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The bureaucratic context of international health: A social scientist's view

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Using primary care as an example, this paper examines how the bureaucratic structures and culture of the international health agencies have affected the planning and delivery of health programs. Many primary health care programs were ineffective, as research undertaken in Nepal has shown, because they reflected the perspective and needs of the health bureaucracies involved rather than those of the local villages receiving services. Similarly, work in other South and Southeast Asian countries reveals that primary health care was interpreted differently in different bureaucratic settings and adapted to bureaucratic needs, but not necessarily adapted to village cultures and conditions. Social scientists, who are trained to analyze and articulate different cultural contexts, can play a key role in helping international health bureaucracies become more sensitive to the rural village cultures they serve.

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... Studies conducted in both developed (Smythe, 2002;Kenny, 2004;Greenhalgh, Robb, & Scambler, 2006) and developing countries (Alubo, 1987;Justice, 1987;Aitken, 1994;Zaman, 2005) demonstrate that power is inherent in the health care systems. In South and Southeast Asia, for instance, primary health care programmes are described as ineffective as they reflect the perspectives and needs of health bureaucracies rather than those of the local communities receiving the services (Justice, 1987). ...
... Studies conducted in both developed (Smythe, 2002;Kenny, 2004;Greenhalgh, Robb, & Scambler, 2006) and developing countries (Alubo, 1987;Justice, 1987;Aitken, 1994;Zaman, 2005) demonstrate that power is inherent in the health care systems. In South and Southeast Asia, for instance, primary health care programmes are described as ineffective as they reflect the perspectives and needs of health bureaucracies rather than those of the local communities receiving the services (Justice, 1987). Power inequality existed between local population and elitist bureaucracy; and health workers recruited from affluent urban backgrounds in Nepal were not accepted by local communities (Justice, 1987). ...
... In South and Southeast Asia, for instance, primary health care programmes are described as ineffective as they reflect the perspectives and needs of health bureaucracies rather than those of the local communities receiving the services (Justice, 1987). Power inequality existed between local population and elitist bureaucracy; and health workers recruited from affluent urban backgrounds in Nepal were not accepted by local communities (Justice, 1987). Health professionals posted in remote hilly areas in Nepal exercise their professional power to remain absent from their workplace (Aitken, 1994). ...
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... This form of incentive is indeed designed to have operational staff perform those tasks and activities that are on the priority list of international organizations, bilateral cooperation agencies and NGOs. These priorities not only change too fast and too frequently to be absorbed by the countries (Justice 1987), they also reflect the values, interests and philosophies of the West, instead of being tuned to local interests and grass-roots priorities (Stone 1992). Besides being ethically questionable (Olweny 1994), this potentially has counter-productive effects: from total failure of programmes due to lack of adjustment to local situations (Banerji 1990;Foster 1987;Justice 1987;Zaidi 1994), to disruption of basic health services as health personnel spend their time attending various seminars and workshops. ...
... These priorities not only change too fast and too frequently to be absorbed by the countries (Justice 1987), they also reflect the values, interests and philosophies of the West, instead of being tuned to local interests and grass-roots priorities (Stone 1992). Besides being ethically questionable (Olweny 1994), this potentially has counter-productive effects: from total failure of programmes due to lack of adjustment to local situations (Banerji 1990;Foster 1987;Justice 1987;Zaidi 1994), to disruption of basic health services as health personnel spend their time attending various seminars and workshops. ...
