Corruption in Sub-Saharan Africa - An Impediment to Economic Growth

Sub-Saharan Africa is faced with many challenges. It is a region bulging with resources but cursed with incredible political and economic greed. With a vast ethnic diversity and an often misconstrued cultural lifestyle, which puts the region on the marginalization line. From a historical context, the impact of colonialism has haplessly set the environment for low leadership standards. The background setting for Sub-Saharan Africa’s economic underdevelopment is uninhibited corruption that exists within Sub-Saharan African societies. This institutional corruption takes a triangular cause - cultural, economic and political; each, together with so many other factors threaten Sub-Saharan Africa’s socio-economic development

Managing Relational Capabilities of Inter-Organizational Innovation Ecosystems: Empirical Investigations

Problem statement: The inter-organizational relationship has become an increasingly emerging configuration in the domains of an innovation ecosystem. The synergy of firms, with diverse institutional logics, motives and resources position has the potential to generate common good, that lie beyond the reach and capability of a single firm. However, managing the idiosyncrasies of firms in such alliances remain highly problematic in practice and largely limited in the extant literature, and thus often results in firms’ unwillingness to engage in a collaborative innovation ecosystem. To address this, first, we conduct a review of the literature to elucidate the research gap, highly influential authors, and countries, the classification of the body of literature according to the network antecedents, management, and performance issues that are fundamental to innovation network projects. These results, however, advance our understanding of the critical issues affecting the practices of co-creation of value and the ecosystem innovation performance. Furthermore, while knowledge on inter-organizational relationship has been dominated in the context of large corporations, a comprehensive understanding of how relational capabilities of a network is linked to the co-value creation of local SMEs network is missing. Second, we try to address this by performing an empirical study of local SMEs business networks, in practical terms, to understand how the network develops and leverages the distinct capabilities and resources of partners while advancing the ecosystem innovation performance. Since the diverse idiosyncrasies associated with firms continue to limit the proliferation of the inter-firm innovation ecosystem, our third chapter tries to examine how institution-based trust-building programs enable the development of actors’ innovation performance in the ecosystem. Finally, despite the presence of prior studies on the inter-firm alliance for commercial purposes, studies on a cause-related alliance of firms in a period of global uncertainty are largely underdeveloped. We addressed this problem in the fourth chapter, by examining the first empirical context of collaborative value practices of a cause-based inter-firm alliance. Research design: To address the gaps, we first reviewed the state-of-the-earth on inter-organizational relationships and integrate the innovation ecosystem literature, to understand the current body of literature and explore the avenue for future research. Based on the result of this study, we conducted two series of qualitative case studies and one quantitative study, analyzing (1) the relational capabilities enabling value co-creation of an inter-firm innovation network, (2) the inter-firm innovation network characterizing the social cause rather than commercial purpose interests, and (3) the development of trust in inter-firm innovation projects. We mainly relied on the explorative, grounded theory methodology to select and analyze our cases. For both case studies, a series of in-depth personal interviews were conducted across two business networks involving the network companies allying. In addition to this, a comprehensive list of secondary data was generated to augment the research process and increase the robustness of the findings. Results: The results of this thesis first map out the state of the earth, describing the emerging themes and direction for future agenda. Based on our review of extant literature, we found that research in inter-organizational innovation is emerging fast. This is due to the plethora of economic and commercial advantages firms derived in their relationship- thus creating an opportunity for more research in the field. Despite the growing attention of researchers in the field, the literature on inter-organizational relationships suffers from many weaknesses - making it problematic to achieve common alliance success. Generally, we discovered that research in the field is highly fragmented. First, research in an inter-organizational business network is, however, still struggling to gain a solid identity in practice because of the nuance of factors and their effects on inter-firm relationships. Our findings showed that several factors caught researchers’ attractions while others remain largely limited. Th results showed that these factors have parsimonious effects on innovation ecosystems– failing many inter-organizational projects across many industries and sectors. These results were further clustered according to three categories of network management: network antecedents, network management, and network performance. The extant literature, however, provides no integrated framework to entangle such challenges in inter-organizational relationships. Second, we empirically examined the development of relational capabilities of local SMEs inter-firm network contracts. The study identifies key antecedents for successful organizing of inter-firm engagement, and the consequent development of network relational dynamic capabilities in a business network environment: