Making mHealth Work for All

Rapid Response BriefingInformation and Communication technologies (ICTs) are going to have a major impact on health and health systems in the near future. To ensure that everyone (including the very poor) benefits from this new technology, it is vital that those designing new technologies, people responsible for health systems and social researchers come together to explore the opportunities and potential challenges, especially for low- and middle-income countries (LMICs)

"It is very difficult in this business if you want to have a good conscience": pharmaceutical governance and on-the-ground ethical labour in Ghana

The governance of pharmaceutical medicines entails complex ethical decisions that should, in theory, be the responsibility of democratically accountable government agencies. However, in many Low- and Middle-Income Countries (LMICs), regulatory and health systems constraints mean that many people still lack access to safe, appropriate and affordable medication, posing significant ethical challenges for those working on the “front line”. Drawing on 18 months of fieldwork in Ghana, we present three detailed case studies of individuals in this position: an urban retail pharmacist, a rural over-the-counter medicine retailer, and a local inspector. Through these case studies, we consider the significant burden of “ethical labour” borne by those operating “on the ground”, who navigate complex moral, legal and business imperatives in real time and with very real consequences for those they serve. The paper ends with a reflection on the tensions between abstract, generalised ethical frameworks based on high-level principles, and a pragmatic, contingent ethics-in-practice that foregrounds immediate individual needs – a tension rooted in the gap between the theory and the reality of pharmaceutical governance that shifts the burden of ethical labour downwards and perpetuates long-term public health risks

“Old people problems”, uncertainty and legitimacy: Challenges with diagnosing Parkinson\u27s disease in Kenya

Very little is known about the experience of people living with Parkinson\u27s disease (PD) in low- and middle-income countries, such as those in sub-Saharan Africa. The number of specialists in the region is low and awareness is limited among the population and healthcare professionals. Drawing on ten months of ethnographic fieldwork in urban and rural Kenya with 55 people living with PD (PwP), 23 family members and 22 healthcare professionals from public and private clinics, we set out to understand the experience of diagnosis among PwP in Kenya. The diagnostic journeys of our study participants were typically long, convoluted and confusing. Lack of relevant information, combined with comorbidities and expectations about ‘normal’ ageing, often conspired to delay interactions with health services for many. There often followed an extended period of diagnostic uncertainty, misdiagnosis and even ‘undiagnosis’, where a diagnostic decision was reversed. Following diagnosis, patients continued to lack information about their condition and prognosis, making it difficult for friends, family members and others to understand what was happening to them. We suggest that awareness of PD and its symptoms needs to improve among the general population and healthcare professionals. However, diagnosis is only the first step, and needs to be accompanied by better access to information, affordable treatment and support

“Old people problems”, uncertainty and legitimacy: Challenges with diagnosing Parkinson's disease in Kenya

Very little is known about the experience of people living with Parkinson's disease (PD) in low- and middle-income countries, such as those in sub-Saharan Africa. The number of specialists in the region is low and awareness is limited among the population and healthcare professionals. Drawing on ten months of ethnographic fieldwork in urban and rural Kenya with 55 people living with PD (PwP), 23 family members and 22 healthcare professionals from public and private clinics, we set out to understand the experience of diagnosis among PwP in Kenya. The diagnostic journeys of our study participants were typically long, convoluted and confusing. Lack of relevant information, combined with comorbidities and expectations about ‘normal’ ageing, often conspired to delay interactions with health services for many. There often followed an extended period of diagnostic uncertainty, misdiagnosis and even ‘undiagnosis’, where a diagnostic decision was reversed. Following diagnosis, patients continued to lack information about their condition and prognosis, making it difficult for friends, family members and others to understand what was happening to them. We suggest that awareness of PD and its symptoms needs to improve among the general population and healthcare professionals. However, diagnosis is only the first step, and needs to be accompanied by better access to information, affordable treatment and support

Context matters: fostering, orphanhood and schooling in Sub-Saharan Africa

A growing body of research suggests that orphanhood and fostering might be (independently) associated with educational disadvantage in sub-Saharan Africa. However, literature on the impacts of orphanhood and fostering on school enrolment, attendance and progress produces equivocal, and often conflicting, results. This paper reports on quantitative and qualitative data from sixteen field-sites in Ghana and Malawi, highlighting the importance of historical and social context in shaping schooling outcomes for fostered and orphaned children. In Malawi, which has been particularly badly affected by AIDS, orphans were less likely to be enrolled in and attending school than other children. By contrast, in Ghana, with its long tradition of ‘kinship fostering’, orphans were not significantly educationally disadvantaged; instead, non-orphaned, purposively fostered children had lower school enrolment and attendance than their peers. Understanding the context of orphanhood and fostering in relation to schooling is crucial in achieving ‘Education for All’

Out of the boxes, out of the silos: The need of interdisciplinary collaboration to reduce poor-quality medical products in the supply chain

In this paper, we argue that understanding and addressing the problem of poor-quality medical products requires a more interdisciplinary approach than has been evident to date. While prospective studies based on rigorous standardized methodologies are the gold standard for measuring the prevalence of poor-quality medical products and understanding their distribution nationally and internationally, they should be complemented by social science research to unpack the complex set of social, economic, and governance factors that underlie these patterns. In the following sections, we discuss specific examples of prospective quality surveys and of social science studies, highlighting the value of cross-sector partnerships in driving high-quality, policy-relevant research in this area

Antimalarial stocking decisions among medicine retailers in Ghana: implications for quality management and control of malaria

Global health efforts such as malarial control require efficient pharmaceutical supply chains to ensure effective delivery of quality-assured medicines to those who need them. However, very little is currently known about decision-making processes within antimalarial supply chains and potential vulnerabilities to substandard and falsified medicines. Addressing this gap, we report on a study that investigated decision-making around the stocking of antimalarial products among private-sector medicine retailers in Ghana. Licensed retail pharmacies and over-the-counter (OTC) medicine retail outlets were sampled across six regions of Ghana using a two-stage stratified sampling procedure, with antimalarial medicines categorised as ‘expensive,’ ‘mid-range,’ and ‘cheaper,’ relative to other products in the shop. Retailers were asked about their motivations for choosing to stock particular products over others. The reasons were grouped into three categories: financial, reputation/experience and professional recommendation. Reputation/experience (76%, 95% CI 72.0% to 80.7%) were the drivers of antimalarial stocking decisions, followed by financial reasons (53.2%, 95% CI 48.1% to 58.3%) and recommendation by certified health professionals (24.7%, 95% CI 20.3% to 29.1%). Financial considerations were particularly influential in stocking decisions of cheaper medicines. Moreover, pharmacies and OTCs without a qualified pharmacist were significantly more likely to indicate financial reasons as a motivation for stocking decisions. No significant differences in stocking decisions were found by geographical location (zone and urban/rural) or outlet (pharmacy/OTC). These findings have implications for the management of antimalarial quality across supply chains in Ghana, with potentially important consequences for malaria control, particularly in lower-income areas where people rely on low-cost medication

Youth livelihoods in the cellphone era: Perspectives from urban Africa

Issues surrounding youth employment and unemployment are central to the next development decade. Understanding how youth use mobile phones as a means of communicating and exchanging information about employment and livelihoods is particularly important given the prominence of mobile phone use in young lives. This paper explores and reflects on youth phone usage in Ghana, Malawi and South Africa, drawing on mixed-methods research with young people aged approximately 9-25 years, in 12 (high density) urban and peri-urban sites. Comparative work across these sites offers evidence of both positive and negative impacts. The final section of the paper considers policy implications