Decolonizing health governance: A Uganda case study on the influence of political history on community participation

This paper presents a case study of how colonial legacies in Uganda have affected the shape and breadth of community participation in health system governance. Using Habermas’s theory of deliberative democracy and the right to health, we examine the key components required for decolonizing health governance in postcolonial countries. We argue that colonization distorts community participation, which is critical for building a strong state and a responsive health system. Participation processes grounded in the principles of democracy and the right to health increase public trust in health governance. The introduction and maintenance of British laws in Uganda, and their influence over local health governance, denies citizens the opportunity to participate in key decisions that affect them, which impacts public trust in the government. Postcolonial societies must tackle how imported legal frameworks exclude and limit community participation. Without meaningful participation, health policy implementation and accountability will remain elusive.publishedVersio

Showcasing the contribution of social sciences to health policy and systems research

Background: This Special Issue represents a critical response to the frequent silencing of qualitative social science research approaches in mainstream public health journals, particularly in those that inform the field of health policy and systems research (HPSR), and the study of equity in health. Methods: This collection of articles is presented by SHAPES, the thematic working group of Health Systems Global focused on social science approaches to research and engagement in health policy and systems. The issue aims to showcase how qualitative and theory-driven approaches can contribute to better promoting equity in health within the field of HPSR. Results: This issue builds on growing recognition of the complex social nature of health systems. The articles in this collection underscore the importance of employing methods that can uncover and help explain health system complexities by exploring the dynamic relationships and decision-making processes of the human actors within. Articles seek to highlight the contribution that qualitative, interpretivist, critical, emancipatory, and other relational methods have made to understanding health systems, health policies and health interventions from the perspective of those involved. By foregrounding actor perspectives, these methods allow us to explore the impact of vital but difficult-to-measure concepts such as power, culture and norms. Conclusion: This special issue aims to highlight the critical contribution of social science approaches. Through the application of qualitative methods and, in some cases, development of theory, the articles presented here build broader and deeper understanding of the way health systems function, and simultaneously inform a more people-centred approach to collective efforts to build and strengthen those systems.publishedVersio

Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity

The 400 million indigenous people worldwide represent a wealth of linguistic and cultural diversity, as well as traditional knowledge and sustainable practices that are invaluable resources for human development. However, indigenous people remain on the margins of society in high, middle and low-income countries, and they bear a disproportionate burden of poverty, disease, and mortality compared to the general population. These inequalities have persisted, and in some countries have even worsened, despite the overall improvements in health indicators in relation to the 15-year push to meet the Millennium Development Goals. As we enter the Sustainable Development Goals (SDGs) era, there is growing consensus that efforts to achieve Universal Health Coverage (UHC) and promote sustainable development should be guided by the moral imperative to improve equity. To achieve this, we need to move beyond the reductionist tendency to frame indigenous health as a problem of poor health indicators to be solved through targeted service delivery tactics and move towards holistic, integrated approaches that address the causes of inequalities both inside and outside the health sector. To meet the challenge of engaging with the conditions underlying inequalities and promoting transformational change, equity-oriented research and practice in the field of indigenous health requires: engaging power, context-adapted strategies to improve service delivery, and mobilizing networks of collective action. The application of systems thinking approaches offers a pathway for the evolution of equity-oriented research and practice in collaborative, politically informed and mutually enhancing efforts to understand and transform the systems that generate and reproduce inequities in indigenous health. These approaches hold the potential to strengthen practice through the development of more nuanced, context-sensitive strategies for redressing power imbalances, reshaping the service delivery environment and fostering the dynamics of collective action for political reform.publishedVersio

Readiness to treat and factors associatedwith survival of newborns with breathingdifficulties in Ethiopia

