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- Convenors:
-
Sigridur Baldursdottir
(University of Iceland)
Jónína Einarsdóttir (University of Iceland)
- Location:
- JUB-G31
- Start time:
- 11 September, 2015 at
Time zone: Europe/London
- Session slots:
- 2
Short Abstract:
The panel explores formulation of global policies, and their impact on health care and access to services in low-income countries. How do community members, national actors and authorities act on these? Theoretical and ethnographically founded papers and those concerned with practice are welcome.
Long Abstract:
The global health landscape, characterized by public and private actors, has a great impact on policy and funding of health interventions in the resource-poor health sector in low-income countries. The level of funds and the priorities shift in line with the political and ideological trends of the time. The neoliberal policies promoted by the World Bank and IMF in the 1980s had a far-reaching impact on the health sector, for instance in sub-Saharan Africa. It resulted in introduction of user fees, cost recovery, private health insurance and public-private partnership with consequent inequalities in access to services. Later, in the 1990s, with the post-Washington consensus, global institutions again recognised health services as the responsibility of the state. Today under the influence of the ideology of Alma Ata, formulated in 1978, the emphasis is on universal health coverage through alleviation of user fees.
This panel explores the production of global policies and how these affect practices in health care and access to services at the local level in low-income countries and resource-poor areas. Are health practices driven by policies or is it practice that produces policy? For whom are health policies and practices designed? How are health policies formulated and acted on by local community members, other national actors and authorities? How does policy affect access to health care? What have we learned from past experience? How can future health policy and approaches benefit from past experience? We welcome theoretical and ethnographically founded papers as well as those concerned with practice.
Accepted papers:
Session 1Paper short abstract:
Based on qualitative data from 2009 to 2012 this paper explores the elaboration of a new community health policy in Guinea-Bissau and its effects based on theories of global governance. It argues for the importance of taking the local context into consideration when elaborating a new health policy.
Paper long abstract:
In recent years there has been an increased interest globally to revitalize the Alma Ata Declaration on primary health care (PHC) from 1978 to achieve the Millennium Development Goals. In Guinea-Bissau, a country where the health policy has been under the influence of Alma Ata, the revitalization process started in 2010. Initially the implementation of PHC went well, but due to a number of reasons it started to deteriorate around the year 2000. Consequently, a new policy was elaborated to revitalize community health care. The new policy emphasized professionalization of community health workers (CHWs) and preventive health care for mothers and children. Traditional birth attendants (TBAs), who had played an important role in the past, were however excluded.
This paper aims to explore the elaboration of the new community health policy in Guinea-Bissau and its effects based on theories of global governance. The data is based on 20 months of anthropological fieldwork between 2009 and 2012.
The Ministry of Health in Guinea-Bissau emphasized the importance of learning from past experience when elaborating the new community health policy, but this study shows that international health policy did influence certain aspects of the policy. During the initial implementation phase there was certain tension related to the selection of new CHWs and the consequent exclusion of older illiterate CHWs and TBAs. Workload of new CHWs was high and they needed appropriate motivation. This paper argues through empirical examples for the importance of taking local contexts into consideration when elaborating a new health policy.
Paper short abstract:
Despite over two decades of WHO policies focused on reducing maternal deaths, the decline has been slow. Through analysis of birth ethnographies and WHO policies I explore whether there is a role for ethnographic research in informing the development of policies relating to pregnancy and childbirth.
Paper long abstract:
Despite over two decades of WHO policies focused on reducing maternal deaths, the decline has been slow. Historically assumed global applicability of WHO policies, without due consideration of the unique beliefs and practises of different societies, has been linked to the past policy failures. Through analysis of birth ethnographies and WHO policies I explore whether there is a role for ethnographic research in informing the development of policies relating to pregnancy and childbirth. I conclude that although current WHO policies do not explicitly call for ethnographic research, they highlight a need for the evidence it generates. Ethnography could provide necessary background information to understand the underlying causes of maternal mortality and help adapt policies so that they are relevant to local socio-cultural contexts. Ethnography could help generate new solutions to problems and legitimise alternatives to a biomedical framework for understanding pregnancy. I conclude the value of ethnography and the type of information it generates could be applied to other spheres of public health beyond maternal health. I recommend that medical anthropology should remain an important part of the curriculum in schools of public health in order to strengthen the awareness of the value of ethnographic methods among those whom graduate to become policy makers at WHO. I recommend that WHO employ anthropologists to actively participate in development and implementation of global health policies.