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This paper is an attempt to identify individual coping strategies of doctors in sub-Saharan Africa. It also provides some indication of the ‘effectiveness’ of these strategies in terms of income generation, and analyses their potential impact on the functioning of the health care system. It is based on semi-structured interviews of 21 doctors working in the public health sector in sub-Saharan Africa and attending in 1995 an international Master's course in Public Health in Belgium or in Portugal. This small sample of physicians yielded reports about 28 different types of individual strategies. Most of these potentially affect health service delivery more through reduced availability of staff than through the more blatant misappropriations. Activities related to the health field are mentioned most often. Allowances and per diems seem to be top regarding frequency and effectiveness, followed by secondary jobs, private practice or gifts from patients. None of the interviewees, however, admits using public resources for private purposes. Side activities may bring in very considerable amounts of income, out of proportion to the official salary, and can also be very time consuming. Nevertheless, all interviewees identify themselves in the first place as civil servants. Individual coping strategies may lead to undesirable side-effects for health care delivery, through a net transfer of resources (qualified personnel-time and material resources) from the public to the private-for-profit sector. There may also be positive effects though, be it in terms of mobilization of additional resources, of stabilization of qualified personnel or of realization of professional goals. However, these emerging strategies call for innovative mechanisms, likely to shape coping strategies in such a way that they remain compatible with equity and quality of care to the population.
... This was well outlined by Judith Justice in her paper: 'The bureaucratic context of international health-a sociologist's view'. 11 She commented that many primary health care programmes were ineffective because they reflect the perspective and needs of the health bureaucracies involved rather than those of the local villages receiving the services. Often primary health care is interpreted differently in different bureaucratic settings and adapted to bureaucratic needs, but not necessarily adapted to the village cultures and conditions. ...
... Often primary health care is interpreted differently in different bureaucratic settings and adapted to bureaucratic needs, but not necessarily adapted to the village cultures and conditions. 11 Another issue was outlined recently in a paper in The Lancet by McFarlane et al., 12 in which they comment that the Declaration of Alma Ata was followed by a series of northern-designed selective initiatives which are still being generated today. Selective vertical programmes enable the International Aid Agencies to measure results and protect their investments from complicated long-term multisectoral and interdepartmental implementation. ...
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... The findings of the first stage of the analysis were used to develop the second phase of the study, which consisted of semi-structured interviews that delved into women's barriers and enablers related to UGS access. The introduction of qualitative components makes it possible to recognize and articulate cultural contexts into policymaking, achieving higher levels of effectiveness in the analysis [78]. The rationale for including two sequential qualitative components in the study (QUAN → QUAL → QUAL) was to deepen the reasons behind the survey's key findings, enriching the robustness of the study's insights by ensuring that the follow-up qualitative data provided a better understanding of the survey results [79]. ...
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During the COVID-19 pandemic, urban green spaces (UGS) have gained relevance as a resilience tool that can sustain or increase well-being and public health in cities. However, several cities in Latin America have seen a decrease in their UGS use rates during the health emergency, particularly among vulnerable groups such as women. Using Mexico City as a case study, this research examines the main barriers affecting women’s access to UGS during the COVID-19 pandemic in Latin America. We applied a sequential mixed-methods approach in which the results of a survey distributed via social media in June 2020 to women aged 18 and older were used to develop semi-structured interviews with 12 women during October 2020. One year later, in November 2021, the continuity of the themes was evaluated through focus groups with the same group of women who participated in the interviews. Our results suggest that (1) prohibiting access to some UGS during the first months of the pandemic negatively impacted UGS access for women in marginalized neighborhoods; (2) for women, the concept of UGS quality and safety are intertwined, including the security level of the surrounding streets; and (3) women who live in socially cohesive neighborhoods indicated using UGS to a greater extent. Our findings highlight that while design interventions can affect women’s willingness to use UGS by improving their perceived safety and comfort, they remain insufficient to fully achieve equity in access to UGS.
... Remote health needs are different to urban needs and bureaucratic decisions do not always reflect remote needs. Judith Justice (1987) suggests that many primary health care programmes are ineffective because they reflect bureaucratic needs, but are not necessarily adapted to local contexts of culture and conditions. Strasser (2003) emphasises the need for the development and delivery of health services in rural areas to be specific to the rural context and different from that in the cities. ...