Background Ethiopia is one of five countries that account for half of the world’s 2.6 million newborn deaths. A quarter of neonatal deaths in Ethiopia are caused by birth asphyxia. Understanding different dimensions of the quality of care for newborns with breathing difficulties can lead to improving service provision environments and practice. We describe facility readiness to treat newborns with breathing difficulties, the extent to which newborn resuscitation is provided, and by modeling the survival of newborns with difficulties breathing, we identify key factors that suggest how mortality from asphyxia can be reduced. Methods We carried out a secondary analysis of the 2016 Ethiopia Emergency Obstetric and Newborn Care Assessment that included 3804 facilities providing childbirth services and 2433 chart reviews of babies born with difficulties breathing. We used descriptive statistics to assess health facilities’ readiness to treat these newborns and a binary logistic regression to identify factors associated with survival. Results Over one-quarter of facilities did not have small-sized masks (size 0 or 1) to complete the resuscitation kits. Among the 2190 cases with known survival status, 49% died before discharge, and among 1035 cases with better data quality, 29% died. The odds of surviving birth asphyxia after resuscitation increased eightfold compared to newborns not resuscitated. Other predictors for survival were the availability of a newborn corner, born at term or post-term, normal birth weight (≥2500 g) and delivered by cesarean or assisted vaginal delivery. Conclusion The survival status of newborns with birth asphyxia was low, particularly in the primary care facilities that lacked the required resuscitation pack. Newborns born in a facility with better data quality were more likely to survive than those born in facilities with poor data quality. Equipping health centers/clinics with resuscitation packs and reducing the incidence of preterm and low birth weight babies should improve survival rates.publishedVersio

From knowing our needs to enacting change: findings from community consultations with indigenous communities in Bangladesh

Introduction: Indigenous peoples are among the most marginalized peoples in the world due to issues relating to well-being, political representation, and economic production. The research consortium Goals and Governance for Global Health (Go4Health) conducted a community consultation process among marginalized groups across the global South aimed at including their voices in the global discourse around health in the post-2015 development agenda. This paper presents findings from the consultations carried out among indigenous communities in Bangladesh. Methods: For this qualitative study, our research team consulted the Tripura and Mro communities in Bandarban district living in the isolated Chittagong Hill Tracts region. Community members, leaders, and key informants working in health service delivery were interviewed. Data was analyzed using thematic analysis. Findings: Our findings show that remoteness shapes the daily lives of the communities, and their lack of access to natural resources and basic services prevents them from following health promotion messages. The communities feel that their needs are impossible to secure in a politically indifferent and sometimes hostile environment. Conclusion: Communities are keen to participate and work with duty bearers in creating the conditions that will lead to their improved quality of life. Clear policies that recognize the status of indigenous peoples are necessary in the Bangladeshi context to allow for the development of services and infrastructure.publishedVersio

Does Information and Communication Technology Add Value to Citizen-Led Accountability Initiatives in Health? Experiences from India and Guatemala

Information and Communication Technology (ICT) may facilitate the collection and dissemination of citizen-generated data to enhance governmental accountability for the fulfillment of the right to health. The aim of this multiple case study research was to distill considerations related to the implementation of ICT and health accountability projects, describe the added operational value of ICT tools (as compared to similar projects that do not use ICT), and make preliminary statements regarding government responsiveness to accountability demands through ICT projects. In all three projects, the need for relationship building, continuous community engagement and technical support, and training for volunteers or service users was identified. Government responsiveness to the data varied, suggesting that political will is lacking in certain contexts. Despite these challenges, ICT initiatives provided an easy, accessible, and low-risk platform for reporting violations and demanding accountability from service providers and decision-makers. ICT-enabled citizen generated data can add significant operational value and some political value to project activities and goals, and may affect systems change when it is part of a broad-based, multi-level civil societal and governmental effort to improve health care quality.publishedVersio

Abuse and discrimination towards indigenous people in public health care facilities: experiences from rural Guatemala

