Evolving stakeholder roles and perceptions of sustainability of low cost housing developments in Msunduzi Municipality : the case of Ambleton.

Thesis (M.Env.Dev.)-University of KwaZulu-Natal, Pietermaritzburg, 2007.Many development agencies active in South Africa including the Built Environment Support Group (BESG) and Hifab International Ab have voiced concern about the sustainability of common housing production practices for low income housing developments. Since early 1999 when the country reached the one million mark of housing subsidies granted by government from 1994, the drive for numbers was gradually replaced by a dawning concern for the likely impacts on health and the environment of the kinds of settlements being produced. The purpose of this dissertation is to use a case study approach to review and assess the changing policies, roles and perceptions of key stakeholders of the sustainability of government supplied low cost housing. The review and assessment is against the legislative framework of the National Environmental Management Act (NEMA), the environmental requirements within the Department of Housing (DOH) policy and principles of sustainability that need to apply in Msunduzi Municipality. In so doing, the intention is to create an integrated picture that covers a socio-economic profile of the inhabitants of the project area, the quality of housing and the environmental conditions prevailing. This aim of the dissertation was achieved by (i) identifying the trends in the roles played in the sustainability of the low cost housing settlements by authorities, house occupants, developers, NGOs and CBOs (ii) identifying the perceptions of the sustainability of the low cost housing projects by the above mentioned stakeholders (iii) understanding the perceptions of communities on the use of the open spaces around their homes and in their communities and (iv) creating an integrated picture of trends in roles and perceptions in the form of a systems diagram. On the basis of the household survey and key informant interviews carried out during the study, the key findings are the following: (1) There is poverty, low levels of formal education and a lack of social cohesion, making it difficult for the home owners to play a positive role in sustaining their settlement. There is need to organize and educate the residents on housing and environmental maintenance issues. This can be done by creating Community Based Organisations (CBOs) in the form of Small, Medium and Micro Enterprises (SMMEs) in which both the municipality and Non Governmental Organisations (NGOs) can participate. The SMMEs are already being planned for by the Msunduzi Municipality. (2) The municipality lacks capacity to fully initiate projects as well as to interpret and implement Environmental Management Plans (EMPs). There is, therefore, a need to train and recruit staff with these skills or engage NGOs with that capacity. On the other hand the indigent policy introduced by the municipality to subsidize basic services will, if well administered, help maintain minimum health standards in the settlement. (3) The septic tank toilet type in the study area is not compatible with the community needs and geotechnically cannot function properly. This causes a lot of dissatisfaction among the residents and is a health hazard. The toilet problem is a priority issue which needs to be addressed. (4) There is a break in the chain of communicating between the community and municipality on housing and environmental issues, due mainly to a lack of implementation of the ward committees and a tenuous relationship between the Department of Housing and the municipality. The ward committees should be set up and a positive mutually beneficial relationship between DOH and the municipality should be developed. (5) The community view about the use of their open spaces is that they should be used for agriculture and business including shops. There is therefore a need to provide agricultural extension services and promote small businesses within the community in order to enhance food security and create employment. (6) The community lacks a clinic, a police station and shops. These services are critical for the smooth functioning of the settlement. The question of how such services are delivered remains a challenge as financial resources remain scarce. Finally, environment, participation, futurity and equity being the four principles which make housing policy and practice sustainable will only be integrated into low cost housing settlements if: (i) the EMP is developed and implemented with involvement of the community (environment and participation principles); (ii) in order to make the houses durable, the norms and standards based on the National Building Regulations and Building Standard Act must be followed (futurity principle); and (iii) skills development, education and creation of jobs will enable residents of the low income settlements to have a share of the national wealth (equity and participation principles)

The Role of Civil Society in Spotlighting Nutrition

Implementation of nutrition interventions and agendas must be accompanied by a good understanding of nutrition among political players, policymakers and the general public. Civil society has a unique role of creating demand and building consciousness towards the importance of nutrition at all levels and among all key stakeholders in nutrition development. Awareness-raising and demand creation are key components of the story of change that has seen public involvement in an issue as important to development as nutrition. As a result, there has been meaningful involvement of the population, especially beneficiaries who are key in determining which interventions should receive most emphasis to bring about lasting improvements in nutrition status. A nutrition-conscious population will always seek for what is best in terms of nutrition, including holding to account duty bearers in the implementation process through effective monitoring mechanisms

Application of system thinking concepts in health system strengthening in low-income settings: a proposed conceptual framework for the evaluation of a complex health system intervention: the case of the BHOMA intervention in Zambia.

