Global HIV/AIDS initiatives, recipient autonomy and country ownership: an analysis of the rise and decline of Global Fund and PEPFAR funding in Namibia

The Global Fund to Fight HIV/AIDS, Malaria and TB and U.S President’s Emergency Fund for AIDS Relief (PEPFAR) are global health initiatives (GHIs) that were established in the early 2000s with the mandates to increase global capacity to address HIV and AIDS rapidly. When the two GHIs were created, Namibia was one of the highest recipients of funding from both GHIs. A significant portion of their support to the country went to the Ministry of Health, which was the principal provider of treatment services in the country. Critics have argued, however, that the rise of financial support from the Global Fund and PEPFAR was associated with the creation of new administrative structures and procedures at the country level. This approach raises important questions about the degree to which Namibian health policymakers were able to exercise autonomy in the presence of GHI support. The aim of this thesis is to analyse the implications for institutional capacity and autonomy at the rise and fall of funding from the Global Fund and PEPFAR to the Ministry of Health concerning financial flows; human resources recruitment; and civil society engagement. With a focus on the changing relationship between the Ministry of Health and the two initiatives, the thesis examines the implications for country ownership and health systems capacity in the context of decreasing financial support from the Global Fund and PEPFAR. The field studies for this research was undertaken in 2011- 2012, when the two GHIs had indicated their intentions to scale-down the financial support made available to Namibia. This thesis uses multiple sources of data to qualitatively analyse the influences of Global Fund and PEPFAR support to Namibia from when the two initiatives were first established in 2002 and 2004, respectively, to 2012. A principal source of data was 43 semi-structured interviews conducted in Namibia during a placement with the Directorate of Special Programs in the Ministry of Health in early 2012. For financial flows, both the Global Fund and PEPFAR channelled and managed their funding through funder-specific structures and procedures that were developed and operated in parallel to existing Ministry of Health operations. Both for financial flows and human resources, initial structures and processes created difficulties for the Ministry of Health’s long-term objectives for HIV and AIDS. For civil society engagement, the thesis examined the Ministry of Health’s relationship with the Global Fund. At the rise of funding, the Global Fund required the establishment of a new multi-sector coordination structure for HIV and AIDS. This new structure operated at the same time as the existing national coordination structure and was perceived as having undermined the Ministry of Health’s role as the primary steward of Namibia's response. The Global Fund was also criticised for initially funding civil society organisations without making provisions for sustaining their capacity in the event of funding decline. The findings presented in this thesis indicate that at the rise of financing, the Ministry of Health’s engagement with the two HIV and AIDS GHIs initiatives was governed by the objectives of the two initiatives, rather than the long-term health systems goals of the Namibian Government. Their relationships with Namibia had an adverse impact on the Ministry of Health’s autonomy in making decisions on the national response to HIV and AIDS. The initial operations of the GHIs also had negative implications for Namibia's ability to sustain the health systems capacity they had helped to increase

Rapid incorporation of carbon from ectomycorrhizal mycelial necromass into soil fungal communities

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Is Scotland a Westminster-style Majoritarian Democracy or a Scandinavian-style Consensus Democracy? A Comparison of Scotland, the UK and Sweden

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What is the 'dominant model' of British policymaking? Comparing majoritarian and policy community ideas

The aim of this article is to help identify the fundamental characteristics of the British policymaking system. It highlights an enduring conflict of interpretation within the literature. On the one hand, most contemporary analysts argue that the ‘Westminster model' is outmoded and that it has been replaced by modern understandings based on ‘governance'. On the other, key ideas associated with the Westminster model, regarding majoritarian government and policy imposition, are still in good currency in the academic literature, which holds firm to Lijphart's description of the United Kingdom as a majoritarian democracy. These very different understandings of British government are both commonly cited, but without much recognition that their conclusions may be mutually incompatible. To address this lack of comparison of competing narratives, the article outlines two main approaches to describe and explain the ‘characteristic and durable' ways of doing things in Britain: the ‘policy styles' literature initiated by Richardson in Policy Styles in Western Europe and the Lijphart account found in Democracies and revised in 1999 as Patterns of Democracy. The article encourages scholars to reject an appealing compromise between majoritarian and governance accounts

Dreaming Characteristics in Non-Rapid Eye Movement Parasomnia and Idiopathic Rapid Eye Movement Sleep Behaviour Disorder: Similarities and Differences