friendship, institutional arrangements, participatory culture, homophily, flexibility, coordination and control, communication/information flows, trust-building, transparency and managing change/adaptability. Our findings also suggest that organizing for inter-firm engagement in a business network context, positively influenced network relational performance over time. Third, we empirically explored institution-based trust-building in the context of an inter-firm innovation ecosystem. The findings show that relational risk mediates the effects of trust in institutional openness and honesty, similarity/identification trust, and institutional reliability on the innovation performance of SMEs. In addition to these findings, our study also established that institutional trust-building practices differ greatly by the size of the enterprise (small vs medium). While small firms are found to be more vulnerable to relational risks of inter-firm similarity (over-familiarity) than medium-sized firms, Medium-sized firms, on the other hand, are vulnerable to high relational risks caused by low institutional openness and low competence on innovation performance. Finally, in the last chapter of this thesis, we empirically explored the value-creating activities of a cause-based social alliance project in Northern Italy, seeking to address the social challenges of society in times of the COVID-19 pandemic. The finding of this study provides evidence that despite the different organizations, motives, and even diverse institutional logics, the collaborative value creation framework is a suitable theoretical lens to understand value generation in cause-based social entrepreneurship (SE) alliance. The study found four critical aspects of collaborative value processes, that enable the alliance actors to leverage the cause-based SE alliance capabilities: value definition, co-value creation, value balance, and value renewal. Due to the idiosyncrasies associated with the alliance firms, our study showed several challenges confronting the alliance, such as finding the right cause-driven social alliance partner, different institutional logics, systems, and operational guidelines, stakeholder commitment to the cause, resource-cause alliance fit, and trust. Contribution: Our results contribute, first, to the literature on managing the inter-organizational innovation network. By considering the context of local SMEs business networks, we provide empirical insights into the relational dynamics of actors in the innovation ecosystem. By the network context, we examined collaborative value processes that are critical to open innovation performance. Second, we bridge social entrepreneurship by better linking inter-firm cause-based alliance literature, a subject that is highly fragmented in the literature. Third, our empirical study of network relational capabilities contributes to the relational dynamic capabilities’ literature – discussing the processes enabling the development of the network’s relational capabilities while organizing inter-firm engagement projects. Lastly, we also contribute to research by empirically exploring the institution-based trust-building in the context of SMEs innovation ecosystem literature. The findings also contribute to the existing empirical studies on how institutional trust factors affect inter-firm innovation performance and the mediating role of relational risk involved in inter-firm business relationships. Finally, we contribute to practice, by arguing that the development of institution-based trust is a critical antecedent of setting up a successful cause-based inter-firm alliance. Limitations: This thesis underlies amongst others three main limitations: First, qualitative studies are prone to researchers’ bias as data is subjectively interpreted by researchers. This, however, makes it impossible to eliminate the influence of researchers’ personal views and perceptions. To minimize this bias, we adopt various triangulations methods thus, addressing the limitation of the case study approach. Second, the generalization of findings is limited by the case studies approach, giving the unique context of each case. Third, the quantitative study adopted is not without limitations. For instance, the small sample size, and use of limited scales, are likely to influence the results of the study. We recognized these limitations and proposed that future research should try to address more context-sensitive theorizing and by discussing findings limited to just specific case contexts. Future Research: This thesis proposed some agenda that future research should address: First, the research on network relational dynamic capabilities across various business networks, could offer more robust generalizable findings. Second, the case study approaches adopted in this thesis, however, has limitations. This limited context inherent in a case study design provides a narrow empirical context for the applicability of the results. Third, the quantitative studies adopted also posed some limitations, and thus, future research could explore other multi-dimensional scales of institutional trust-building practices for bigger firms, and even in different sectors/industries, or even across different geographic locations. Finally, future studies may also try to replicate the collaborative value practices of a cause-based SE network, addressing a particular industry or market, or even comparing across different network levels with a diverse membership, and market/industry structure. Thus, the samples from bigger firms and corporations and their attitude to a social cause may be highly influenced by the size, capability, and motives, since our current case is largely by SMEs. Further, a quantitative study on how collaborative value practices influence actors’ social performance, could yield interesting findings to the cause-based social entrepreneurship alliance literature

Vaccine wastage in The Gambia: a prospective observational study.