BACKGROUND: The current drive to strengthen health systems provides an opportunity to develop new strategies that will enable countries to achieve targets for millennium development goals. In this paper, we present a proposed framework for evaluating a new health system strengthening intervention in Zambia known as Better Health Outcomes through Mentoring and Assessment. APPROACH: We briefly describe the intervention design and focus on the proposed evaluation approach through the lens of systems thinking. DISCUSSION: In this paper, we present a proposed framework to evaluate a complex health system intervention applying systems thinking concepts. We hope that lessons learnt from this process will help to adapt the intervention and limit unintended negative consequences while promoting positive effects. Emphasis will be paid to interaction and interdependence between health system building blocks, context and the community

Intersectoral Coordination for Nutrition in Zambia

The underlying determinants of nutritional status are adequate food, health and care; the goods and services related to these will necessarily be available from a range of sectors, provided in a coordinated fashion for maximum effect. Despite this recognition, there is currently little evidence of coordination between nutrition relevant sectors in Zambia. In Mumbwa District, a facilitated process is underway to coordinate ministries and NGOs involved in the provision of nutrition-related services. The creation of a District Nutrition Coordination Committee (DNCC) has been useful, and sustained facilitation has built trust and mutually supportive learning between diverse stakeholders. While recognising that it will take time for fully effective and implementable solutions to emerge, the DNCC is a potentially durable and effective way of addressing undernutrition over the long term. This article describes some of the theories, processes, challenges and learning from the first two years of the DNCC in Mumbwa

Systems thinking in practice: the current status of the six WHO building blocks for health system strengthening in three BHOMA intervention districts of Zambia: a baseline qualitative study.

BACKGROUND: The primary bottleneck to achieving the MDGs in low-income countries is health systems that are too fragile to deliver the volume and quality of services to those in need. Strong and effective health systems are increasingly considered a prerequisite to reducing the disease burden and to achieving the health MDGs. Zambia is one of the countries that are lagging behind in achieving millennium development targets. Several barriers have been identified as hindering the progress towards health related millennium development goals. Designing an intervention that addresses these barriers was crucial and so the Better Health Outcomes through Mentorship (BHOMA) project was designed to address the challenges in the Zambia's MOH using a system wide approach. We applied systems thinking approach to describe the baseline status of the Six WHO building blocks for health system strengthening. METHODS: A qualitative study was conducted looking at the status of the Six WHO building blocks for health systems strengthening in three BHOMA districts. We conducted Focus group discussions with community members and In-depth Interviews with key informants. Data was analyzed using Nvivo version 9. RESULTS: The study showed that building block specific weaknesses had cross cutting effect in other health system building blocks which is an essential element of systems thinking. Challenges noted in service delivery were linked to human resources, medical supplies, information flow, governance and finance building blocks either directly or indirectly. Several barriers were identified as hindering access to health services by the local communities. These included supply side barriers: Shortage of qualified health workers, bad staff attitude, poor relationships between community and health staff, long waiting time, confidentiality and the gender of health workers. Demand side barriers: Long distance to health facility, cost of transport and cultural practices. Participating communities seemed to lack the capacity to hold health workers accountable for the drugs and services. CONCLUSION: The study has shown that building block specific weaknesses had cross cutting effect in other health system building blocks. These linkages emphasised the need to use system wide approaches in assessing the performance of health system strengthening interventions

Application of balanced scorecard in the evaluation of a complex health system intervention: 12 months post intervention findings from the BHOMA intervention: a cluster randomised trial in Zambia.

INTRODUCTION: In many low income countries, the delivery of quality health services is hampered by health system-wide barriers which are often interlinked, however empirical evidence on how to assess the level and scope of these barriers is scarce. A balanced scorecard is a tool that allows for wider analysis of domains that are deemed important in achieving the overall vision of the health system. We present the quantitative results of the 12 months follow-up study applying the balanced scorecard approach in the BHOMA intervention with the aim of demonstrating the utility of the balanced scorecard in evaluating multiple building blocks in a trial setting. METHODS: The BHOMA is a cluster randomised trial that aims to strengthen the health system in three rural districts in Zambia. The intervention aims to improve clinical care quality by implementing practical tools that establish clear clinical care standards through intensive clinic implementations. This paper reports the findings of the follow-up health facility survey that was conducted after 12 months of intervention implementation. Comparisons were made between those facilities in the intervention and control sites. STATA version 12 was used for analysis. RESULTS: The study found significant mean differences between intervention(I) and control (C) sites in the following domains: Training domain (Mean I:C; 87.5.vs 61.1, mean difference 23.3, p = 0.031), adult clinical observation domain (mean I:C; 73.3 vs.58.0, mean difference 10.9, p = 0.02 ) and health information domain (mean I:C; 63.6 vs.56.1, mean difference 6.8, p = 0.01. There was no gender differences in adult service satisfaction. Governance and motivation scores did not differ between control and intervention sites. CONCLUSION: This study demonstrates the utility of the balanced scorecard in assessing multiple elements of the health system. Using system wide approaches and triangulating data collection methods seems to be key to successful evaluation of such complex health intervention. TRIAL NUMBER: ClinicalTrials.gov NCT01942278

Measuring governance at health facility level: developing and validation of simple governance tool in Zambia.

