The Making of the ‘Informal State’ in Uganda

This article analyses the evolution, reproduction, and sustenance of what I refer to as the ‘informal state’ in Uganda – a distinct mode of organising and broadcasting power that simultaneously centralises and fragments the state system. The ‘informal state’ is manifest in the construction of structures parallel to the legal and constitutional ones. This article departs from other studies of stateness in Africa that accent colonial legacies, illicit economic activities, and social conflict in accounting for the so called ‘African state’ that supposedly fails to approximate to the model (modern) state. Instead I argue that Uganda’s ‘informal state’ is a consequence of three key factors: the country’s postindependence experience with wide-spread insecurity and political instability in the 1970s and 1980s, the belief in militarism as an ideology by the new (post- 1986) group of rulers along with the imperatives of retention of political power, and foreign-aid flows as reward for embracing neoliberal economic reforms. The article also shows that the ‘informal state’ system reproduces its survival and legitimates its rule through maintaining aspects of legal-rational state structures, ceding power to varied constituencies as well as expanding the patronage network through the creation of numerous agencies

The Efficacy of a Tropical Constructed Wetland for Treating Wastewater during the Wet Season: The Kenyan Experience

Constructed Wetlands are among the most promising treatment options for domestic and industrial wastewater streams in places where land is available. They need more land than conventional wastewater treatment plants but occupy less space when compared to waste stabilization ponds. They are generally affordable in operational and maintenance costs while offering effective and reliable service. Constructed Wetlands are manmade wastewater treatment systems that consist of shallow ponds and channels that have been planted with macrophytes. They rely on natural, microbial, biological, physical and chemical processes to treat wastewater. They normally comprise of impervious clay liners clay liners and engineered structures to control the flow direction, wastewater retention times and water levels. Research wok was conducted on a tropical constructed wetland to establish its capability to treat wastewater during the wet season. A comparison of its efficacy with that of conventional wastewater treatment plants was made on the basis of measured water quality parameters. Temperature, pH, dissolved oxygen, and conductivity were measured in situ. Total suspended solids (TSS), total dissolved solids (TDS), biochemical oxygen demand (BOD5), chemical oxygen demand (COD) phosphorus, ammonia, and nitrites were analyzed in the laboratory. Faecal coliforms were enumerated and Escherichia coli counts were determined. The TSS values were reduced from a mean of 116 mg/l at the influent point to 24 mg/l at the effluent point, depicting a reduction of 79.31%. Influent TDS averaged 847 mg/l, while the effluent averaged 783mg/l. Wet season BOD5 levels were reduced from an average of 472 mg/l at the inlet point to 24 mg/l at the outlet, depicting a reduction efficiency of 94.9%. COD levels were reduced from a mean of 2174.2 mg/l to 71mg/l, representing a removal efficiency of 96.7%. Phosphorus was reduced from a mean of 14 mg/l to 11 mg/l representing a percentage removal of 21.4%. Levels of ammonia reduced from an influent mean of 61 mg/l to an effluent mean of 48 mg/l representing a percentage reduction of 21.3%. There were a 99.99% reduction for both the faecal coliforms and E.coli counts. Conductivity of wastewater increased from 1.08mS to 1.98mS, while the p H increased from 6.23 at the inlet point to 7.99 at the outlet of the system. Temperature and dissolved oxygen measurements showed a diurnal variation. The wet season wastewater heavy metal concentrations were in the following ranges: Pb (7.9-11.9ppm), Cd (1.0-3.8ppm), Cr (1.4-8.8ppm), Zn (0.1-10.4ppm), Ni (2.2-8.3ppm) with Cu not being detected in the wastewater samples. Overall, tropical constructed wetlands are effective in treating wastewater streams and they perform a lot better than the popularly used waste stabilization ponds. This paper recommends their widespread use within the tropics as the prevalence of warm temperatures all the year round enhances their performance. Keywords: Constructed Wetlands, Microbial, Physical, Chemical, Heavy metals, Tropic

‘I stayed with my illness’: a grounded theory study of health seeking behaviour and treatment pathways of patients with obstetric fistula in Kenya

