Paper short abstract:

this paper investigates how contextual variations in the production of the category malaria in Tanzanian health facilities influence the generation of indicators aiming to represent the mosquito-borne affliction

Paper long abstract:

Mirroring the rise of the performance-based paradigm in global health, monitoring and evaluation (M&E) has become a central feature in contemporary malaria control and elimination efforts. These technologies of audit and performance evaluation are used to measure and assess the outputs of interventions and aim to promote their transparency and accountability. Indicators (along with targets) are at the core of M&E activities: used to measure and contrast the inputs, outputs and outcomes of interventions, indicators not only facilitate comparison and ranking of interventions but are also used to inform and justify policy decisions or funding allocation. Hence, attaining high indicator-based rankings is becoming increasingly important to institutions and countries, raising the question how the necessary data are generated especially in low-income countries where health information systems often manifest significant weaknesses.

This paper draws on long-term ethnographic fieldwork in southern Tanzania to examine routine data production on malaria in the government health system. It traces how context-specific variations such as those involving human resources or diagnostic technologies profoundly shape knowledge practices at rural health facilities. These variable practices result in the production of ontologically diverse "malaria's" that are collapsed into a single category through routine recording practices, obfuscating its variable content and the wider contextual and structural issues that underlie this variability. This black-boxing raises questions about the content of the category malaria and the indicators generated from these data.

Paper short abstract:

Ethnographic research in 6 Indonesian field sites will be used to evaluate standard WHO global health indicators relating to malaria and population ageing.

Paper long abstract:

The World Health Organisation records roughly 50 categories of health indicator for Indonesia (of which there are myriad sub-classifications). These measures are drawn from survey sources that rely on the much more extensive inquiries of the Indonesian statistical office, the BPS. We propose to discuss the set of indicators that relate to two major current global health concerns, population ageing and malaria. Drawing on qualitative and quantitative research over the last 15 years (in three ethnic groups on the main islands of Java and Sumatra, and three small ethnicities on the island of Alor in the Eastern Archipelago), we will consider the sub-set of indicators that describe the health and social conditions of places such as these with respect to ageing and malaria. What is intended is an off-the-record critique of the stories that can be built with survey variables from the perspective of in-depth ethnography of social, economic and cultural variation in the six sites, the forces that shape health variation at the local level, and the degree to which variables applied on a nationwide basis can be expected to capture it.

Paper short abstract:

Mindful of height as both a measure and source of inequalities, this paper explores the linkages between international child growth standards and the meanings of height in the Philippines by presenting a local history of growth charts and drawing from an “ethnography of height” in a Philippine city.

Paper long abstract:

Over the past half century, height has emerged as a key indicator of health, both at the level of populations and individuals, particularly children. Malnutrition is a persistent problem, and this has given rise to the measuring and monitoring of children's growth, using international 'child growth standards'. The contemporary picture is that of inequality, with significant differences between the global North and South, as well as between rich and poor within the same populations.

Inspired by Canguilheim's deconstruction of the "normal" and "pathological" in scientific and medical praxis, my paper looks at the history of growth charts, both globally and in the Philippines, and the local discourses (anxieties, aspirations) that were generated by the shift towards an international 'child growth standard' in the early 2000s. I then draw from my ethnographic work among young people and in health centers in Puerto Princesa, Philippines, to situate public health practice in the everyday lives of mothers, chilren, and health workers. Finally I offer a broader view of what height means for the Philippines, where the average height is 163 cm for males and 154 cm for females.

Concerns and practices about children's growth and particularly height, I argue, are inexorably linked to the meanings of height in the Philippines. In turn, these meanings, which engage notions of race, beauty, class, and status, inform and give rise to practices of height-making that converge (and diverge) with public health and pediatric knowledge in interesting ways.

Paper short abstract:

The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) is a performance based financial instrument. By using the example of Nepal, we assess how the generation of mandatory data has significant effects on how programmes are run.

Paper long abstract:

The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) has highlighted investing for impact as its core funding strategy for the period of 2012-2016. As an international financial instrument, it focuses on achievements of targets through investments in these three diseases, as well as on "health system strengthening". It also demands outcome-based evaluation metrics to link disbursement of resources to performance in lieu of achievement of clear and measurable results. All the grants from GFATM have a transparent performance framework and the recipients report their service delivery results against this framework.