... As seen from the results, it is precisely the intrinsic characteristics of the Italian healthcare context that determine the possible explanation of the use methods, albeit mediated by Hofstede's approach. In other words, in the context of national culture, a decisive role is played, also in this case in an integrated way, by the operational particularities of the sector in which the actors involved in the decisions of use operate [68]. ...
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Background: Current research demonstrates that health information technology can improve the efficiency and quality of health services. However, many implementation projects have failed due to behavioural problems associated with technology usages, such as underuse, resistance, sabotage, and even rejection by potential users. Therefore, user acceptance was one of the main factors contributing to the success of health information technology implementation. However, research suggests that behavioural models do not universally hold across cultures. The present article considers national cultural values (power distance, uncertainty avoidance, individualism/collectivism, masculinity/femininity, and time orientation) as individual difference variables that affect user behaviour and incorporates them into the Technology Acceptance Model (TAM) as moderators of technology acceptance relationships. Therefore, this research analyses which national cultural values affect technology acceptance behaviour in hospitals. Methods: The authors develop and test seven hypotheses regarding this relationship using the partial least squares (PLS) technique, a structural equation modelling method. The authors collected data from 160 questionnaires completed by clinicians and non-clinicians working in one hospital. Results: The findings show that uncertainty avoidance, masculinity/femininity, and time orientation are the national cultural values that affect technology acceptance in hospitals. In particular, individuals with masculine cultural values, higher uncertainty avoidance, and a long-term orientation influence behavioural intention to use technology. Conclusion: The bureaucratic model still decisively characterises the Italian health sector and consequently affects the choices of firms and workers, including the choice of technology adoption. Cultural values of masculinity, risk aversion, and long-term orientation affect intention to use through social norms rather than through perceived utility.
... Yet some views are simply not taken into account. This is a source of contention for anthropologists such as Judith Justice, who have focused on the applicability of global norms to communities (Justice 1987). The national-level civil servants who sign up to agreements in Geneva are not the same people who survey supermarkets for inappropriate marketing practices. ...
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Medical knowledge is always in motion. It moves from the lab to the office, from a press release to a patient, from an academic journal to a civil servant’s desk and then on to a policymaker. Knowledge is deconstructed, reconstructed, and transformed as it moves. The dynamic, ever-evolving nature of medical knowledge has given rise to different concepts to explain it: diffusion, translation, circulation, transit, co-production. At the same time, its movements—and the ways in which we conceptualize and describe them—have material consequences. For instance, value judgements on the validity of certain forms of knowledge determine the direction of clinical research. Policy decisions are taken in relation to existing knowledge. The acceptance or rejection of treatment protocols based on medical ‘facts’ impacts on patients, dependents, health providers, and society at large. Simply put, knowledge and the movement of knowledge matter. How do they matter, though? The contributors to this volume examine the complexity of medical knowledge in everyday life. We demonstrate not only the pervasive influence of knowledge in medical and public health settings, but also the range of methodological and theoretical tools to study knowledge. Ours is a multidisciplinary approach to the medical humanities, presenting both contemporary and historical perspectives in order to explore the borderlands between expertise and common knowledge.
... These arguments were buttressed by Justice's follow up study, "The Bureaucratic Context of International Health," which drew from work in Sri Lanka, Indonesia, and Thailand. These studies addressed how socio-cultural information could improve formulation of health policies and systems and how anthropologists and health planners could overcome the barriers to more effectively working together (Justice, 1983(Justice, , 1987). Justice noted: ...
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Ethnographies of health systems are a theoretically rich and rapidly growing area within medical anthropology. Critical ethnographic work dating back to the 1950s has taken policymakers and health staff as points of entry into the power structures that run through the global health enterprise. In the last decade, there has been a surge of ethnographic work on health systems. We conceptualize the anthropology of health systems as a field, review the history of this body of knowledge, and outline emergent literatures on policymaking; HIV; hospitals; Community Health Workers; health markets; pharmaceuticals; and metrics. High-quality ethnographic work is an excellent way to understand the complex systems that shape health outcomes, and provides a critical vantage point for thinking about global health policy and systems. As theory in this space develops and deepens, we argue that anthropologists should look beyond the discipline to think through what their work does and why it matters.