Paper short abstract:
This presentation draws on humanitarian healthcare professionals’ accounts of morally distressing encounters with death and dying, and Nguyen’s work on therapeutic citizenship (2010) to unpack the politics of palliative care in humanitarian emergencies.
Paper long abstract:
Rescue is central tenet of humanitarian healthcare in practice. For some, this is a practical reality of response. For others, such as Redfield, the rescue imperative is also political: a refusal of dominant biopolitics and its grossly unequal distribution of life and death across the globe (Redfield 2012, 2013). There will always be, however, some individuals in contexts of humanitarian crises whose lives cannot be saved. The recent Ebola crisis, so obviously challenging the intentions of healthcare professionals to offer curative assistance, has foregrounded this inevitability. Can and should humanitarian healthcare providers be responsible for ensuring a certain standard of care to those likely to die in humanitarian crises? This is an ethical, practical, and political question our research group (Humanitarian Healthcare Ethics Research Group) is currently working on in collaboration with members of the World Health Organization initiative to strengthen palliative care. In this presentation, we draw on our interviews with humanitarian healthcare professionals and Nguyen's work on therapeutic citizenship (2010) to unpack the politics of palliative care in humanitarian emergencies. A key question we ask is: How is providing palliative care in emergencies similar or different - in terms of its moral, political, and lived implications - from the broader biopolitics of life and death that determine whose lives are prioritized and whose are not in humanitarian practice?
Paper short abstract:
This paper explores the drivers behind the generation of maternal health user-fee policies in West Africa, in particular whose voices are heard and the dynamics and tensions between international and local aims, agendas and evidence.
Paper long abstract:
To decrease maternal mortality rates, increase facility delivery and reduce financial burdens on women, policy makers in several African countries have recently instituted user fee reduction or exemption plans in maternal health care. Less attention in the literature has been paid to how these policies came to be generated (Meesen et al 2009, among others), instead, more has been written about their implementation and impact. One of the aims of the FEMHealth project was to go beyond policy content and “what happened” and explore the often neglected question of “what explains what happened”(Gilson & Raphaely 2008). This paper is based on global level interviews with actors in maternal health policy and financing, and draws on further case study research in Benin, Burkina Faso, and Morocco – all countries that have recently initiated policies in this domain.
Analysis suggests that while international influences have been important in shaping the global climate which permeates the three countries, decision-making was created in a context of locally driven goals and objectives. Having gone in a circle from free health care, to user fees, and now to selective fee removal policies, donor advice was given a new rank – one that became devalued as aid-dependent countries rallied for technical and financial support from other sources. This paper explores how a few key individuals were able to establish roles that brought about policy changes at both local and international levels, and what this can tell us about the ways in which ideas and ideologies are translated into policies.
Paper short abstract:
Based on data collected in 2011, this presentation aims to evaluate the implementation of the Bamako Initiative in general, but in particular in Guinea-Bissau. The question posed is: Can universal health coverage be realized, as currently advocated by global institutions?
Paper long abstract:
UNICEF and WHO jointly formulated a statement that became known as the Bamako Initiative after its adoption by the African Ministers of Health in 1987. The aim was to rescue primary health care from privatization with user fees and selling of drugs. Later, the World Bank embraced the approach, and its list of assumed benefits included additional revenues, improved quality of services, efficiency, privatization, transfer of revenues from richer urban areas to poorer rural ones, decentralization, and sustainability. The ability to pay was found adequate, or at least be cheaper than the traditional system. The Initiative was assumed to improve access to services, and those unable to pay should be exempted through solidarity fund.
This presentation aims to evaluate the implementation of the Bamako Initiative generally, and in particular in Guinea-Bissau. It is based on data collected in the country in 2011. The benefits attributed to the approach have rarely been realized. Thanks to user fees and informal payments, the Bissau-Guinean nurses may have kept their health centers open during turbulent times. Nonetheless, the poorest part of the population has been excluded from the services, reflected in the low level of attendance and limited revenues. Due to general poverty and consequent difficulties in deciding whom to exempt from payment, no solidarity funds were established. Policy changes are needed to address inequality in access to health care and increase its quality. Will the implementation of universal health coverage, as currently advocated by donors, become more successful than the Bamako Initiative?
