bank networks, and in the process are productive of both affect and power. Attention to frictions in the use of economic tools ought to help motivate more just global health governance, taking into account political considerations that are built into expert practice.
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Zhou A. Therapeutic citizens and clients: diverging healthcare practices in Malawi's prenatal clinics. SOCIOLOGY OF HEALTH & ILLNESS 2019; 41:625-642. [PMID: 30671979 DOI: 10.1111/1467-9566.12841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This article examines how HIV policies and the funding priorities of global institutions affect practices in prenatal clinics and the quality of healthcare women receive. Data consist of observations at health centres in Lilongwe, Malawi and interviews with providers (N = 37). I argue that neoliberal ideology, which structures the global health field, produces a fragmented healthcare system on the ground. Findings show two kinds of healthcare practices within the same clinic: donor-funded NGOs took on HIV services while government providers focused on prenatal care. NGO practices were defined by surveillance, where providers targeted pregnant HIV-positive women and intensively monitored their adherence to drug treatment. In contrast, state-led practices were defined by rationing. Government providers worked with all pregnant women, but with staff and resource shortages, they limited time and services for each patient in order to serve everyone. This paper builds on concepts of therapeutic citizenship and clientship by exploring how global health priorities produce different conditions, practices and outcomes of NGO and state-led care.
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Affiliation(s)
- Amy Zhou
- Institute for Practical Ethics, University of California, San Diego, USA
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Abstract
Austerity across Africa has been operationalized through World Bank
and IMF structural adjustment programs since the 1980s, later rebranded euphemistically
as poverty reduction strategies in the late 1990s. Austerity’s constraints
on public spending led donors to a “civil society” focus in which NGOs would fill
gaps in basic social services created by public sector contraction. One consequence
was large-scale redirection of growing foreign aid flows away from public services
to international NGOs. Austerity in Africa coincides with the emergence of what
some anthropologists call “audit cultures” among donors. Extraordinary data collection
infrastructures are demanded from recipient organizations in the name of
transparency. However, the Mozambique experience described here reveals that
these intensive audit cultures serve to obscure the destructive effects of NGO proliferation
on public health systems.
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Abstract
This introduction posits that austerity is an instantiation of structural
adjustment programs (SAPs) and thus must be revisited in two ways, involving
its historical and geographical rendering. First, anthropological accounts should
think of austerity in the long term, providing encompassing genealogies of the
concept rather than seeing it as breach to historical continuity. Second, the discipline
should employ the comparative approach to bring together analyses of SAPs
in the Global South and austerity measures in the Global North, providing a more
comprehensive analysis of this phenomenon. We are interested in what austerity
does to people’s temporal consciousness, and what such people do toward a policy
process that impacts their lives. We find, in this comparative pursuit, instead of
Foucauldian internalization, dissent and dissatisfaction.
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