... Fourth, the health systems in most of the SSA countries are characterised by inequitable distribution of health care facilities, weakness in managerial practices and the lack of coordination mechanisms. Countless studies have repeatedly argued that the lack of coordination between health projects deteriorates the effectiveness of aid disbursed to health sector (Justice, 1987;Cliff, 1993). The coefficients of control variables seem to be in line with prior expectations and of interpretable magnitudes. ...
... Fourth, the health systems in most of the SSA countries are characterised by inequitable distribution of health care facilities, weakness in managerial practices and the lack of coordination mechanisms. Countless studies have repeatedly argued that the lack of coordination between health projects deteriorates the effectiveness of aid disbursed to health sector (Justice, 1987;Cliff, 1993). The coefficients of control variables seem to be in line with prior expectations and of interpretable magnitudes. ...
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Out of pocket health expenditure (OOPHE) represents a substantial share of health spending in Sub-Sahara Africa (SSA). OOPHE consumes a large proportion of the population’s incomes and, therefore, pushes them into sever poverty. In this paper, we examine whether and to what extent foreign aid and its interaction with the recipient country’s institutional quality reduce OOPHE. We apply fixed-effects instrumental variables (FE-IV) panel regressions for data set belongs to 45 SSA countries over the period 1995-2015. We find that aid does not robustly affect OOPHE. Neither does the effect of aid depend on institutional quality. Finally, we test whether aid affects public health expenditure (PHE), which is arguably the dominant transmission channel through which aid should affect OOPHE. We find that aid had no effect on PHE indicating the rejection of fungibility hypothesis.
... Yet some views are simply not taken into account. This is a source of contention for anthropologists such as Judith Justice, who have focused on the applicability of global norms to communities (Justice 1987). The national-level civil servants who sign up to agreements in Geneva are not the same people who survey supermarkets for inappropriate marketing practices. ...
... Remote health needs are different to urban needs and bureaucratic decisions do not always reflect remote needs. Judith Justice (1987) suggests that many primary health care programmes are ineffective because they reflect bureaucratic needs, but are not necessarily adapted to local contexts of culture and conditions. Strasser (2003) emphasises the need for the development and delivery of health services in rural areas to be specific to the rural context and different from that in the cities. ...
... Structural forces also shape the experiences of CHWs on the ground, as they experience disjunctures between accomplishing the goals of standardized health interventions designed by global actors and meeting the local health needs of patients (Djellouli & Quevedo-Gómez, 2015;Justice, 1987;Nugus et al., 2018). In terms of local factors, CHW programs assume low-resource communities to be coherent spatial, bureaucratic, and social units (De Wet, 2011). ...
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Task shifting from trained clinicians to community health workers (CHWs) is a central, primary health care strategy advocated by global health policy planners in resource-poor settings where trained health professionals are scarce. The evidence base for the efficacy of these programs, however, is limited—in particular, research that identifies their potential unintended consequences. Based on sustained ethnographic study of CHWs working for AIDS projects in South Africa at the height of the country’s AIDS epidemic, this article identifies how structural and local factors produced unintended consequences for CHW programs. These consequences were (a) CHWs moonlighting for multiple organizations, (b) CHWs freelancing in communities without regulation, and (c) adverse patient outcomes resulting from uncoordinated care. These consequences stemmed from structural elements of a bureaucratically weak health system and from local grassroots dynamics that jeopardized long-term CHW program ustainability and eroded national health goals.
