Using power and influence analysis to address corruption risks: the case of the Ugandan drug supply chain

Power and influence analysis can be used to assess corruption vulnerabilities in the public sector. This approach helps identify powerful stakeholders that should be engaged to achieve maximum impact for anti-corruption strategies. It also helps reveal informal political networks and relationships that can hamper anti-corruption efforts. Power and influence analysis was applied to the Ugandan public sector drug supply chain and suggested that interventions aimed at reducing corruption risks would need to take into account the influence of informal political power in addition to the formal institutional mandates, and the prevalence of a vast network of patronage networks across the country

Local health governance in Tajikistan: accountability and power relations at the district level

Relationships of power, responsibility and accountability between health systems actors are considered central to health governance. Despite increasing attention to the role of accountability in health governance a gap remains in understanding how local accountability relations function within the health system in Central Asia. This study addresses this gap by exploring local health governance in two districts of Tajikistan using principal-agent theory

Social Accountability and its Conceptual Challenges: An analytical framework

Social accountability has become a favored approach among most major multilateral and bilateral donors to develop grass roots mechanisms for democratic governance. In a successful scenario, citizen participation can promote more responsive governments and better provision of basic services by linking users' feedback to the policy design, implementation and monitoring activities typically undertaken by the state. However, there is a lack of agreement about which specific types of social accountability interventions yield the best results and what are the causal pathways that are critical to generate positive changes. This paper presents an analytical framework that identifies the key components that are required to exercise effective direct accountability and provides a blueprint to assess social accountability initiatives

A Framework to Assess Governance of Health Systems in Low Income Countries

As awareness of the role governance in the performance of health systems has increased, so has the need to come up with systematic means to evaluate governance shortcomings to develop adequate interventions. This working paper describes a framework to assess governance in the health systems of low-income countries that is intended to have empirical applicability with a problem-driven approach. The analysis is grounded on a re-categorization of governance dimensions for greater heuristic power, with an emphasis made on the importance of strategic systems design and accountability. The proposed methodology includes mapping of both formal and informal institutions, actors and networks. This underscores the idea that in order to properly address governance weaknesses it is of utmost importance to have an insight into whether the interplay of formal and informal norms facilitates or undermines system performance

Performance-based financing, basic packages of health services and user fee exemption mechanisms: An analysis of health financing policy integration in three fragile and conflict-affected settings

Sophie Witter - ORCID 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Maria Paola Bertone - ORCID 0000-0001-8890-583X https://orcid.org/0000-0001-8890-583XBackground: As performance-based financing (PBF) is increasingly implemented across sub-Saharan Africa, some authors have suggested that it could be a ‘stepping stone’ for health system strengthening and broad health financing reforms. However, so far few studies have looked at whether and how PBF is aligned to and integrated with national health financing strategies, particularly in fragile and conflict-affected settings.Objective: This study attempts to address the existing research gap by exploring the role of PBF with reference to (i) user fees/exemption policies and (ii) basic packages of health services and benefit packages in Central African Republic, Democratic Republic of Congo and Nigeria.Methods: The comparative case study is based on document review, key informant interviews and focus group discussions with stakeholders at national and subnational levels.Results: The findings highlight different experiences in terms of PBF’s integration. Although (formal or informal) fee exemption or reduction practices exist in all settings, their implementation is not uniform and they are often introduced by external programmes, including PBF, in an uncoordinated and vertical fashion. Additionally, the degree to which PBF indicators lists are aligned to the national basic packages of health services varies across cases, and is influenced by factors such as funders’ priorities and budgetary concerns.Conclusions: Overall, we find that where national leadership is stronger, PBF is better integrated and more in line with the health financing regulations and, during phases of acute crisis, can provide structure and organisation to the system. Where governmental stewardship is weaker, PBF may result in another parallel programme, potentially increasing fragmentation in health financing and inequalities between areas supported by different donors.We acknowledge the financial support of The UK Department for International Development (DFID) through the ReBUILD grant, as well as the support of the African Economic Research Council (AERC). The views expressed do not necessarily reflect official policies of the UK government or of our funders.https://doi.org/10.1007/s40258-020-00567-818pubpu

Performance-based financing in three humanitarian settings: Principles and pragmatism

The Authors acknowledge the financial support of DFID through the ReBUILD grant, as well as of the African Economic Research Council (AERC).Maria Bertone - orcid: 0000-0001-8890-583X https://orcid.org/0000-0001-8890-583XSophie Witter - orcid: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Background: Performance based financing (PBF) has been increasingly implemented across low and middleincome countries, including in fragile and humanitarian settings, which present specific features likely to require adaptation and to influence implementation of any health financing programme. However, the literature has been surprisingly thin in the discussion of how PBF has been adapted to different contexts, and in turn how different contexts may influence PBF. With case studies from three humanitarian settings (northern Nigeria, Central African Republic and South Kivu in the Democratic Republic of Congo), we examine why and how PBF has emerged and has been adapted to those unsettled and dynamic contexts, what the opportunities and challenges have been, and what lessons can be drawn. Methods: Our comparative case study is based on data collected from a document review, 35 key informant interviews and 16 focus group discussions with stakeholders at national and subnational level in the three settings. Data were analysed in order to describe and compare each setting in terms of underlying fragility features and their implications for the health system, and to look at how PBF has been adopted, implemented and iteratively adapted to respond to acute crisis, deal with other humanitarian actors and involve local communities. Results: Our analysis reveals that the challenging environments required a high degree of PBF adaptation and innovation, at times contravening the so-called ‘PBF principles’ that have become codified. We develop an analytical framework to highlight the key nodes where adaptations happen, the contextual drivers of adaptation, and the organisational elements that facilitate adaptation and may sustain PBF programmes. Conclusions: Our study points to the importance of pragmatic adaptation in PBF design and implementation to reflect the contextual specificities, and identifies elements (such as, organisational flexibility, local staff and knowledge, and embedded long-term partners) that could facilitate adaptations and innovations. These findings and framework are useful to spark a reflection among PBF donors and implementers on the relevance of incorporating, reinforcing and building on those elements when designing and implementing PBF programmes.sch_iih12 [28]pub5409pu