Background Health inequalities disproportionally affect indigenous people in Guatemala. Previous studies have noted that the disadvantageous situation of indigenous people is the result of complex and structural elements such as social exclusion, racism and discrimination. These elements need to be addressed in order to tackle the social determinants of health. This research was part of a larger participatory collaboration between Centro de Estudios para la Equidad y Gobernanza en los Servicios de Salud (CEGSS) and community based organizations aiming to implement social accountability in rural indigenous municipalities of Guatemala. Discrimination while seeking health care services in public facilities was ranked among the top three problems by communities and that should be addressed in the social accountability intervention. This study aimed to understand and categorize the episodes of discrimination as reported by indigenous communities. Methods A participatory approach was used, involving CEGSS’s researchers and field staff and community leaders. One focus group in one rural village of 13 different municipalities was implemented. Focus groups were aimed at identifying instances of mistreatment in health care services and documenting the account of those who were affected or who witnessed them. All of the 132 obtained episodes were transcribed and scrutinized using a thematic analysis. Results Episodes described by participants ranged from indifference to violence (psychological, symbolic, and physical), including coercion, mockery, deception and racism. Different expressions of discrimination and mistreatment associated to poverty, language barriers, gender, ethnicity and social class were narrated by participants. Conclusions Addressing mistreatment in public health settings will involve tackling the prevalent forms of discrimination, including racism. This will likely require profound, complex and sustained interventions at the programmatic and policy levels beyond the strict realm of public health services. Future studies should assess the magnitude of the occurrence of episodes of maltreatment and racism within indigenous areas and also explore the providers’ perceptions about the problem

The right to health of non-nationals and displaced persons in the sustainable development goals era: challenges for equity in universal health care

Introduction: Under the Millennium Development Goals (MDGs), United Nations (UN) Member States reported progress on the targets toward their general citizenry. This focus repeatedly excluded marginalized ethnic and linguistic minorities, including people of refugee backgrounds and other vulnerable non-nationals that resided within a States’ borders. The Sustainable Development Goals (SDGs) aim to be truly transformative by being made operational in all countries, and applied to all, nationals and non-nationals alike. Global migration and its diffuse impact has intensified due to escalating conflicts and the growing violence in war-torn Syria, as well as in many countries in Africa and in Central America. This massive migration and the thousands of refugees crossing borders in search for safety led to the creation of two-tiered, ad hoc, refugee health care systems that have added to the sidelining of non-nationals in MDG-reporting frameworks. Conclusion: We have identified four ways to promote the protection of vulnerable non-nationals’ health and well being in States’ application of the post-2015 SDG framework: In setting their own post-2015 indicators the UN Member States should explicitly identify vulnerable migrants, refugees, displaced persons and other marginalized groups in the content of such indicators. Our second recommendation is that statisticians from different agencies, including the World Health Organization’s Gender, Equity and Human Rights programme should be actively involved in the formulation of SDG indicators at both the global and country level. In addition, communities, civil society and health justice advocates should also vigorously engage in country’s formulation of post-2015 indicators. Finally, we advocate that the inclusion of non-nationals be anchored in the international human right to health, which in turn requires appropriate financing allocations as well as robust monitoring and evaluation processes that can hold technocratic decision-makers accountable for progress.publishedVersio

Looking forward to the next 15 years: innovation and new pathways for research in health equity

Since our launch in 2002, the International Journal for Equity in Health (IJEqH) has furthered our collective understanding of equity in health and health services by providing a platform on which academics and practitioners can share their work. Today, we celebrate our fifteenth anniversary with an article collection that presents a call for new and novel research in equity in health and we invite our authors to use new approaches and methods, and to focus on emerging areas of research related to health equity in order to set the stage for the next fifteen years of health equity research. Our anniversary issue provides a platform for expanding the conceptualization, diversity of populations and study designs, and for increasing the use of novel methodologies in the field. The IJEqH has helped to support the wider group of researchers, policymakers and practitioners with a commitment to social justice and equity but there is still more to do. With the help of the highly committed editorial team and editorial board, the innovative work of researchers worldwide, and the countless of hours dedicated by hundreds of reviewers, we are confident in the IJEqH’s ability to continue supporting the dissemination of health equity research for years to come.publishedVersio