Chapter 4 Federalism, devolution, and territorially-based cleavages in Africa

Whether it is possible to ensure stability, peace and social cohesion in countries with deep societal divisions where identity prevails over other bases of mobilisation is one of the central political questions of our time. What type of institutional design suits deeply mobilised cleavages? This chapter discusses the different institutional approaches adopted in three federations of Africa to manage politically mobilised cleavages, and examines whether institutional design matters in addressing demands from politically mobilised groups. The main issue is whether such divisions should be treated as building-blocks for political engagement and institutions built around them, or rather be diffused and deliberately divided into several sub-units. It is argued that institutional design does matter, particularly when there are deep territorially-based divisions, and proposes consociational parliamentary federations as opposed to integrationist presidential federations. The latter aim to divide major ethnic groups into many small-size states denying their self-government right, while the former aim to empower groups by redrawing territories to ensure they become a majority at sub-state level. They also bring the major political actors into power and minimise the risks of ‘winner-takes-all’ politics associated with presidential systems

Chapter 4 Federalism, devolution, and territorially-based cleavages in Africa

Whether it is possible to ensure stability, peace and social cohesion in countries with deep societal divisions where identity prevails over other bases of mobilisation is one of the central political questions of our time. What type of institutional design suits deeply mobilised cleavages? This chapter discusses the different institutional approaches adopted in three federations of Africa to manage politically mobilised cleavages, and examines whether institutional design matters in addressing demands from politically mobilised groups. The main issue is whether such divisions should be treated as building-blocks for political engagement and institutions built around them, or rather be diffused and deliberately divided into several sub-units. It is argued that institutional design does matter, particularly when there are deep territorially-based divisions, and proposes consociational parliamentary federations as opposed to integrationist presidential federations. The latter aim to divide major ethnic groups into many small-size states denying their self-government right, while the former aim to empower groups by redrawing territories to ensure they become a majority at sub-state level. They also bring the major political actors into power and minimise the risks of ‘winner-takes-all’ politics associated with presidential systems

Bibliography of the Literatures on Tuberculosis, TB/HIV and MDRTB in Ethiopia from 2001 – 2017

Ethiopia is among the thirty-high tuberculosis (TB) burden countries with multidrug resistant tuberculosis (MDR-TB) and Tuberculosis/Human Immunodeficiency Virus (TB/HIV). Given the public health importance of the problem, it is apparent that probing the work done in this regard is essential to mitigate the problem and thus we reviewed research repositories and compile directories of researches in Ethiopia from Jan 1, 2001 to Dec 30, 2017 in order to avail evidence-based information to stakeholders and beneficiaries intervening the problem in the country. The evidences generated in this bibliography are through different databases and websites using key terms. A range of different published and unpublished literatures (journal articles, conference presentations, reports/manual/book, and graduate theses or dissertations) on TB, MDR-TB, extensively drug resistant TB (XDR-TB), or TB/HIV are presented. We presented literatures by four themes (Biomedical and clinical researches, epidemiological researches, operational or implementation researches, and health systems researches). A total of 1571 researches and reports were accessed through the above search engines and revealed 635 epidemiological researches followed by 538 clinical or biomedical researches, 257 operational or implementation research, and 141 health systems research. Interestingly, up to 2008 clinical or biomedical researchers were the leading researches and from 2009 onwards, epidemiological researches held the largest constituency. In conclusion, TB or TB/HIV and MDR-TB literatures in Ethiopia have substantially increased over years. Referred journal publications took theleading source and epidemiologic studies were the commonest one. We suggest the need to focus on operational or implementation and health system researches to plummet the disease spreading, drug resistance and impact. We also recommend a regular update of the bibliography every 3 to 4 years with annotations

Trends in HIV/AIDS morbidity and mortality in Eastern 3 Mediterranean countries, 1990–2015: findings from the Global 4 Burden of Disease 2015 study

