Paper short abstract:

Health systems have for a long time operated as neo-colonial paternalistic institutions. This paper explores the role of Citizens Health Watch Zimbabwe as a boundary spanning organisation, analysing the roles of location, credibility and , legitimacy in the navigation of entrenched social worlds.

Paper long abstract:

Health systems across the developing world have for a long time been viewed as neo-colonial paternalistic institutions, driven by the privileged knowledge, skills, intellect and insights of trained clinicians, regulators and allied professionals. This deeply embedded and pervasive model of operation, derived from and based-on western allopathic health care models, has remained enduring and tenacious, to the extent that efforts across many countries to 'put patients first' have remained mere aspirations with no programmes of work behind the rhetoric. This is highly unsurprising, as hegemonic models of practice do tend to proceed and survive by way of entrenching themselves and closing out spaces for alternatives. Citizens' Health Watch (CHW) Zimbabwe was established in 2013 to serve as an inclusive, citizen-centred, knowledge-based platform for harnessing and deploying individual and collective patient and care-giver experiences in health system strengthening. This paper explores the role of CHW as a boundary spanning organisation, in particular analysing the roles of location, credibility, legitimacy and salience in the organisation's navigation of multiple, contentious and entrenched social worlds, and contribution to the emergence of innovative, inclusive and accountable maternal and adolescent health care programmes across the country. In the final analysis, the paper argues how CHW is an illustration that untangling and decentring entrenched and privileged models of practice are exercises hinging on the quality of linkage between knowledge and action and the decision space that links the two. That space requires innovative interaction between, communication and stabilisation of, multiple messages.

Paper short abstract:

We present a case study of public engagement with research involving indigenous groups in Northern Thailand to illustrate processes and benefits of the co-production of knowledge in global health.

Paper long abstract:

Global health policy champions modernism and biomedical knowledge but often neglects knowledge, beliefs, and identity of indigenous communities in low- and middle-income countries. The growing emphasis in medicine on public engagement with science offers an opportunity to broaden discourses and incorporate local knowledge in hitherto unprecedented ways.

We exemplify the case of antimicrobial resistance (AMR) as a global health priority and present a case study of public engagement with research involving indigenous groups in Chiang Rai, Northern Thailand. Involving a photography exhibition of traditional "Tales of Treatment" and half-day bi-directional educational activities in three Chiang Rai villages, our case study will:

• Exemplify disjunctions and blends of AMR policy and global health discourses on the one hand, and indigenous knowledge on the other hand.

• Outline the process, lessons, and difficulties of developing bi-directional communication activities that respond to—and that enable actors to learn from—local medical knowledge.

• Analyse behavioural research hypotheses based on local understandings of medicine.

• Reflect on the mechanisms required to establish a process of knowledge co-production that will be essential for alternative approaches to AMR policy.

Our case study adds nuance to biomedical discourse, helping to break up stereotypes and to understand the behaviour and history of indigenous groups. Traditional practices and behaviours that are seen as a threat to health can be an alternative to modern pharmaceutical interpretations of care, which have fuelled much of current antimicrobial use and thus antimicrobial resistance.

Paper Download (2.9 MB)

Paper short abstract:

This paper will advance a decolonial critique of paradigmatic approaches to intimate partner violence (IPV) in public health discourse. The aim is to increase reflexivity about the 'situatedness' of these constructs in western epistemology and to propose more cosmology-sensitive approaches.

Paper long abstract:

Intimate partner violence (IPV) has comprised one of the priority areas of public health research and practice, especially in relation to African development. However, this scholarship and practice has been dominated by gender-based violence (GBV) aetiologies that conceptualise IPV almost invariably in reference to hierarchical gender systems and relations. These aetiologies are recurrently transposed cross-culturally through a sociological methodology that is rarely informed by comprehensive ethnographic studies of IPV from specific societies. Consequently, such aetiologies have not integrated well local knowledge systems and worldviews, and especially religious belief systems. On the other hand, studies based on more empirical or anthropological evidence do not eschew epistemological limitations by remaining situated in western metaphysics of gender and religion. This can hinder understanding the contextual and nuanced mechanisms that sustain or facilitate conjugal abuse or favourable attitudes about it in societies outside of western epistemology, and especially those that are embedded in authoritative indigenous religious traditions. To demonstrate this I will draw from a year-long ethnographic study of conjugal abuse from an Orthodox society of Ethiopia that accounted for the religio-cultural cosmology of the research participants in analysing interactions between gender norms, individual attitudes and human behaviour associated with conjugal abuse. To overcome the epistemological limitations of all ethnographic research and analysis, the methodology integrated ethnographic with participatory research approaches that prioritised the discourses of the local populations. The overall aim of this research has been to consolidate a model of development research and practice that is centred on local worldviews.

Paper short abstract:

Using a historical, comparative approach focused on technological advance, and which draws on evolutionary, institutional analysis of the health industry, its sub-sector capabilities, and local applications, this paper addresses challenges to ideas of a cohesive post-colonial global south.

Paper long abstract:

Colonisation has had a significant influence on economic development experience and economic analysis. Yet, independent countries have distinct industrial and technological features. This paper argues for a comparative evolutionary, institutional approach to economic development with industry-level analysis focused on uneven and dynamic local capabilities. The health industry is a good test case to probe this assertion, historically playing a critical industrial and social policy role. This industry, with distinct local product and process capabilities, has been unevenly developed to address local health needs across post-colonial contexts by states, local firms, and other stakeholders. Using Asian, African, and Latin American health industry cases from secondary data, the paper addresses the importance of differentiating national autonomy and domestic development capability by industry-level analysis. This allows economic development theories to move away from the requirement of a cohesive post-colonial global south.

