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Austerity in Africa

Audit cultures and the weakening of public sector health systems

James Pfeiffer

Austerity across Africa has been operationalized through World Bank and IMF structural adjustment programs since the 1980s, later rebranded euphemistically as poverty reduction strategies in the late 1990s. Austerity’s constraints on public spending led donors to a “civil society” focus in which NGOs would fill gaps in basic social services created by public sector contraction. One consequence was large-scale redirection of growing foreign aid flows away from public services to international NGOs. Austerity in Africa coincides with the emergence of what some anthropologists call “audit cultures” among donors. Extraordinary data collection infrastructures are demanded from recipient organizations in the name of transparency. However, the Mozambique experience described here reveals that these intensive audit cultures serve to obscure the destructive effects of NGO proliferation on public health systems.

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Social Capital and Health

Research Findings and Questions on a Modern Public Health Perspective

Ota de Leonardis

This article aims at contributing to the discussion on the features of public health systems consistent with the broader definition of health – broader than the strictly bio-medical one – which is currently accepted in the related literature. The questions it raises are on how social capital influences well-being, and on whether and how it can be recognized and cultivated as a basic resource for health, and integrated into the health systems. In the first part, research literature on the ways health conditions are correlated with both poverty and social capital is briefly discussed. In the second part, several cases on health prevention and rehabilitation programs are analysed in some detail, as they appear to improve the health conditions of a community by investing in its 'social capital'. The main insights are on how to combine social protection with individual agency.

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Franca Maino

A year ago, assessing the health-care situation, Enza Caruso and Nerina

Dirindin wrote: “The year 2007 can only be described as a positive one

for health in terms of planning, given the great number of programs

launched, commissions and councils put in place, and protocols of

agreement signed by the Ministry of Health. Finance within the health

sector was also notable for complying with the health pact and the rigorous

control of public accounts backed up by deficit reduction plans,

which regions under financial warning had to observe scrupulously or

be put under compulsory administration.” The year 2008, however,

began and then continued with a shocking series of health-care mismanagement

cases, including the controversy over the appointment

procedure for general managers and chief medical officers of health-care

providers, the question of controlling health expenses, and the possible

compulsory administration of regions that are unable to meet deficit

reduction plans.

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Theodore Randall

This article discusses the medically pluralistic character of malaria prevention and treatment-based health-seeking behaviour among the inhabitants of a predominantly Jola village in the Gambia, West Africa. Through the presentation of ethnographic data obtained between 2003 and 2004, the paper demonstrates that traditional health services - represented by traditional medical practitioners and medicinal plant usage - among the Jola appear as much, if not more accessible, available, affordable and acceptable than the biomedical services - represented by biomedical practitioners and antimalarial medication usage - provided by the Gambian government health system. This accessibility, availability, affordability and acceptability occur to the extent that many of the villagers suggest that traditional health services become incorporated into the Gambian government health system. The need to integrate traditional and biomedical services becomes especially relevant given the existence of traditional services within the context of biomedical hegemony and limited Jola accessibility, availability and affordability of biomedical services.

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'Fire from Above, Fire from Below'

Health, Justice and the Persistence of the Sacred

James R. Cochrane

The essay refers to a concern for social justice in the origins of public health, borne in part by religious commitments, and to more recent expressions of a similar concern in debates about health equity. Equity, moreover, is affected by discursive power relations (dominant/hegemonic versus local/suppressed), which are discussed in relation to current research in the African Religious Health Assets Programme on the interaction of particular 'healthworlds' (a conceptual innovation) that shape the choices and behaviour of health-seekers. Two background theoretical positions guide the argument: Amartya Sen's claim that development is linked to freedom (including religious freedom); and, building on Sen's and Martha Nussbaum's human capabilities theory, an asset-based community approach to the building or reconstruction of public health systems. On this basis, it is argued that health systems and health interventions are just to the extent that they mediate between the necessary leadership or polity from 'above' (techné) and the experience and wisdom (métis) of those who are 'below', taking into account the asymmetries of power that this equation represents. Because difference and diversity are so often expressed in what we might reasonably call 'religious' terms, I specifically emphasize the continuing persistence of religion and, hence, the importance of accounting for its pertinence in social theory generally, and in relation to discourses of health and justice in the African context specifically. Acknowledging the ambiguities of religion, I nevertheless argue that an appreciative alignment between public health systems and religious or faith-based initiatives in health promotion, prevention and care is crucial to sustainable and just health systems in Africa.

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Robin Oakley

The constitution, the law of the land of the modern state, is fertile ground for the Eurocentric imagination of the Canadian polity as a result of the resiliency of Victorian-era sentiments. The ethno-racial hierarchy contained within this political imagery merges well with the public health mandate process of 'othering'. Othering situates the causes of disease and illness in foreign bodies rather than in the social structures of industrial capitalism. Chief among its morbid symptoms, othering produces a sense of alienation in those subjected to it. Sri Lankan Tamils are one of the newer migrant populations who have been subjected to, and have resisted this intrinsically violent othering process. This article examines the Canadian constitution as it relates to ethno-racial classification, and then explores how this scheme is reproduced in common experiences of the public health system and its effects on the health and well-being of Canadian Tamils.

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Eliana Elisabeth Diehl and Esther Jean Langdon

English abstract:

In 1990, the Brazilian Unified Health System institutionalized new relationships between the government and society. In recognition of the inequalities and inequities inflicted upon Indigenous Peoples, the Indigenous Health Subsystem was established in 1999. Roles were created for the democratic exercise of Indigenous participation and prominence in three border spaces: Indigenous health agents as members of health teams; Indigenous representatives on health councils; and Indigenous organizations as primary care providers. This article explores these spaces based on ethnographic research from southern Brazil. It concludes that the roles created for Indigenous participation and governance are ambiguous and contradictory. When participating in new opportunities created by the government, Indigenous actors are subjected to a centralized and bureaucratized system that offers little possibility of autonomous decision- making or action.

Spanish abstract:

En 1990, el Sistema Único de Salud institucionalizó nuevas relaciones entre el gobierno y la sociedad, estableciendo en 1999 el Subsistema de Salud Indígena. Se crearon nuevos roles para el ejercicio democrático de la participación indígena con prominencia en tres espacios de frontera: agentes indígenas de salud como miembros de los equipos de salud; representantes indígenas en los consejos de salud; y organizaciones indígenas como proveedores de atención primaria. Este artículo explora estos espacios basado en investigación etnográfi ca del sur de Brasil. Se concluye que los roles creados para la participación y gobernanza indígena son ambiguos y contradictorios. Cuando se participa en nuevas oportunidades creadas por el gobierno, los actores indígenas son sometidos a un sistema que ofrece poca posibilidad de tomar decisiones autónomas o actuar.

French abstract:

1990 le système unique de santé brésilien, le SUS (Sistema Único de Saúde) institutionnalisait de nouvelles relations entre le gouvernement et la société en donnant aux usagers un rôle central et en leur att ribuant une large participation dans tous les secteurs des soins. En reconnaissance des inégalités et iniquités historiques infl igées aux peuples indigènes, le sous-système de soin indigène fut établi en 1999. De nouveaux rôles furent créés pour l’exercice démocratique de la participation indigène et sa reconnaissance dans trois zones d’action et de communication délimitées. Cet article explore ces espaces sur la base de recherches ethnographiques réalisées au Sud du Brésil et conclut que les rôles créés pour la participation indigène et la notion associée de gouvernance sont souvent ambigus et contradictoires.