Objectives We used the results of the Global Burden of Disease 2015 study to estimate trends of HIV/AIDS burden in Eastern Mediterranean Region (EMR) countries between 1990 and 2015. Methods Tailored estimation methods were used to produce final estimates of mortality. Years of life lost (YLLs) were calculated by multiplying the mortality rate by population by age-specific life expectancy. Years lived with disability (YLDs) were computed as the prevalence of a sequela multiplied by its disability weight. Results In 2015, the rate of HIV/AIDS deaths in the EMR was 1.8 (1.4–2.5) per 100,000 population, a 43% increase from 1990 (0.3; 0.2–0.8). Consequently, the rate of YLLs due to HIV/AIDS increased from 15.3 (7.6–36.2) per 100,000 in 1990 to 81.9 (65.3–114.4) in 2015. The rate of YLDs increased from 1.3 (0.6–3.1) in 1990 to 4.4 (2.7–6.6) in 2015. Conclusions HIV/AIDS morbidity and mortality increased in the EMR since 1990. To reverse this trend and achieve epidemic control, EMR countries should strengthen HIV surveillance,and scale up HIV antiretroviral therapy and comprehensive prevention services

Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016

The UN’s Sustainable Development Goals (SDGs) are grounded in the global ambition of “leaving no one behind”. Understanding today’s gains and gaps for the health-related SDGs is essential for decision makers as they aim to improve the health of populations. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016), we measured 37 of the 50 health-related SDG indicators over the period 1990–2016 for 188 countries, and then on the basis of these past trends, we projected indicators to 2030

Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016

Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND: Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI). METHODS: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate. FINDINGS: The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9-78·6) for females and 72·0 years (68·8-75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0-49·5]) and for males was in Lesotho (41·5 years [39·0-44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97-6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74-6·27) for males and 6·49 years (6·08-6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61-1·93) for males and 1·96 years (1·69-2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (-2·3% [-5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally. INTERPRETATION: At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support. FUNDING: Bill & Melinda Gates Foundation

Intra-Unit Minorities in the Context of Ethno-National Federation in Ethiopia

After years of centralized rule emphasizing unity and territorial integrity, Ethiopia in 1991 adopted a federal system that aimed at accommodating its diversity. The system is designed to empower hitherto marginalized ethno-national groups by ensuring self-government in nine constituent units and redrawing boundaries to match with ethno-national boundaries. By designing constituent units, and, in some cases, local governments that ensure self-rule to major ethno-national groups, the constitution transforms these groups into majorities within the territories they control at constituent and local level. This article argues that while conferring territorial autonomy and self-rule to mobilized, territorially grouped ethno-national groups may be a step in the right direction to address the age-old ‘nationality question’, the design establishes a titular ethno-national group that claims exclusive control over territory, dominates public institutions, perpetuates majority rule and replicates the problems of the ‘nation-state’ at constituent-unit level. The combination of majority rule by titular ethno-national group and exclusive control over territory at constituent-unit level in a context of heterogeneous constituent units and increased inter-regional state mobility has therefore had grave consequences for intra-unit minorities. What the design provides is autonomy for a particular titular ethno-national group, not autonomy for all inhabitants in the constituent unit. Hence, the question arises: What institutional and policy options do we have to address the rights of intra-unit minorities in the states? It is argued that the process of empowering ethno-nationalist group at regional-state level was conducted without putting relevant institutional and policy mechanisms in place to minimize the marginalization of intra-unit minorities. The article therefore examines the institutional, political, legal and policy safeguards that exist for intra-unit minorities. It proposes four mechanisms that aim to address the concerns of intra-unit minorities: power-sharing as well as non-territorial autonomy; external checks by the federal government to monitor constituent units’ compliance with intra-unit minorities; and strict enforcement of human rights throughout the country. Enforcement of these packages of supplementary measures would mitigate the situation of intra-unit minorities and recast the conception of political power and territory in such a way that they are understood not as the exclusive property of a particular ethno-national group but a shared common good for all inhabitants of the constituent units