Paper short abstract:

Infectious disease control is a matter of global concern and national interest. Indian vaccination programme is situated in the context of its colonial history of public health, and its modern aspirations as a nation that wants to emerge as a leader in low-cost innovative vaccine/health solutions.

Paper long abstract:

Vaccines, especially introduction of new ones are often see as silver bullets of technology, especially since the idea persists that science can be effectively used to address social problems like disease or poverty. Introduction of public health in India through the process of application of technology to address infectious disease control and sanitation began during colonial times. Medical interventions like vaccinations for smallpox became an example of biomedicine in a way that it understood people's health as a matter of public and state concern. Concerned by deaths due to tropical diseases, British promoted research and established about fifteen vaccine institutes beginning in the 1890s.

When India gained independence, Indian nationalists sought to build the identity of the nation, including its medical systems, based on their own ideas of geography, people and welfare. The concept of national medicine in this respect may have tried to achieve a balance between colonial medicine and a more indigenous system. As India moves towards becoming a more 'modern' nation in terms of development indicators, especially health, improvements in health surveillance such as greater vaccine coverage and adoption of new and advanced combination vaccines serve as useful tools. While this 'technology transfer' has been critiqued for distortion of national health priorities, India's emergence as one of the major vaccine producers and the growth of its exports is also seen as a source of national pride. In this paper I explore how vaccine programme in India and introduction of new vaccines is located within these contesting claims.

Paper short abstract:

Drawing from the focus of robust political economy on incentives and knowledge, we propose a framework for addressing emerging questions concerning the capacity of governance across multiple scales and policy sectors to coordinate the effective delivery of global health programmes.

Paper long abstract:

In the post-colonial era, while the governance of global health programmes has been opened up to community participation, the power and influence of supranational organisations is also increasing through organizations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. Simultaneously, especially in conflict zones, or so-called failed states, the channelling of funds and programs through centralised bureaucracies in developing countries, a characteristic of the immediate post-colonial period, has come under greater scrutiny. Following high, documented levels of corruption and delays in fund disbursement, there is an increasing effort to avoid or bypass these risks and threats to successful program implementation at national scale by moving power and authority either to the supranational or local levels. Such strategies for ‘rescaling’ global health governance, while potentially improving programme delivery, particularly in emergency or outbreak situations, require careful consideration. Adopting a ‘robust political economy’ approach (Cowen 2016; Pennington 2017), we propose a framework for engaging more closely with this emerging research agenda concerning the capacity of governance institutions and arrangements in this changing context to promote global health, while also avoiding a supranational tendency towards forms of neo-colonialism. The dual focus of the approach upon both the incentives-related and epistemological dimensions of such coordination challenges for governance is demonstrated to be of pertinence for emerging questions about global health, such as building health system capacity to reduce long-term dependency on the assistance of former colonial powers. Exploring the epistemological dimension, it is argued, which involves considering the range of different locally situated forms of knowledge and expertise involved in health programme delivery, is of fundamental importance for governance evaluation, yet relatively neglected by established approaches.

Paper short abstract:

Using a historical political economy methodology and case studies of Tanzania and Zimbabwe, this paper investigates the interaction of local industrial change, especially in health-related industries, with health system accessibility and local appropriateness, and draw policy lessons.

Paper long abstract:

The "health industries", including production of pharmaceuticals, diagnostics, other medical devices and hygiene inputs, have transformed health care across the world since 1945. Yet the social determinants of health literature largely ignores the impact of these industries' structure and location on health care access, quality and inequity. This paper uses a historical political economy methodology to investigate the proposition that the local co-evolution and interaction of health industries and health services is an important driver of local health care access and outcomes. The paper traces the evolving interactions between industrialisation/ deindustrialisation with particular reference to health industries, and the changing organisation and inequity of access to health services, in Tanzania and Zimbabwe from the colonial era to the present, using a mix of historical sources and recent fieldwork, and a historical political economy methodology. We show that periods of success in each country linked local industrialisation to expansion of primary health care. Local pharmaceutical firms have served private, NGO and public sector markets since early post-colonial periods; have been a source of emergency supply response in hard times; and have contributed to rural access. Meanwhile government leadership and investment have been key in periods when linkages improved equity as well as access. We argue that one element of decolonising health research is to re-embed it within broader ambitions for more locally led and sustainable local economic development.

Paper short abstract:

Based on a systematic literature review of 5 bibliographic databases, we investigate links between traditional and biomedical health services in Africa. In-depth analysis of the literature indicates diverse disconnects between traditional and biomedical health services, requiring further research.

Paper long abstract:

Health is recognised as being central to the SDGs with one specific goal focused on health, while aspects of health pervade many other goals and targets. Recently, some academics and civil society actors have argued that there is too much emphasis on scientific knowledge at the expense of other types of knowledge within the SDG process. This is a particularly important issue in the health sector in many LMICs where biomedical services are unable to fill the enormous gap between demand and supply and where local knowledge - under the guise of traditional medicine - is providing a majority of health services. In Africa, 80% of services are provided by traditional medicine. In this paper, we employ a critical interpretive synthesis (CIS) method, namely a form of systematic literature review, to search and select studies from 5 electronic databases, yielding 159 studies. After review, a final total of 26 studies were relevant for analysis. The theoretical framework is provided by the structural, relational and cognitive components of social capital. In-depth analysis indicated evidence of cognitive (different knowledge systems, different status), structural (legislative framework, educational systems) and relational (trust/distrust, lack of connecting networks) disconnects between traditional and biomedical health services with only one study specifically focusing on linking the two systems. We conclude that improving the links between traditional and biomedical health services has not been widely studied in the scientific literature. Further research should focus on case studies at local and national level.