The Political Economy of Tobacco in Mozambique and Zimbabwe: A Triangulation Mixed Methods Protocol

Changing global markets have generated a dramatic shift in tobacco consumption from high-income countries (HICs) to low- and middle-income countries (LMICs); by 2030, more than 80% of the disease burden from tobacco use will fall on LMICs. Propelling this shift, opponents of tobacco control have successfully asserted that tobacco is essential to the economic livelihoods of smallholder tobacco farmers and the economy of tobacco-growing countries. This nexus of economic, agricultural and public health policymaking is one of the greatest challenges facing tobacco control efforts, especially in LMICs. To date, there is a lack of comparative, individual level evidence about the actual livelihoods of tobacco-growing farmers and the political economic context driving tobacco production. This comparative evidence is critically important to identify similarities and differences across contexts and to provide local evidence to inform policies and institutional engagement. Our proposed four-year project will examine the economic situation of smallholder farmers in two major tobacco-growing LMICs—Mozambique and Zimbabwe—and the political economy shaping farmers’ livelihoods and tobacco control efforts. We will collect and analyze the existing data and policy literature on the political economy of tobacco in these two countries. We will also implement household-level economic surveys of nationally representative samples of farmers. The surveys will be complimented with focus group discussions with farmers across the major tobacco-growing regions. Finally, we will interview key informants in these countries in order to illuminate the policy context in which tobacco production is perpetuated. The team will develop country-level reports and policy briefs that will inform two sets of dissemination workshops in each country with relevant stakeholders. We will also conduct workshops to present our findings to the survey and focus group participants, and other members of these tobacco-growing communities, so they can directly benefit from the research to which they are contributing

The Political Economy of Tobacco in Mozambique and Zimbabwe: A Triangulation Mixed Methods Protocol.

Changing global markets have generated a dramatic shift in tobacco consumption from high-income countries (HICs) to low- and middle-income countries (LMICs); by 2030, more than 80% of the disease burden from tobacco use will fall on LMICs. Propelling this shift, opponents of tobacco control have successfully asserted that tobacco is essential to the economic livelihoods of smallholder tobacco farmers and the economy of tobacco-growing countries. This nexus of economic, agricultural and public health policymaking is one of the greatest challenges facing tobacco control efforts, especially in LMICs. To date, there is a lack of comparative, individual level evidence about the actual livelihoods of tobacco-growing farmers and the political economic context driving tobacco production. This comparative evidence is critically important to identify similarities and differences across contexts and to provide local evidence to inform policies and institutional engagement. Our proposed four-year project will examine the economic situation of smallholder farmers in two major tobacco-growing LMICs-Mozambique and Zimbabwe-and the political economy shaping farmers' livelihoods and tobacco control efforts. We will collect and analyze the existing data and policy literature on the political economy of tobacco in these two countries. We will also implement household-level economic surveys of nationally representative samples of farmers. The surveys will be complimented with focus group discussions with farmers across the major tobacco-growing regions. Finally, we will interview key informants in these countries in order to illuminate the policy context in which tobacco production is perpetuated. The team will develop country-level reports and policy briefs that will inform two sets of dissemination workshops in each country with relevant stakeholders. We will also conduct workshops to present our findings to the survey and focus group participants, and other members of these tobacco-growing communities, so they can directly benefit from the research to which they are contributing

Who is paid in pay-for-performance? Inequalities in the distribution of financial bonuses amongst health centres in Zimbabwe

Although pay-for-performance (P4P) schemes have been implemented across low- and middle-income countries (LMICs), little is known about their distributional consequences. A key concern is that financial bonuses are primarily captured by providers who are already better able to perform (for example, those in wealthier areas), P4P could exacerbate existing inequalities within the health system. We examine inequalities in the distribution of pay-outs in Zimbabwe’s national P4P scheme (2014–2016) using quantitative data on bonus payments and facility characteristics and findings from a thematic policy review and 28 semi-structured interviews with stakeholders at all system levels. We found that in Zimbabwe, facilities with better baseline access to guidelines, more staff, higher consultation volumes and wealthier and less remote target populations earned significantly higher P4P bonuses throughout the programme. For instance, facilities that were 1 SD above the mean in terms of access to guidelines, earned 90 USD more per quarter than those that were 1 SD below the mean. Differences in bonus pay-outs for facilities that were 1 SD above and below the mean in terms of the number of staff and consultation volumes are even more pronounced at 348 USD and 445 USD per quarter. Similarly, facilities with villages in the poorest wealth quintile in their vicinity earned less than all others—and 752 USD less per quarter than those serving villages in the richest quintile. Qualitative data confirm these findings. Respondents identified facility baseline structural quality, leadership, catchment population size and remoteness as affecting performance in the scheme. Unequal distribution of P4P pay-outs was identified as having negative consequences on staff retention, absenteeism and motivation. Based on our findings and previous work, we provide some guidance to policymakers on how to design more equitable P4P schemes

The NCRM wayfinder guide to equitable research relations in and after Covid-19

The Covid-19 pandemic has had a significant impact on international research practices. Restrictions on global travel have disrupted planned research projects and encouraged researchers to explore new ways of undertaking research ‘at a distance’, either directly or through collaborations with international partners. A previous Wayfinder Guide on ethical practices during Covid-19 identified how the pandemic has exposed historic and exploitative inequalities within the global research community, as well as providing opportunities to do research differently. This guide draws upon workshop discussions and recent literature to provide pointers and ideas on how experience of the pandemic might be mobilised to establish more equitable research practices

Pay for Performance: A Reflection on How a Global Perspective Could Enhance Policy and Research

Pay-for-performance (P4P) is the provision of financial incentives to healthcare providers based on pre-specified performance targets. P4P has been used as a policy tool to improve healthcare provision globally. However, researchers tend to cluster into those working on high or low- and middle-income countries (LMICs), with still limited knowledge exchange, potentially constraining opportunities for learning from across income settings. We reflect here on some commonalities and differences in the design of P4P schemes, research questions, methods and data across income settings. We highlight how a global perspective on knowledge synthesis could lead to innovations and further knowledge advancement