BACKGROUND: Vaccination is a cost-effective and life-saving intervention. Recently several new, but more expensive vaccines have become part of immunization programmes in low and middle income countries (LMIC). Monitoring vaccine wastage helps to improve vaccine forecasting and minimise wastage. As the costs of vaccination increases better vaccine management is essential. Many LMIC however do not consistently monitor vaccine wastage. METHODS: We conducted two surveys in health facilities in rural and urban Gambia; 1) a prospective six months survey in two regions to estimate vaccine wastage rates and type of wastage for each of the vaccines administered by the Expanded programme on Immunization (EPI) and 2) a nationwide cross sectional survey of health workers from randomly selected facilities to assess knowledge, attitude and practice on vaccine waste management. We used WHO recommended forms and standard questionnaires. Wastage rates were compared to EPI targets. RESULTS: Wastage rates for the lyophilised vaccines BCG, Measles and Yellow Fever ranged from 18.5-79.0%, 0-30.9% and 0-55.0% respectively, mainly through unused doses at the end of an immunization session. Wastage from the liquid vaccines multi-dose/ single dose vials were minimal, with peaks due to expiry or breakage of the vaccine diluent. We interviewed 80 health workers and observed good knowledge. Batching children for BCG was uncommon (19%) whereas most health workers (73.4%) will open a vial as needed. CONCLUSION: National projected wastage targets were met for the multi-dose/single dose vials, but for lyophilised vaccines, the target was only met in the largest major health facility

Rheumatic heart disease in The Gambia: clinical and valvular aspects at presentation and evolution under penicillin prophylaxis

BACKGROUND: Rheumatic heart disease (RHD) remains the leading cause of cardiac-related deaths and disability in children and young adults worldwide. In The Gambia, the RHD burden is thought to be high although no data are available and no control programme is yet implemented. We conducted a pilot study to generate baseline data on the clinical and valvular characteristics of RHD patients at first presentation, adherence to penicillin prophylaxis and the evolution of lesions over time. METHODS: All patients registered with acute rheumatic fever (ARF) or RHD at two Gambian referral hospitals were invited for a clinical review that included echocardiography. In addition, patients were interviewed about potential risk factors, disease history, and treatment adherence. All clinical and echocardiography information at first presentation and during follow-up was retrieved from medical records. RESULTS: Among 255 registered RHD patients, 35 had died, 127 were examined, and 111 confirmed RHD patients were enrolled, 64% of them females. The case fatality rate in 2017 was estimated at 19.6%. At first presentation, median age was 13 years (IQR [9; 18]), 57% patients had late stage heart failure, and 84.1% a pathological heart murmur. Although 53.2% of them reported history of recurrent sore throat, only 32.2% of them had sought medical treatment. A history suggestive of ARF was reported by 48.7% patients out of whom only 15.8% were adequately treated. Two third of the patients (65.5%) to whom it was prescribed were fully adherent to penicillin prophylaxis. Progressive worsening and repeated hospitalisation was experienced by 46.8% of the patients. 17 patients had cardiac surgery, but they represented only 18.1% of the 94 patients estimated eligible for cardiac surgery. CONCLUSION: This study highlights for the first time in The Gambia the devastating consequences of RHD on the health of adolescents and young adults. Our findings suggest a high burden of disease that remains largely undetected and without appropriate secondary prophylaxis. There is a need for the urgent implementation of an effective national RHD control programto decrease the unacceptably high mortality rate, improve case detection and management, and increase community awareness of this disease

Impact of routine vaccination against Haemophilus influenzae type b in The Gambia: 20 years after its introduction.

