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- Convenors:
-
John Manton
(LSHTM)
Holly Ashford (University of Cambridge)
David Bannister (University of Oslo)
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- Stream:
- Health
- Location:
- Gordon Aikman Lecture Theatre
- Sessions:
- Wednesday 12 June, -, -
Time zone: Europe/London
Short Abstract:
This panel scrutinises the framing, evolution, and implementation of programmes in primary health care (PHC) in Africa, emphasising connections and disjunctures between present-day philanthrocapitalist, and prior modes of extending and funding PHC, in a long history before and since Alma Ata.
Long Abstract:
The Alma Ata Declaration of 1978 gave rise to renewed commitment at state level, and a range of economic and organisational strategies, aimed at developing and strengthening public health systems, under the banner of promoting 'health for all' through primary health care (PHC). Across Africa, this aspiration promised the consolidation of a range of humanitarian and postcolonial state interventions, pilots and programmes into a concerted drive for donor-, tax-, and loan-funded systematisations in the health sector at national level. The optimism, and the commitment of resources, proved shortlived. Now, in a very different political and economic dispensation, the superficially connected call for 'Universal Health Coverage' in global health is equally galvanising. Is it equally vulnerable?
This panel proposes a critical scrutiny of the framing, evolution, and implementation of programmes in public health and primary health care in Africa, emphasising the connections between present-day philanthrocapitalist alignments around funding circumscribed forms of equity in public health, and prior modes of extending and funding PHC, in a long history before and since Alma Ata. Papers from a wide range of disciplines are invited to dwell on the salience of aspiration, hope and emotional commitment around a notion of health as a public good; connections, coalitions and tensions between interest groups at community, national, and international levels; disruption, failure and resuscitation in planning for PHC; exemplary programmes and signal successes or failures in public health implementation; and disjunctures between past and present modes and framings of coverage in primary health care in Africa.
Accepted papers:
Session 1 Wednesday 12 June, 2019, -Paper short abstract:
The 1970s saw a sharp shift in rhetoric on women's reproductive health in Ghana. From an economic development policy, family planning became a cornerstone of PHC. However, gendered biases survived this shift and restricted promises of 'health for all'.
Paper long abstract:
When family planning came to Ghana in the late 1960s, it was prescriptive, funded by - largely US - philanthropic organisations. They worked alongside the Ghanaian government, which was keen to reinvigorate the nation with renewed promises of development. Family planning was about population control, its framework was economic development. Family planning programmes promised prosperity for individual families and threatened stagnated national growth if fertility was not reined in. By the time the National Family Planning Programme was launched in May 1970, there were already worries about contraceptives being offered outside of a maternal and child health (MCH) system. The 1970s saw a shift both 'on the ground' and at the international level. Throughout the 1970s Primary Health Care (PHC) was being formulated at the international level. A shift towards PHC began to take place de facto in Ghana at the same. The promise of health for all can be understood in a longer historical trajectory through looking at women's reproductive health. Traditional birth attendants, long feared by governments hoping to spread orthodox medicine, were suddenly to be embraced. It was no longer seen as appropriate to run a family planning system that was not anchored in health practices. Women, long targeted for nutrition programmes, homecraft classes and mothercraft talks, were officially recognised as drivers of localised health care and, in theory, offered support. This paper will argue that gendered biases seeped into PHC from its inception, compromising promises of 'health for all.'
Paper short abstract:
This paper, using an ethno-linguistic analyses, highlighting patterns in intergenerational and gendered constructions, systematically shows how the conceptualisations of health and ill-health influences patients health-seeking behaviours and the treatment regimen from the biomedical health providers
Paper long abstract:
In Africa, the huge gaps between biomedical models and cultural constructions of health and ill-health have been a source of interest for researchers (Helman 2000). Modern biomedicine stresses on physiological manifestations of health and ill-health. The complexity of human illness however requires holistic approaches to understanding how societies construct health and ill-health. Such studies in mainstream humanities are rare in Africa resulting in huge intellectual gaps in our understanding of every day constructions of disease, illness and health. This poses a great challenge in achieving the goal of health for all, since it requires the full participation of individuals and families in the community in order to make health services acceptable and accessible.