This paper analyzes how the GFATM strategy is experienced by different stakeholders involved in receiving the GFATM resources in the context of Nepal. These institutional entities are the principal recipients (PRs), which receive funding directly from the GFATM and sub-recipients (SRs), which receive funding from their respective PRs. The PRs (Government bodies and International NGOs) and SRs (mainly INGOs and NGOs) are the main organizations involved in health sector development, either working vertically in one or some of these three disease arenas, or in other areas of health development. The paper shows the empirical realities of operationalizing this target based funding modality in various parts of Nepal. In doing so, it pays attention to the unintended consequences of such funding. It also sheds light on how attempting to reach targets with the predetermined activities is linked to generating quantitative data. In focusing on this, the attention towards broader impact tends to become secondary to reaching numerical targets.

Paper short abstract:

Creating ‘hard’ maternal mortality indicators has become a global research priority. Researchers recognize that such indicators distort the reality they supposedly measure. Yet, they have limited power to rectify such distortion within a culture in which such indicators have acquired immense power.

Paper long abstract:

Statistical indicators have acquired a life of their own within the global health enterprise, though not all indicators have equal value. Today, the donors who drive global health tend to value 'hard' indicators of health outcomes over 'softer' indicators of the processes involved in healthcare delivery. This paper examines how the cultural value and prestige associated with methodological rigour reinforces not only the scientific, but also political, authority of such indicators.

The paper draws on a broader ethnography of the global advocacy coalition for safe motherhood that has, since the late 1980s, sought to generate political commitment to reducing maternal mortality. Through in-depth interviews and participant-observation within elite global health academic networks in Europe and the US, we show how the creation of better indicators of maternal mortality has become a research priority, displacing the field's earlier emphasis on methodologically diverse health systems research. While they have vigorously pursued the production of such indicators, in private many researchers question their value for improving global health practice, not least because they recognise that certain indicators distort the reality they supposedly measure. While researchers express a wish to rectify such distortion, their limited power to do so reflects not only the scientific prestige associated with specific indicators, but also the extent to which researchers have become positioned as key actors within global health initiatives that compete with each other - a competition in which 'hard' indicators have acquired immense power.

Paper short abstract:

Drawing on fieldwork on international initiatives to control the tobacco epidemic in the global South, this paper argues that the ubiquity of numbers in global health today is related to the influence of epidemiological styles of reasoning across the field.

Paper long abstract:

In this paper, I suggest that the ubiquity of regimes of quantification, counting practices, metrics and numbers in contemporary global health comes from the way in which the field has been shaped by epidemiological styles of reasoning - grids of intelligibility and action articulated around theories, techniques and institutions that stem from epidemiology and related bodies of knowledge. In contrast to much of the literature on the subject, which focuses on the shortcomings of epidemiological reason, the paper draws attention to the productive dimension of epidemiologists and epidemiological knowledge by showing how they contribute to the production of new forms of government and accountability of life. Furthermore, eschewing the often vague and facile association of epidemiological reason with neoliberal theories and audit culture found in much of the literature, the paper also seeks to emphasise the much longer and more complex genealogy of this thought style. To do this, the article focuses on the efforts of the Bloomberg and Gates foundations to address the smoking epidemic in the developing world, which I have been researching over the last few years.

Paper short abstract:

Health profiles as a form of epidemiological knowledge is seen as 'evidence' in 'evidence-based policy. This recasts them as 'policies' and eliminates the gap between research and policymaking. However, the most pervasive influence of the statistics is not only numbers but also categories.

Paper long abstract:

Statistics can be understood in two ways: one that focuses on the numbers as representations of a reality that was there before the statistics measured it, and another that approaches the statistics as social constructions. The idea of 'evidence-based policy' takes the former as a starting point, while the latter allows us to see the health profiles as elements in the construction of the stat, in the perspective of global/local, and as categories that construct individuals in relation to health measurements. I will discuss a specific form of health statistics, the 'health profiles', as a form of epidemiological knowledge, but also as the 'global' localised, turning comparison into a key concept in policymaking in the neo-liberal knowledge society. I will demonstrate how numbers and categories that should create order and simplify complexity are not neutral, even if they seem natural. Thus, I will argue that even if the health profiles in a historical perspective are just another example of epidemiological knowledge that has influenced policymaking for centuries, an ideology of comparison and individualism has found its way into the construction of the state, together with an increased focus on efficiency and 'what works'. The status of the health profile as 'evidence' seems unquestionable, and their role in policymaking is characterised by an entanglement that does not allow room for a debate on their trustworthiness.