Governance and participation in health

The visa conundrum in global health
Vervoort D: The BMJ Opinion, June 2019

There is a growing push to include local voices in global health initiatives and policies to promote ownership of downstream implementation, but also to get a proper sense of the realities on the ground. Many governments gladly jump on the bandwagon. Yet when it comes to it, visa applications are often rejected on feeble grounds. Physicians and medical students with booked return flights, domestic hospital affiliations, formal invitation letters and even proof that they will not be a financial liability are rejected. Academia increasingly understands the need for local authorship and ownership of global health programmes, and rightfully so. However, a colonial trend persists in the wider community. Policies and resolutions are driven by high income country actors or government officials who are, by definition, detached from what is happening on the ground. Civil society actors who live among the realities of poverty are left behind.

‘Prejudiced’ Home Office refusing visas to African researchers
Grant H: The Guardian, June 2019

The UK Home Office is reported to be accused of institutional racism and to be damaging British research projects through increasingly arbitrary and “insulting” visa refusals for African academics. In April, a team of six Ebola researchers from Sierra Leone were unable to attend vital training in the UK, funded by the Wellcome Trust as part of a £1.5m flagship pandemic preparedness programme. At the LSE Africa summit, also in April, 24 out of 25 researchers were missing from a single workshop. Shortly afterwards, the Save the Children centenary events were marred by multiple visa refusals of key guests. The article refers to a parliamentary inquiry into visa refusals hearing evidence that there is “an element of systemic prejudice against applicants”. In a letter in the Observer, 70 senior leaders from universities and research institutes across the UK warn that “visa refusals for African cultural, development and academic leaders … [are] undermining ‘Global Britain’s’ reputation as well as efforts to tackle global challenges”. The system is reported to be so difficult to predict or navigate that meetings, including conferences funded with British government money, are now being held in other countries.

Press Statement on Government’s Continued Non-involvement of Botswana Labour Migrants Association (BoLAMA) in TB Programme Management
Botswana Labour Migrants Association (BoLAMA): Gaberone, May 2019

BoLAMA report in a press statement that it has without much success made all efforts to engage and collaborate with the Government of Botswana on miners’ right to health, specifically for those suffering from TB and other occupational diseases. BoLAMA assert that TB rates in Botswana remain high and a multi-sectoral accountability framework is required. This framework which is aligned with the End TB Strategy and UN Political Declaration on TB requires key populations and civil society to work in collaboration with Governments. The regional TB/Silicosis class action is seen as an opportunity to reduce the economic hardships of ex-miners who due to contracting occupational lung diseases have been rendered redundant and not in gainful employment. The court case, to which BoLAMA has been party, is slated to be finalized in 2019. BoLAMA called on the Government of Botswana to; i) remember her commitments under the WHO EndTB Strategy from which the TB National Strategic Plan is aligned; ii) implement the UN Political Declaration on the fight against TB; iii) ensure an inter-ministerial committee including BoLAMA deal with ex-miners issues; and iv) provide support in the TB/Silicosis regional class suit.

“We come as friends”: approaches to social accountability by health committees in Northern Malawi
Lodenstein E; Molenaar J; Ingemann C; Botha K; et al: BMC Health Services Research 19(279) 1-14, 2019

This study explores how health facility committees monitor the quality of health services and how they demand accountability of health workers for their performance in Malawi. Documentary analysis and key informant interviews were complemented by interviews with purposefully selected health facility committees members and health workers regarding their experiences with health facility committees. The informal and constructive approach that most health facility committees use is shaped both by formal definition and expectations of their role and resource constraints. The primary social accountability role of health facility committees appeared to be co-managing the social relations around the health facility and promoting access to and quality of services. The results suggest that health facility committees can address poor health worker performance and the authors suggest that social accountability approaches with health facility committees be integrated in existing quality of care programs and that accountability arrangements and linkages with upward accountability approaches be clarified.

G20-Africa engagement: Finding a roadmap to shared development
van Staden C; Sidiropoulos E: South African Institute of International Affairs (SAIIA) Occasional Paper No 294, 2019

The G20 plays an important role in global rule-making. Africa is significantly under-represented in this body, with only South Africa a permanent member. This makes Africa a rule-taker. At the same time the G20 has started to pay more attention to Africa and the continent’s future development now occupies a somewhat more central position on the grouping’s agenda. The G20 Initiative on Supporting Industrialization in Africa and Least Developed Countries, launched under China’s G20 presidency of 2016, and the 2017 German presidency’s Compact with Africa offered unprecedented moments of engagement. However, the question remains how Africa can use these initiatives to deepen its engagement with the G20 and boost its own development. This paper draws on extensive interviews with key stakeholders to analyse G20–Africa engagement by focusing on three presidencies: China in 2016, Germany in 2017, and Argentina in 2018. It shows how China’s Industrialisation Initiative was crucially informed by its pre-existing African engagement, while Germany’s Compact with Africa both gained and suffered from a more narrowly focused commercial engagement. It then shows how Argentina, despite lacking a similar African initiative, managed to continue G20–Africa engagement through person-to-person diplomacy. The paper points out both the benefits and the limits of these engagements and suggests a series of further initiatives that could allow Africa a more significant say in the G20.