This paper, using an ethno-linguistic analyses comprising the systemic collection and analyses of ethnic terminologies, coinages, phrases and words among the Ga, Ashanti, and Kasena, highlighting patterns in intergenerational and gendered constructions, systematically shows how the conceptualisations of health and ill-health influences patients health-seeking behaviours and the treatment regimen from the biomedical health providers.
The data, spanning a period of before and after Alma Ata, is drawn from a larger study that elicited information from about 80 individuals each (between 18 and 75 years) from the three ethnic groups, using interviews and focus group discussions.
The study calls for a greater attention to be given to the cultural context and the so called subjective explanations of health phenomena as it key to achieving universal health coverage.
Paper short abstract:
How UHC will be implemented in poor countries raises many issues. Particularly, in those nations whose health sectors are characterized by chronic and structural underfunding, as in most African countries. This paper examines the feasibility of UHC policy, from the analysis of the Nigerien case.
Paper long abstract:
This paper aims at reflecting on the viability of UHC approach in low-income African countries. Over the last decade, African governments have strived to find solutions that enable the most deprived segments of the population to access public health care. Consequently, financial mechanisms that charge users before illness episodes happen, in terms of risk sharing benefits, have been studied in order to bring poor people closer to health facilities and to prevent households from exhausting their financial resources during episodes of serious illness. This idea is not entirely new. The Equity Funds created in the early 2000s were based on a similar principle in which UHC approach underlies, that is, to promote access to healthcare facilities for those who were unable to pay for it. However, this initiative has not been successful due to, among other things, never-ending funding problems. Based on the Nigerien experience, this paper will discuss the feasibility of UHC policy by exploring two different aspects. The first relates to public healthcare system's dysfunctionality and ineffectiveness. Without a resolution of these issues, UHC will be doomed to failure. And the second concerns the security of permanent and regular health funds. When half the population lives on less than two dollars a day, taxing the informal sector or promoting mutual health organizations will not solve the health funding issue. Therefore, it is concluded that public-private partnerships, like Global Fund, are probably the most sustainable long-term solution.
Paper short abstract:
In this paper I will reframe the history of the WHO's concept of Community Based Rehabilitation for people with disabilities. Drawing on evidence from Kenya and Tanzania, I scrutinise the novelty of this concept and look at why its implementation was ultimately far removed from its initial aims.
Paper long abstract:
Einar Helander described the rehabilitation of people with disabilities as the 'fourth component' of the Alma Ata Declaration, next to promotion, prevention and cure. He developed the concept of Community Based Rehabilitation (CBR) at the WHO headquarters in the late 1970s. This supposedly new paradigm was to introduce a bottom-up approach to the development of rehabilitation services in the so-called developing countries, introducing a more participatory approach that could be adapted to local circumstances.
With Kenya and Tanzania as case studies, I contextualise this history of CBR within a longer timeframe, focusing on what actually happened on the ground. I contend that this longer and more grounded history of the 'fourth pillar' of Alma Ata can tell us a lot about what happened when these ambitious programs 'travelled', and their transformation between the stages of conceptualisation and actual implementation. In Kenya and Tanzania, CBR was introduced in contexts where ideas about and practices of rehabilitation had developed since late colonial times. This first of all meant that CBR was not something radically new, but also that its implementation had to be negotiated between a multitude of actors: The state, philanthropic, humanitarian and religious organisations, and of course people with disabilities themselves. That process made for a considerable discrepancy between the idea and the implementation of CBR. This paper will thus contribute to a better understanding of how to interpret ambitious PHC programs such as CBR within longer histories of rehabilitation on the African continent.
Paper short abstract:
This paper examines the framing of health needs and coverage in Nigeria between 1936 and 1988, amid the shifting local and global politics of disease control, sanitary organisation, health financing, training, and the diversification of health and medical services.