Paper short abstract:
The policy towards TBAs in Uganda is highly un-social and fails to address the underlying reasons for the existence of TBAs. By drawing from a global menu that is insensitive to local peculiarities the policy tends to work in tandem with the goal of access to maternal health for the vulnerable women
Paper long abstract:
In the 1960s, WHO championed policies for integration of traditional birth attendants (TBAs) in the delivery of maternal health services. By the1990s there was a realization that TBAs were not reducing maternal mortality and a new policy promoting skilled attendants saw national governments discouraging and banning activities of TBAs. Using ethnographic methods in a rural community of Luwero, Uganda, I investigated how this policy shift affected the configuration of maternity services. Because practicing TBAs are threatened with arrest they demand cash payment upfront from clients. Due to fear, TBAs refrain from helping delivering women even in circumstances where skilled attendants cannot be accessed. Many women navigate this situation through syncretic utilization of both TBA and formal healthcare which they keep secret from the formal healthcare authorities. Some mothers avoid formal maternity care due to fear of being reprimanded for utilizing TBA services. The policy towards TBAs produced an ambiguous environment in which access maternal health services are re-configured into two contradictory system embodied by rural women who have to navigate them to access maternity care. I conclude that policy towards TBAs is highly un-social, top-down, overly medicalized, and fails to address the underlying reasons for the existence of TBAs, perhaps precisely because of their marginalisation within the health system structure. The policy draws from a global menu that is insensitive to local peculiarities and as a result tends to reproduce and by default work in tandem with the broader goal of access to health for the vulnerable in the community.
Paper short abstract:
This presentation describes and analyses the services of TBAs in Monkey Bay Area in Mangochi District in Malawi for the period 2004-2011, and evaluates the impact of the ban. It exemplifies the difficulties to apply ambitious global goals to diverse local settings.
Paper long abstract:
In an attempt to lower the prevailing high maternal and child mortality rates, and the reach MDG5 by 2015, the Government of Malawi decided in October 2008 to prohibit Traditional Birth Attendants (TBAs) to assist births in Malawi. The aim of the paper is to describe and analyse the services of TBAs in Monkey Bay Area in Mangochi District in Malawi for the period 2004-2011, and evaluate the impact of the ban. It builds on an analysis of data in the Health Monitoring Information System (HMIS), and qualitative interviews with TBAs conducted before and after the ban. In general, TBAs assisted women to deliver in about 1/3 of all births before the ban; after the ban, birth attendance by health professionals increased by about 50-75% in the two state-run health facilities, and three CHAM facilities. At the same time, community expressed their anger about the ban, and its implementation. The ban on TBA exemplifies the difficulties to apply ambitious global goals to diverse local settings. Within the current socio-economic situation of Malawi, shared with many low-income countries in sub-Saharan Africa, it is difficult to see how TBAs can be excluded to serve women to deliver in their own communities. Ways need to be sought to integrate their activities in the over-all health services, first for preventive activities, but also how to improve the quality of their work, and referral practices.
Paper short abstract:
Partner involvement is encouraged for first antenatal care visit, which consequently expose and exclude single women. Men wish to join to ensure quality of care but are denied access and increased commitment. Partner involvement should be embraced but only upon the consent of the expectant mother.
Paper long abstract:
The objective of this study was to explore perspectives and experiences of antenatal care and partner involvement among women who nearly died during pregnancy ('near-miss'). Qualitative data were collected between March 2013 and April 2014 in Kigali, Rwanda and included extended in-community participant observation, semi-structured interviews, and focus group discussions. All informants were aware of the recommendations of male involvement for HIV-testing at first antenatal care visit. However, this recommendation was seen as a clear link in the chain of delays and led to severe consequences, especially for the women without an engaged partner. The overall quality of antenatal services was experienced as substandard, potentially missing the opportunity to provide preventive measures and essential health education intended for both parents. This seemed to contribute to women's disincentive to complete all four recommended visits and men's interest in joining to ensure their partners reception of care. However, the participants experienced a restriction of men's access during subsequent antenatal visits, which made men feel denied for their increased involvement during pregnancy. These findings suggest a need for increased flexibility in the antenatal care recommendations to encourage women to attend care with or without their partner, and to create open health communication about women's real needs within the context of their social situations. Supportive partners should not be denied at any stage of pregnancy, but should be received only upon consent of the expectant mother.