Background: Obstetric fistula classic symptoms of faecal and urinary incontinence cause women to live with social stigma, isolation, psychological trauma and lose their source of livelihoods. There is a paucity of studies on the health seeking behaviour trajectories of women with fistula illness although women live with the illness for decades before surgery. We set out to establish the complete picture of women’s health seeking behaviour using qualitative research. We sought to answer the question: what patterns of health seeking do women with obstetric fistula display in their quest for healing? Methods: We used grounded theory methodology to analyse data from narratives of women during inpatient stay after fistula surgery in 3 hospitals in Kenya. Emergent themes contributed to generation of substantive theory and a conceptual framework on the health seeking behaviour of fistula patients. Results: We recruited 121 participants aged 17 to 62 years whose treatment pathways are presented. Participants delayed health seeking, living with fistula illness after their first encounter with unresponsive hospitals. The health seeking trajectory is characterized by long episodes of staying home with illness for decades and consulting multiple actors. Staying with fistula illness entailed health seeking through seven key actions of staying home, trying home remedies, consulting with private health care providers, Non-Governmental organisations, prayer, traditional medicine and formal hospitals and clinics. Long treatment trajectories at hospital resulted from multiple hospital visits and surgeries. Seeking treatment at hospital is the most popular step for most women after recognizing fistula symptoms. Conclusions: We conclude that the formal health system is not responsive to women’s needs during fistula illness. Women suffer an illness with a chronic trajectory and seek alternative forms of care that are not ideally placed to treat fistula illness. The results suggest that a robust health system be provided with expertise and facilities to treat obstetric fistula to shorten women’s treatment pathways

Computerized Childbirth Monitoring Tools for Health Care Providers Managing Labor: A Scoping Review

Background: Proper monitoring of labor and childbirth prevents many pregnancy-related complications. However, monitoring is still poor in many places partly due to the usability concerns of support tools such as the partograph. In 2011, the World Health Organization (WHO) called for the development and evaluation of context-adaptable electronic health solutions to health challenges. Computerized tools have penetrated many areas of health care, but their influence in supporting health staff with childbirth seems limited. Objective: The objective of this scoping review was to determine the scope and trends of research on computerized labor monitoring tools that could be used by health care providers in childbirth management. Methods: We used key terms to search the Web for eligible peer-reviewed and gray literature. Eligibility criteria were a computerized labor monitoring tool for maternity service providers and dated 2006 to mid-2016. Retrieved papers were screened to eliminate ineligible papers, and consensus was reached on the papers included in the final analysis. Results: We started with about 380,000 papers, of which 14 papers qualified for the final analysis. Most tools were at the design and implementation stages of development. Three papers addressed post-implementation evaluations of two tools. No documentation on clinical outcome studies was retrieved. The parameters targeted with the tools varied, but they included fetal heart (10 of 11 tools), labor progress (8 of 11), and maternal status (7 of 11). Most tools were designed for use in personal computers in low-resource settings and could be customized for different user needs. Conclusions: Research on computerized labor monitoring tools is inadequate. Compared with other labor parameters, there was preponderance to fetal heart monitoring and hardly any summative evaluation of the available tools. More research, including clinical outcomes evaluation of computerized childbirth monitoring tools, is needed.publishedVersio

An Algorithm (LaD) for Monitoring Childbirth in Settings Where Tracking All Parameters in the World Health Organization Partograph Is Not Feasible: Design and Expert Validation