Paper long abstract:
This paper focuses on attempts to consolidate the organisation of health services in colonial and independent Nigeria, examining how developing modes of planning in international public health were articulated locally amid the politics of health care, regionalisation, and state and economic planning in Nigeria. It traces the organisational forms, information flows, and agents of planning and consolidation at regional and federal level, as well as the effects of global programmes and international governmental and philanthropic health financing on trends in health services organisation.
Specifically, it examines how need and coverage were framed and assessed amid the shifting politics of disease control, sanitary organisation, health financing, training, and the diversification of health and medical services as bodies such as the World Health Organization, the World Bank, and the Rockefeller Foundation became more prominent in guiding sectoral reform in health services, and the strengthening of developing world health services. Tracing the interplay of programmes, ideas, and policies, from early moves to regulate health services at a colony-wide level in the 1930s to the publication of 'The National Health Policy and Strategy to Achieve Health for all Nigerians' in 1988, it offers a system-wide perspective on medicine, health, equity, and coverage in Nigeria.
Paper short abstract:
Alma Ata inspired community healthcare was implemented in Guinea-Bissau from 1978 to 2012. Examination exposed how changes in global health policies impacted on its execution. Aid dependency led Guinea-Bissau to align revitalized policy with global trends, but failed to consider local realities.
Paper long abstract:
This paper examines the implementation of community-based primary health care in Guinea-Bissau, inspired by the Alma Ata Declaration in 1978. It is based on 20 months of ethnographic fieldwork in 2009-2012.
In 1977, a community health program was initiated in Guinea-Bissau with assistance of donors. Village health units were constructed and staffed with volunteer community health workers (CHWs) and traditional birth attendants (TBAs). In the 1990s, villagers appreciated community health care and its implementation was considered successful. Due to a range of circumstances, including shifts in donors' priorities, aid shock, and a military uprising in 1998, the first decade of the 21st century resulted in degradation of community health care. In 2010, the Ministry of Health elaborated a new community health policy in collaboration with donors that emphasized professionalization of CHWs whilst excluding TBAs. The Ministry of Health was to lead implementation, but due to military coup in 2012, it was bypassed by donors with NGOs taking on a prominent role.
This paper argues that the health policy of Guinea-Bissau has been influenced by swift changes in global health policies and priorities. Due to its aid dependency, the country realigned its new policy with global trends hoping to improve its indicators for the Millennium Development Goals. However, the policy did not take local realities into consideration, leading to discontent among villagers who were not consulted. This study shows that despite the appeal of volunteer work and community participation, community health care is neither cheap nor easy to implement.
Paper short abstract:
Based on oral histories, a study of generational memories of the shifting diffusion of 'global health' policies in Ghana from 1966-2018 - the implication of these policy shifts and diffusions for conceptions of the public good and an equitable provision of health services.
Paper long abstract:
From 1966, following the overthrow of sub-Saharan Africa's first independent government, Ghana's health system entered a period of relative stasis and dissolution. Although its achievements were uneven and not sustained, the independence-era government had invested in the expansion of some health services, guided by 5-year national plans. The country was ruled by six governments in the 15 years from 1966-1981, when the authoritarian government of Jerry Rawlings took power - at a time of apparent reform and renewal in the world of international health. Rawlings oversaw the imposition of Structural Adjustment in Ghana, and the country's return to multi-party elections in 1993. From the mid-1960s and into the era of Structural Adjustment, health services in Ghana declined. Since the late 1990s they have entered an unsteady phase of renewal, with the creation of a community-based health service and a national health insurance scheme. In the past decade talk has turned to Universal Health Coverage, an imprecise term with many possible meanings and implications.
Based on interviews with officials who oversaw health services from the 1970s to 2018, and with healthworkers and communities who witnessed successive changes from the 1950s, this paper discusses how shifting policies, aspirations and debates about financing - emerging at the international level from specific constellations of actors - diffused by various routes to shape Ghana's health system over time. It examines the effect that these changes may have had on generational expectations for health services, and discusses the value of oral history for postcolonial health research.