The C-Word: Tackling the enduring legacy of colonialism in global health
Saha S; Kavattur P; Goheer A: Health Systems Global blog, April 2019

The authors write that definitions of “global health” are generally depoliticized and invoke trans-national health issues and collaboration. Yet they argue that global health is only the newest iteration of what was formerly “international health”, “tropical medicine” and “colonial medicine”, with historical roots lie in colonial endeavours and imperial interests. They report a widespread frustration with how global health is taught in universities in ways that create and perpetuate neo-colonial relations; and a desire for alternative conceptualizations of the “global” that fundamentally tackle structures of power. The authors observe in the paper the various issues that need to be tackled if there is an intent to 'decolonise' global health, commenting that it is not a one-day event or a checkbox. It is a process that leads to futures that are unknown, but that one should dare to imagine.

A panel discussion how to base country health priorities on the Sustainable Development Goals. Zambia and other country cases.
Byskov J; Zulu J; Silumbwe A; et al: Summary of presentation in International Conference on Priorities in Health, Linköping, September 2018

The ever increasing evidence and technical developments supporting population health have not yet reached the goal of health for all. The decision making for population health has not led to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. This presentation discusses Zambia as a case study country, finding that national governance results in policy based choices are not necessarily helpful at implementation and community levels. The authors present evidence that if one comprehensively addresses a particular disease burden it does decrease, but limits other action. The Sustainable Development goals included democratic cross sector processes in their formulation, but the targets applied in health still tend to receive funding from competing sectors and programs.

Climate change adaptation in South Africa: a case study on the role of the health sector
Chersich M; Wright C: Globalisation and Health 15(22), doi:, 2019

In this systematic review the authors assessed progress with climate change adaptation in the health sector in South Africa, providing useful lessons for other African countries. Very few of the studies found presented findings of an intervention or used high-quality research designs. Several policy frameworks for climate change have been developed at national and local government levels. These, however, pay little attention to health concerns and the specific needs of vulnerable groups. Systems for forecasting extreme weather, and tracking malaria and other infections appear well established. Yet, there is little evidence about the country’s preparedness for extreme weather events, or the ability of the already strained health system to respond to these events. Seemingly, few adaptation measures have taken place in occupational and other settings. To date, little attention has been given to climate change in training curricula for health workers. Overall, the authors note that the volume and quality of research is disappointing, and disproportionate to the threat posed by climate change in South Africa. This is surprising given that the requisite expertise for policy advocacy, identifying effective interventions and implementing systems-based approaches rests within the health sector. They suggest that more effective use of data, a traditional strength of health professionals, could support adaptation and promote accountability of the state. With increased health-sector leadership, climate change could be reframed as a health issue, one necessitating an urgent, adequately-resourced response.

Why the world needs an African ecofeminist future
Kelleher F: African Arguments, March 2019

The author points to how women and feminist activists are on the front line of the battle for ecological sustainability on the continent. Their everyday struggles, commitment, and willingness to envision a future in which justice, equity and rights harmonise with environmental sovereignty is said to have the potential to save us all. Wangari Maathai and her Green Belt Movement are said to epitomise the essence of African ecofeminism and the collective activism that defines it. As the first environmentalist to win the Nobel Peace Prize, in 2004, Maathai highlighted the close relationship between African feminism and African ecological activism, which challenge both the patriarchal and neo-colonial structures undermining the continent. Lesser -known activists, however, have also long been at the intersection of gender, economic, and ecological justice. Ruth Nyambura of the African Eco Feminist Collective, for example, uses radical and African feminist traditions to critique power, challenge multinational capitalism, and re-imagine a more equitable world. Organisations like African Women Unite Against Destructive Resource Extraction (WoMin) campaign against the devastation of extractive industries. Meanwhile, localised organising is also resisting ecologically-damaging corporatisation: in South Africa, Women Mapella residents fought off land grabs by mining companies; in Ghana, the Concerned Farmers Association, led largely by women, held mining companies accountable for pollution of local watersheds; and in Uganda, women of the Kizibi community seed bank are preserving local biodiversity in the face of the commercialisation of seeds by corporate multinationals. From Ghana to South Africa and beyond, women-organised seed-sharing initiatives continue to resist corporatisation. Activists like Mariama Sonko in Senegal continue to lead on agroecological farming initiatives for localised and sustainable food production. The author argues that the crisis of Africa’s current trajectory is a crisis of visioning: the inability of the continent’s leaders to imagine a process of development less destructive, more equitable, less unjust, more uniquely African, and – quite simply – more exciting. The positions, passions, and holistic approaches offered by African ecofeminism are argued to provide key ingredients for an alternative to the capital-centric ideals of economic growth that have defined progress so far.

Applying an intersectionality lens to examine health for vulnerable individuals following devolution in Kenya
McCollum R; Taegtmeye M; Otiso L; Tolhurst R; et al: International Journal for Equity in Health18(24) 1-15, 2019

This paper examines health for vulnerable individuals following devolution in Kenya through a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from across the health system in ten counties, 14 focus group discussions with community members in two of these counties and photovoice participatory research with nine young people. The authors adopted an intersectionality lens to reveal how power relations intersect to produce vulnerabilities for specific groups in specific contexts, and to identify examples of the tacit knowledge about these vulnerabilities held by priority-setting stakeholders. The authors identified a range of ways in which longstanding social forces and discriminations limit the power and agency individuals can exercise. These are mediated by social determinants of health, their exposure to risk of ill health from their living environments, work, or social context, and by social norms relating to their gender, age, geographical residence or socio-economic status. While a range of policy measures have been introduced to encourage participation by typically ‘unheard voices’, devolution processes have yet to adequately challenge the social norms and power relations which contribute to discrimination and marginalisation. The authors conclude that if key actors in devolved decision-making structures are to ensure progress towards universal health coverage, there is need for intersectoral action to address these social determinants and to identify ways to challenge and shift power imbalances in priority-setting processes.