Background: After determining the key childbirth monitoring items from experts, we designed an algorithm (LaD) to represent the experts’ suggestions and validated it. In this paper we describe an abridged algorithm for labor and delivery management and use theoretical case to compare its performance with human childbirth experts. Objective: The objective of this study was to describe the LaD algorithm, its development, and its validation. In addition, in the validation phase we wanted to assess if the algorithm was inferior, equivalent, or superior to human experts in recommending the necessary clinical actions during childbirth decision making. Methods: The LaD algorithm encompasses the tracking of 6 of the 12 childbirth parameters monitored using the World Health Organization (WHO) partograph. It has recommendations on how to manage a patient when parameters are outside the normal ranges. We validated the algorithm with purposively selected experts selecting actions for a stratified sample of patient case scenarios. The experts’ selections were compared to obtain pairwise sensitivity and false-positive rates (FPRs) between them and the algorithm. Results: The mean weighted pairwise sensitivity among experts was 68.2% (SD 6.95; 95% CI 59.6-76.8), whereas that between experts and the LaD algorithm was 69.4% (SD 17.95; 95% CI 47.1-91.7). The pairwise FPR among the experts ranged from 12% to 33% with a mean of 23.9% (SD 9.14; 95% CI 12.6-35.2), whereas that between experts and the algorithm ranged from 18% to 43% (mean 26.3%; SD 10.4; 95% CI 13.3-39.3). The was a correlation (mean 0.67 [SD 0.06]) in the actions selected by the expert pairs for the different patient cases with a reliability coefficient (α) of .91. Conclusions: The LaD algorithm was more sensitive, but had a higher FPR than the childbirth experts, although the differences were not statistically significant. An electronic tool for childbirth monitoring with fewer WHO-recommended parameters may not be inferior to human experts in labor and delivery clinical decision support.publishedVersio

Ecohydrological characterization of the Nyando wetland, Lake Victoria, Kenya: A State of System (SoS) analysis

Lake Victoria floodplain wetlands have a complex hydrological setting characterized by transition from a terrestrial to an aquatic environment. A state-of-system (SoS) analysis was carried out in a papyrus dominated wetland in the Nyando River Delta, on the eastern shores of Lake Victoria, Kenya, to characterize and provide data for detailed ecohydrological studies. The objectives of the study were to: (1) determine the spatio- temporal changes in the wetland evolution and (2) analyze the main hydrological factors that have influenced wetland evolution. Multi-temporal dry-season Landsat MSS, Landsat TM and Landsat ETM+ imagery covering Nyando Wetland and its surrounding area were processed and analyzed to generate time series polygon and polyline maps of the wetland and river. Results show that the wetland increased in size from 5,925 ha in 1950 to 9,925 ha in 1973, and declined to 4,527 ha in 2008. In the last 60 years, Nyando River has migrated in a general eastward direction. Time series hydrological data (1950-2009) were statistically tested for homogeneity  using the Spearman’s rank test for linear trends, Pettit test and Standard Normal Homogeneity test (SNHT) for change point analysis, and split-record tests performed for variance (F-test) and mean (t-test). In addition, data were analyzed using descriptive statistics and frequency analyses. Statistical test results show that the hydrological data series were homogeneous. Results of change point analyses indicate that total annual rainfall in Nyando declined in 1979, while the mean annual discharge for Nyando River and Lake Victoria levels had significant upward shifts in 1961. The decadal mean discharges varied significantly over time and increased by 80% from 11.45 m3/s observed in the 1950-1961 subset, reducing by 11.4 and 21.9% in the next two decadal sub-sets, before rising by 35.0% in 1990s and dropping by 24.0% in the last decade. The decadal mean annual lake levels increased from 1134.0 to 1135.43 m in the 1951-1961 and 1962-1972 and remained above the longterm mean of 1135.0 m for 43 years since 1962 before dropping drastically by 1.4 m to an average of 1134 m/year in 2005-2009. The highest recorded lake level at Kisumu Station was 1136.2 m in 1964 after increasing by 2.5 m from 1961. Discharge data exhibit trimodal seasonal patterns, while the lake levels had two peaks. The lake levels are more sensitive to direct lake rainfall. Changes in the Nyando wetland area are linked to the seasonal and episodic flood and drought events coupled with anthropogenic activities (regulation of lake levels, modification of river including cut-off meanders, river training and construction of dykes, drainage of wetland for cultivation, settlement and livestock grazing, abstraction of water for irrigation). A combination of these hydrological and human factors is the main cause of the Nyando Wetland evolution. If the land use trend continues unabated, then the increase in papyrus losses will pose a big challenge to the ecological functioning of the wetland and its support to sustaining community livelihoods.Key words: Nyando Wetland, River, ecohydrology, Lake Victoria

Pathways to antibiotics in Bangladesh: a qualitative study investigating how and when households access medicine including antibiotics for humans or animals when they are ill