LERU roadmap towards Open Access

Money which is not directly spent on research and education, even though it is largely taxpayers' money. As Harvard University already denounced in 2012, many large journal publishers have rendered the situation "fiscally unsustainable and academically restrictive", with some journals costing as much as $40,000 per year (and publishers drawing profits of 35% or more). If one of the wealthiest universities in the world can no longer afford it, who can? It is easy to picture the struggle of European universities with tighter budgets. In addition to subscription costs, academic research funding is also largely affected by "Article Processing Charges" (APC), which come at an additional cost of (sic)2000/article, on average, when making individual articles Gold Open Access. Some publishers are in this way even being paid twice for the same content ("double dipping"). In the era of Open Science, Open Access to publications is one of the cornerstones of the new research paradigm and business models must support this transition. It should be one of the principal objectives of Commissioner Carlos Moedas and the Dutch EU Presidency (January-June 2016) to ensure that this transition happens. Further developing the EU's leadership in research and innovation largely depends on it. With this statement "Moving Forwards on Open Access", LERU calls upon all universities, research institutes, research funders and researchers to sign this statement and give a clear signal towards the European Commission and the Dutch EU Presidency.Peer reviewe

Incidence of Interval Colorectal Cancer After Negative Results From First-Round Fecal Immunochemical Screening Tests, by Cutoff Value and Participant Sex and Age

Background & Aims: We evaluated the incidence of interval cancers between the first and second rounds of colorectal cancer (CRC) screening with the FOB-Gold fecal immunochemical test (FIT), and the effects of different cutoff values and patient sex and age. Methods: We collected data from participants in a population-based

Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study)

Background: Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications. The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas. Methods/design. Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma 3 cm, located between 115 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane i

Beyond normative technicism: institutionalist approaches to health systems governance in Tajikistan

Health systems are the result of decisions on how resources are raised and spent, which groups in society are involved in the process of decision-making, or which needs and interests are responded to, and the incentives this creates for those delivering services. These decisions are shaped by the interests and convictions of those in power and depend on how they exercise this power. This puts governance at the centre stage of health systems research. Until recently however, health governance research was dominated by normative and ‘technicist’ approaches that focused on technical dimensions of health administration following the good governance paradigm and had limited empirical validation. Many low-income, fragile settings present a complex context for which frameworks based on an understanding of centralised and coherent health systems do not easily fit. This calls for approaches that allow for a more contextualised understanding of governance with an explicit focus on the way political, social and economic interactions in the health system are shaped by humanly devised constraints, also known as institutions. The primary aim of this thesis is to explore governance of the health system in Tajikistan with such a neo-institutionalist perspective, drawing on political economy analysis, principal-agent theory, collective action theory and the concept of social capital. Tajikistan is a low income, post-Soviet and post-conflict setting with features of neo-patrimonialism and state fragility. The combination of a Soviet legacy, including a large public health infrastructure, fragile state capacity, a precarious power balance, partly stemming from a recent experience with conflict, and limited public resources available for health presents deep challenges to health service delivery. Little is known about what political factors have been inhibiting the introduction of health system reforms, and what these entail at the local level. The relationship between key governance actors and the role of political-economic interests, social norms and the wider political-economic context in the health governance process, including at district and community levels, have received less attention in scholarly debate. This includes attention to what citizen engagement in the area of health, and local governance structures at the community level actually entail in practice. The research presented in this thesis draws on literature review and qualitative research conducted in Tajikistan at central policy level, district level and among communities and health workers. The thesis first of all sets out to develop an understanding of useful concepts to explore the governance of basic services in neo-patrimonial systems of governance in general; Secondly, it identifies the main governance constraints to the introduction and implementation of the Basic Benefit Package reforms and associated health management changes, by analysing the interactions of the main stakeholders with the political and socioeconomic context in relation to the technical dimensions of the reform. Third, it offers an analysis of meso-level accountability in the health system in terms of principal-agent relationships as a key process in district-level health governance; and lastly it explores how social capital facilitates the engagement with external development agents and local health governance actors, and fosters collective action around village organisations and community-based health funds. With explicit attention to the political economy in which health policy changes and the interventions from development agencies take place, and the interconnectedness of central, local and community level governance the research highlights the role of particular interests, resource-seeking motivations and entrenched power relations in shaping the health system. It shows how these result in and are affected by unclear mandates, policy incoherence and informal accountability mechanisms. The findings furthermore emphasise the precarious position that health workers as frontline bureaucrats in the system, and citizens find themselves in, in relation to government. Building on this, the study has provided new insight into important mechanisms that underpin the mixed results in engaging citizens through community-based health insurance for greater financial protection. Ultimately these insights serve to underline the relevance of contextualising health programmes and addressing the (informal) resource distribution mechanisms, power dynamics and collective action challenges that are so important in shaping health systems governance