Background: Speech graph analysis (SGA) of dreams has recently shown promise as an objective and language-invariant diagnostic tool that can aid neuropsychiatric diagnosis. Whilst the notion that dreaming mentations reflect distinct physiologic processes is not new, such studies in patients with sleep disorders remain exceptionally scarce. Here, using SGA and other dream content analyses, we set to investigate structural and thematic differences in morning dream recalls of patients diagnosed with Non-Rapid Eye Movement Parasomnia (NREMP) and Idiopathic REM Sleep Behavior Disorder (iRBD). Methods: A retrospective cross-sectional study of morning dream recalls of iRBD and NREMP patients was undertaken. Traditional dream content analyses, such as Orlinsky and Hall and Van de Castle analyses, were initially conducted. Subsequently, SGA was performed in order to objectively quantify structural speech differences between the dream recalls of the two patient groups. Results: Comparable rate of morning recall of dreams in the sleep laboratory was recorded; 25% of iRBD and 18.35% of NREMP patients. Aggression in dreams was recorded by 28.57% iRBD versus 20.00% in NREMP group. iRBD patients were more likely to recall dreams (iRBD vs NREMP; P = 0.007), but they also had more white dreams, ie having a feeling of having dreamt, but with no memory of it. Visual and quantitative graph speech analyses of iRBD dreams suggested stable sequential structure, reflecting the linearity of the chronological narrative. Conversely, NREMP dream reports displayed more recursive, less stable systems, with significantly higher scores of graph connectivity measures. Conclusion: The findings of our exploratory study suggest that iRBD and NREMP patients may not only differ on what is recalled in their dreams but also, perhaps more strikingly, on how dreams are recalled. It is hoped that future SGA-led dream investigations of larger groups of patients will help discern distinct mechanistic underpinnings and any associated clinical implications

A 'Multiple Lenses' Approach to Policy Change: the Case of Tobacco Policy in the UK

This article examines a period of rapid policy change following decades of stability in UK tobacco. It seeks to account for such a long period of policy stability, to analyse and qualify the extent of change, and to explain change using a 'multiple lenses' approach. It compares the explanatory value of policy network models such as punctuated equilibrium and the advocacy coalition framework, with models stressing change from 'above and below' such as multi-level governance and policy transfer. A key finding is that the value of these models varies according to the narrative of policy change that we select. The article challenges researchers to be careful about assuming the nature of policy change before embarking on explanation. While the findings of the case study may vary with other policy areas in British politics, the call for clarity and lessons from multiple approaches are widely applicable

Exploring the science–policy interface on climate change: The role of the IPCC in informing local decision-making in the UK

Building on the Intergovernmental Panel on Climate Change’s (IPCC) review of how to make its Assessment Reports (ARs) more accessible in the future, the research reported here assesses the extent to which the ARs are a useful tool through which scientific advice informs local decision-making on climate change in the United Kingdom. Results from interviews with local policy representatives and three workshops with UK academics, practitioners and local decision makers are presented. Drawing on these data, we outline three key recommendations made by participants on how the IPCC ARs can be better utilized as a form of scientific advice to inform local decision-making on climate change. First, to provide more succinct summaries of the reports paying close attention to the language, content, clarity, context and length of these summaries; second, to better target and frame the reports from a local perspective to maximize engagement with local stakeholders; and third, to work with local decision makers to better understand how scientific advice on climate change is being incorporated in local decision-making. By adopting these, the IPCC would facilitate local decision-making on climate change and provide a systematic review of how its reports are being used locally. We discuss implications of these recommendations and their relevance to the wider debate within and outside the IPCC as to the most effective way the IPCC can more effectively tailor its products to user needs without endangering the robustness of its scientific findings. This article is published as part of a collection on scientific advice to government

A systematic review of frameworks for the interrelationships of mental health evidence and policy in low- and middle-income countries

Background: The interrelationships between research evidence and policy-making are complex. Different theoretical frameworks exist to explain general evidence–policy interactions. One largely unexplored element of these interrelationships is how evidence interrelates with, and influences, policy/political agenda-setting. This review aims to identify the elements and processes of theories, frameworks and models on interrelationships of research evidence and health policy-making, with a focus on actionability and agenda-setting in the context of mental health in low- and middle-income countries (LMICs). Methods: A systematic review of theories was conducted based on the BeHeMOTh search method, using a tested and refined search strategy. Nine electronic databases and other relevant sources were searched for peer-reviewed and grey literature. Two reviewers screened the abstracts, reviewed full-text articles, extracted data and performed quality assessments. Analysis was based on a thematic analysis. The included papers had to present an actionable theoretical framework/model on evidence and policy interrelationships, such as knowledge translation or evidence-based policy, specifically target the agenda-setting process, focus on mental health, be from LMICs and published in English. Results: From 236 publications included in the full text analysis, no studies fully complied with our inclusion criteria. Widening the focus by leaving out ‘agenda-setting’, we included ten studies, four of which had unique conceptual frameworks focusing on mental health and LMICs but not agenda-setting. The four analysed frameworks confirmed research gaps from LMICs and mental health, and a lack of focus on agenda-setting. Frameworks and models from other health and policy areas provide interesting conceptual approaches and lessons with regards to agenda-setting. Conclusion: Our systematic review identified frameworks on evidence and policy interrelations that differ in their elements and processes. No framework fulfilled all inclusion criteria. Four actionable frameworks are applicable to mental health and LMICs, but none specifically target agenda-setting. We have identified agenda-setting as a research theory gap in the context of mental health knowledge translation in LMICs. Frameworks from other health/policy areas could offer lessons on agenda-setting and new approaches for creating policy impact for mental health and to tackle the translational gap in LMICs