Background To understand how to reduce antibiotic use, greater knowledge is needed about the complexities of access in countries with loose regulation or enforcement. This study aimed to explore how households in Bangladesh were accessing antimicrobials for themselves and their domestic animals. Methods In-depth interviews were conducted with 48 households in one urban and one rural area. Households were purposively sampled from two lower income strata, prioritising those with under 5-year olds, older adults, household animals and minority groups. Households where someone was currently ill with a suspected infection (13 households) were invited for a follow-up interview. Framework analysis was used to explore access to healthcare and medicines. Findings People accessed medicines for themselves through five pathways: drugs shops, private clinics, government/charitable hospitals, community/family planning clinics, and specialised/private hospitals. Drug shops provided direct access to medicines for common, less serious and acute illnesses. For persistent or serious illnesses, the healthcare pathway may include contacts with several of these settings, but often relied on medicines provided by drug shops. In the 13 households with an unwell family member, most received at least one course of antibiotics for this illness. Multiple and incomplete dosing were common even when prescribed by a qualified doctor. Antibiotics were identified by their high cost compared to other medicines. Cost was a reported barrier to purchasing full courses of antibiotics. Few households in the urban area kept household animals. In this rural area, government animal health workers provided most care for large household animals (cows), but drug shops were also important. Conclusions In Bangladesh, unregulated drug shops provide an essential route to medicines including those prescribed in the formal sector. Wherever licensed suppliers are scarce and expensive, regulations which prohibit this supply risk removing access entirely for many people

What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study

Background Over-prescribing and inappropriate use of antibiotics contributes to the emergence of antimicrobial resistance (AMR). Few studies in low and middle-income settings have employed qualitative approaches to examine the drivers of antibiotic sale and dispensing across the full range of healthcare providers (HCPs). We aimed to explore understandings of the use and functions of antibiotics; awareness of AMR and perceived patient or customer demand and adherence among HCPs for human and animal medicine in Bangladesh. Methods We used an ethnographic approach to conduct face-to-face, in-depth interviews with 46 community HCPs in one urban and one rural area (Gazipur and Mirzapur districts respectively). We purposefully selected participants from four categories of provider in human and veterinary medicine: qualified; semi-qualified; auxiliary and unqualified. Using a grounded theory approach, thematic analysis was conducted using a framework method. Results Antibiotics were considered a medicine of power that gives quick results and works against almost all diseases, including viruses. The price of antibiotics was equated with power such that expensive antibiotics were considered the most powerful medicines. Antibiotics were also seen as preventative medicines. While some providers were well informed about antibiotic resistance and its causes, others were completely unaware. Many providers mistook antibiotic resistance as the side effects of antibiotics, both in human and animal medicine. Despite varied knowledge, providers showed concern about antibiotic resistance but responsibility for inappropriate antibiotic use was shifted to the patients and clients including owners of livestock and animals. Conclusions Misconceptions and misinformation led to a wide range of inappropriate uses of antibiotics across the different categories of human and animal healthcare providers. Low awareness of antibiotic action and antibiotic resistance were apparent among healthcare providers, particularly those with little or no training and those in rural areas. Specific and targeted interventions to address AMR in Bangladesh should include educational messages on the rational use of antibiotics and how they work, targeting all types of healthcare providers. While tailored training for providers may increase understanding of antibiotic action and improve practices, more far-reaching structural changes are required to influence and increase responsibility for optimising antibiotic dispensing among all HCPs

Motivating antibiotic stewardship in Bangladesh:identifying audiences and target behaviours using the behaviour change wheel

BACKGROUND: South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals and from a lack of policy compliance among healthcare providers. Additionally, there is high population density and high infectious disease burden. This paper describes the development of social and behavioural change communication (SBCC) to increase the appropriate use of antibiotics.METHODS: We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) registered physicians and 4) pharmaceutical companies/medical sales representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, prioritise audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings.RESULTS: Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritised as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change: suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek registered physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, important antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions, referring them to registered physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course.CONCLUSIONS: We prioritised drug shops for intervention delivery to all drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and address the impact on profit and livelihoods for drug shop staff for optimal compliance.</p