BACKGROUND: In 1997, The Gambia introduced three primary doses of Haemophilus influenzae type b (Hib) conjugate vaccine without a booster in its infant immunisation programme along with establishment of a population-based surveillance on Hib meningitis in the West Coast Region (WCR). This surveillance was stopped in 2002 with reported elimination of Hib disease. This was re-established in 2008 but stopped again in 2010. We aimed to re-establish the surveillance in WCR and to continue surveillance in Basse Health and Demographic Surveillance System (BHDSS) in the east of the country to assess any shifts in the epidemiology of Hib disease in The Gambia. METHODS: In WCR, population-based surveillance for Hib meningitis was re-established in children aged under-10 years from 24 December 2014 to 31 March 2017, using conventional microbiology and Real Time Polymerase Chain Reaction (RT-PCR). In BHDSS, population-based surveillance for Hib disease was conducted in children aged 2-59 months from 12 May 2008 to 31 December 2017 using conventional microbiology only. Hib carriage survey was carried out in pre-school and school children from July 2015 to November 2016. RESULTS: In WCR, five Hib meningitis cases were detected using conventional microbiology while another 14 were detected by RT-PCR. Of the 19 cases, two (11%) were too young to be protected by vaccination while seven (37%) were unvaccinated. Using conventional microbiology, the incidence of Hib meningitis per 100?000-child-year (CY) in children aged 1-59 months was 0.7 in 2015 (95% confidence interval (CI)?=?0.0-3.7) and 2.7 (95% CI?=?0.7-7.0) in 2016. In BHDSS, 25 Hib cases were reported. Nine (36%) were too young to be protected by vaccination and five (20%) were under-vaccinated for age. Disease incidence peaked in 2012-2013 at 15 per 100?000 CY and fell to 5-8 per 100?000 CY over the subsequent four years. The prevalence of Hib carriage was 0.12% in WCR and 0.38% in BHDSS. CONCLUSIONS: After 20 years of using three primary doses of Hib vaccine without a booster Hib transmission continues in The Gambia, albeit at low rates. Improved coverage and timeliness of vaccination are of high priority for Hib disease in settings like Gambia, and there are currently no clear indications of a need for a booster dose

Impact of early kangaroo mother care versus standard care on survival of mild-moderately unstable neonates <2000 grams: A randomised controlled trial.

BACKGROUND: Understanding the effect of early kangaroo mother care on survival of mild-moderately unstable neonates 24 h after admission (control) versus KMC initiated <24 h after admission (intervention). Randomisation was stratified by weight with twins in the same arm. The primary outcome was all-cause mortality at 28 postnatal days, assessed by intention to treat analysis. Secondary outcomes included: time to death; hypothermia and stability at 24 h; breastfeeding at discharge; infections; weight gain at 28d and admission duration. The trial was prospectively registered at www.clinicaltrials.gov (NCT03555981). FINDINGS: Recruitment occurred from 23rd May 2018 to 19th March 2020. Among 1,107 neonates screened for participation 279 were randomly assigned, 139 (42% male [n = 59]) to standard care and 138 (43% male [n = 59]) to the intervention with two participants lost to follow up and no withdrawals. The proportion dying within 28d was 24% (34/139, control) vs. 21% (29/138, intervention) (risk ratio 0·84, 95% CI 0·55 - 1·29, p = 0·423). There were no between-arm differences for secondary outcomes or serious adverse events (28/139 (20%) for control and 30/139 (22%) for intervention, none related). One-third of intervention neonates reverted to standard care for clinical reasons. INTERPRETATION: The trial had low power due to halving of baseline neonatal mortality, highlighting the importance of implementing existing small and sick newborn care interventions. Further mortality effect and safety data are needed from varying low and middle-income neonatal unit contexts before changing global guidelines

<i>Histoplasma</i> seropositivity and environmental risk factors for exposure in a general population in Upper River Region, The Gambia: A cross-sectional study.

Robust surveillance of Histoplasma species is warranted in endemic regions, including investigation of community-level transmission dynamics. This cross-sectional study explored anti-Histoplasma antibody seroprevalence and risk factors for exposure in a general population in Upper River Region (URR), The Gambia. Study participants were recruited (December 2022-March 2023) by random household sampling across 12 Enumeration Areas (EAs) of URR. A questionnaire and clinical examination were performed; exploring demographic, clinical and environmental risk factors for Histoplasma exposure. One venous blood sample per participant was subject to IMMY Latex Agglutination Histoplasma test to determine presence of a recent IgM response to Histoplasma. Seropositivity risk factors were explored by multi-level, multivariable logistic regression analysis. The study population (n = 298) aged 5-83 years, demonstrated a positively skewed age distribution and comprised 55.4% females. An apparent seroprevalence of 18.8% (n = 56/298, 95% CI 14.5-23.7%) was measured using the LAT. A multivariable model demonstrated increased odds of Histoplasma seropositivity amongst female participants (OR = 2.41 95% CI 1.14-5.10); and participants reporting involvement in animal manure management (OR = 4.21 95% CI 1.38-12.90), and management of domestic animals inside the compound at night during the dry season (OR = 10.72 95% CI 2.02-56.83). Increasing age (OR = 0.96 95% CI 0.93-0.98) was associated with decreased odds of seropositivity. Clustering at EA level was responsible for 17.2% of seropositivity variance. The study indicates frequent recent Histoplasma exposure and presents plausible demographic and environmental risk factors for seropositivity. Histoplasma spp. characterisation at this human-animal-environment interface is warranted, to determine public health implications of environmental reservoirs in The Gambia. The study was supported by Wellcome Trust (206,638/Z/17/Z to CES) and a University of Liverpool-funded PhD studentship (to TRC)

Clinical characteristics and outcomes of patients with cirrhosis and hepatocellular carcinoma in The Gambia, west Africa: a prospective cohort study.