BACKGROUND: Governance has been cited as a key determinant of economic growth, social advancement and overall development. Achievement of millennium development goals is partly dependant on governance practices. In 2007, Health Systems 20/20 conducted an Internet-based survey on the practice of good governance. The survey posed a set of good practices related to health governance and asked respondents to indicate whether their experience confirmed or disconfirmed those practices. We applied the 17 governance statements in rural health facilities of Zambia. The aim was to establish whether the statements were reliable and valid for assessing governance practices at primary care level. METHODS: Both quantitative and qualitative methods were used. We first applied the governance statements developed by the health system 20/20 and then conducted focus group discussion and In-depth interviews to explore some elements of governance including accountability and community participation. The target respondents were the health facility management team and community members. The sample size include 42 health facilities. Data was analyzed using SPSS version 17 and Nvivo version 9. RESULTS: The 95% one-sided confidence interval for Cronbach's alpha was between 0.69 and 0.74 for the 16 items.The mean score for most of the items was above 3. Factor analysis yielded five principle components: Transparency, community participation, Intelligence & vision, Accountability and Regulation & oversight. Most of the items (6) clustered around the transparency latent factor. Chongwe district performed poorly in overall mean governance score and across the five domains of governance. The overall scores in Chongwe ranged between 51 and 94% with the mean of 80%. Kafue and Luangwa districts had similar overall mean governance scores (88%). Community participation was generally low. Generally, it was noted that community members lacked capacity to hold health workers accountable for drugs and medical supplies. CONCLUSIONS: The study successfully validated and applied the new tool for evaluating health system governance at health facility level. The results have shown that it is feasible to measure governance practices at health facility level and that the adapted tool is fairly reliable with the 95% one-sided confidence interval for Cronbach's alpha laying between 0.69 and 0.74 for the 16 items. Caution should be taken when interpreting overall scores as they tended to mask domain specific variations

Model parameterization to simulate and compare the PAR absorption potential of two competing plant species

Mountain pastures dominated by the pasture grass Setaria sphacelata in the Andes of southern Ecuador are heavily infested by southern bracken (Pteridium arachnoideum), a major problem for pasture management. Field observations suggest that bracken might outcompete the grass due to its competitive strength with regard to the absorption of photosynthetically active radiation (PAR). To understand the PAR absorption potential of both species, the aims of the current paper are to (1) parameterize a radiation scheme of a two-big-leaf model by deriving structural (LAI, leaf angle parameter) and optical (leaf albedo, transmittance) plant traits for average individuals from field surveys, (2) to initialize the properly parameterized radiation scheme with realistic global irradiation conditions of the Rio San Francisco Valley in the Andes of southern Ecuador, and (3) to compare the PAR absorption capabilities of both species under typical local weather conditions. Field data show that bracken reveals a slightly higher average leaf area index (LAI) and more horizontally oriented leaves in comparison to Setaria. Spectrometer measurements reveal that bracken and Setaria are characterized by a similar average leaf absorptance. Simulations with the average diurnal course of incoming solar radiation (1998–2005) and the mean leaf–sun geometry reveal that PAR absorption is fairly equal for both species. However, the comparison of typical clear and overcast days show that two parameters, (1) the relation of incoming diffuse and direct irradiance, and (2) the leaf–sun geometry play a major role for PAR absorption in the two-big-leaf approach: Under cloudy sky conditions (mainly diffuse irradiance), PAR absorption is slightly higher for Setaria while under clear sky conditions (mainly direct irradiance), the average bracken individual is characterized by a higher PAR absorption potential. (∼74 MJ m−2 year−1). The latter situation which occurs if the maximum daily irradiance exceeds 615 W m−2 is mainly due to the nearly orthogonal incidence of the direct solar beam onto the horizontally oriented frond area which implies a high amount of direct PAR absorption during the noon maximum of direct irradiance. Such situations of solar irradiance favoring a higher PAR absorptance of bracken occur in ∼36% of the observation period (1998–2005). By considering the annual course of PAR irradiance in the San Francisco Valley, the clear advantage of bracken on clear days (36% of all days) is completely compensated by the slight but more frequent advantage of Setaria under overcast conditions (64% of all days). This means that neither bracken nor Setaria show a distinct advantage in PAR absorption capability under the current climatic conditions of the study area

Agriculture, Food Systems, Diets and Nutrition in Zambia

Zambian agricultural production is focused on one staple cereal: maize. Maize makes up the major part of the national diet, while nutrient-rich foods such as legumes, animal-source foods, fruit and vegetables are eaten in small quantities, particularly amongst the poorest families. Many Zambians live with food insecurity and malnutrition as a result of poor diets: seasonal hunger affects countless families; a significant proportion of children suffer from stunted growth; and overweight and attendant diseases are increasing in adults. National nutrition and agricultural policy in Zambia recognises the need to increase and diversify the production of nutritious foods to tackle hunger and improve diets. However, in practice, most government agricultural funding is still spent promoting maize production, despite repeated findings that this does not reduce food insecurity in the most vulnerable farming households. This policy brief describes how diversification of agriculture and food systems in Zambia can contribute to improving Zambian food and nutrition security, while also building more resilient food systems. It clearly outlines policy recommendations on how the food and agriculture sector can better serve the country’s population through the development of sustainable diets for all