BACKGROUND: Chronic liver disease is a major cause of premature death in sub-Saharan Africa. Efficacy of antiviral therapy among patients with hepatitis B virus (HBV)-related cirrhosis is not well established in Africa. We described the clinical characteristics and outcomes of patients with cirrhosis and hepatocellular carcinoma in The Gambia and assessed the impact of tenofovir disoproxil fumarate (TDF) on survival of HBV-infected patients with cirrhosis. METHODS: In this prospective cohort study, we followed up adults who were consecutively diagnosed with cirrhosis or hepatocellular carcinoma between 2012 and 2015 in The Gambia, west Africa. Patients with chronic HBV infection and cirrhosis, without hepatocellular carcinoma, were offered TDF. Primary outcome was overall survival. To determine the effect of TDF on survival, we performed a Cox proportional hazard regression model with inverse probability of treatment weighting (IPTW) based on propensity score. FINDINGS: Of 529 patients enrolled in this study, 336 patients (252 with hepatocellular carcinoma and 84 with cirrhosis) were analysed. Patients were predominantly male (253 [75%] men and 83 [25%] women), with a median age of 42 years (IQR 33-55). 276 (84%) of 327 of patients with data were positive for HBV biomarkers, 31 (10%) of 311 were positive for hepatitis C virus antibodies, and 22 (10%) of 223 were positive for hepatitis D virus antibodies. 64% of patients with hepatocellular carcinoma had multifocal tumour, with a median size of 7·5 cm (IQR 5·4-10·8). 173 patients with hepatocellular carcinoma and 70 patients with cirrhosis were included in the survival analysis. Median survival was 1·5 months (95% CI 1·1-2·0) in patients with hepatocellular carcinoma and 17·1 months (11·2-24·0) in patients with cirrhosis (log-rank p<0·0001). In patients with hepatocellular carcinoma, ascites (hazard ratio [HR] 1·78, 95% CI 1·21-2·60), partial or complete portal thrombosis (HR 2·61, 1·58-4·30), and platelet count (HR 1·80, 1·19-2·70) were independent predictive factors of mortality at baseline. In HBV-infected patients with cirrhosis, median turnaround time between cirrhosis diagnosis and TDF initiation was 4·9 months (IQR 3·2-7·3). In IPTW analysis, TDF treatment was associated with improved survival in patients with HBV-related cirrhosis (adjusted HR 0·14, 0·06-0·34; p<0·0001). INTERPRETATION: These results highlight poor survival of patients with cirrhosis or hepatocellular carcinoma as well as the effectiveness of TDF in reducing the premature mortality of patients with cirrhosis and HBV infection. Interventions for early diagnosis and treatment of cirrhosis as well as screening programmes for hepatocellular carcinoma are urgently required in Africa. FUNDING: European Commission and Medical Research Council UK. TRANSLATION: For the French translation of the abstract see Supplementary Materials section

Staphylococcus aureus Bacteremia in Children of Rural Areas of The Gambia, 2008–2015

Staphylococcus aureus bacteremia is a substantial cause of childhood disease and death, but few studies have described its epidemiology in developing countries. Using a population-based surveillance system for pneumonia, sepsis, and meningitis, we estimated S. aureus bacteremia incidence and the case-fatality ratio in children <5 years of age in 2 regions in the eastern part of The Gambia during 2008–2015. Among 33,060 children with suspected pneumonia, sepsis, or meningitis, we performed blood culture for 27,851; of 1,130 patients with bacteremia, 198 (17.5%) were positive for S. aureus. S. aureus bacteremia incidence was 78 (95% CI 67–91) cases/100,000 person-years in children <5 years of age and 2,080 (95% CI 1,621–2,627) cases/100,000 person-years in neonates. Incidence did not change after introduction of the pneumococcal conjugate vaccine. The case-fatality ratio was 14.1% (95% CI 9.6%–19.8%). Interventions are needed to reduce the S. aureus bacteremia burden in The Gambia, particularly among neonates