... As rituals they also serve to validate and legitimize institutions, individuals, values and ideas (cf. Fortes, 1962;Justice, 1987;Moore & Myerhoff, 1977;Turner, 1974). The WHA is a site where a durable social reality is created and woven into resolutions and policies which are made 'official' through their adoption by the WHA. ...
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The World Health Assembly is the WHO’s supreme decision-making body and consists of representatives from the 194 WHO Member States who take formal decisions on the WHO’s policies, workplan and budget. The event is also attended by representatives of non-governmental organisations, the private sector, the press and even members of the public. Based on participant observation at six World Health Assemblies, in-depth interviews with 53 delegates to the WHA, and an analysis of WHA Official Records, this article examines the ritualistic aspects of WHA negotiations. We argue that analysing the WHA as a ritual provides an insight into power and legitimacy within global health. Not only are certain understandings of health issues and courses of actions decided by the Assembly, but also the very boundaries of global health community are set. The rules of the ritual place limits on different categories of actors, while both formal and informal rules of behaviour further serve to include or exclude actors from the rituals. Success in negotiation is measured by through the inclusion of certain ideas, norms and values in the wording of resolutions and is achieved through the repetition of language in speeches and by adhering to the rules of behaviour.
... Organizational studies suggest the bureaucracy and authority gradients have direct effects on relationships between different categories of healthcare professionals (Justice, 1987;McCue and Beach 1994;Speroff et al. 2010). Bureaucracy and authority gradients are attributed to the creation of a dominant system of roles among different categories of healthcare professionals and are believed to encourage individual or single professional group decision-making, resulting in the fragmentation of patient care and systematic biases leading to patient safety concerns (Mannion and Thompson 2014). ...
Article
Studies show that if quality of healthcare in a country is to be achieved, due consideration must be given to the importance of the core cultural values as a critical factor in improving patient safety outcomes. The influence of Bhutan's traditional (core) cultural values on the attitudes and behaviours of healthcare professionals regarding patient care are not known. This study aimed to explore the possible influence of Bhutan's traditional cultural values on staff attitudes towards patient safety and quality care. Undertaken as a qualitative exploratory descriptive inquiry, a purposeful sample of 94 healthcare professionals and managers were recruited from three levels of hospitals, a training institute and the Ministry of Health. Interviews were transcribed verbatim and analysed using thematic analysis strategies. The findings of the study suggest that Bhutanese traditional cultural values have both productive and counterproductive influences on staff attitudes towards healthcare delivery and the processes that need to be in place to ensure patient safety. Productive influences encompassed: karmic incentives to avoid preventable harm and promote safe patient care; and the prospective adoption of the 'four harmonious friends' as a culturally meaningful frame for improving understanding of the role and importance of teamwork in enhancing patient safety. Counterproductive influences included: the adoption of hierarchical and authoritative styles of management; unilateral decision-making; the legitimization of karmic beliefs; differential treatment of patients; and preferences for traditional healing practices and rituals. Although problematic in some areas, Bhutan's traditional cultural values could be used positively to inform and frame an effective model for improving patient safety in Bhutan's hospitals. Such a model must entail the institution of an 'indigenized' patient safety program, with patient safety research and reporting systems framed around local patient safety concerns and solutions, including religious and cultural concepts, values and perspectives.
... While often focused on 'local' experiences, anthropologists are increasingly turning their attention to the internal dynamics of the global health enterprise itself, including those shaping public-private partnerships like the Glona Fund to Fight AIDS etc rather than HIV, Tuberculosis and Malaria (Kapilashrami & McPake, 2012). Building on earlier analyses of international health bureaucracies (Foster, 1977;Justice, 1987), anthropologists have begun to study the politics of global health evidence production and research (Béhague & Storeng, 2008;Geissler & Molyneux, 2011;Lambert, 2013) and the discourses underpinning global health work (Lakoff, 2010). These include how the rise of 'audit culture' and business-oriented approaches shape global-level debates about health systems (Storeng & Behague, 2014), the popularity of neoliberal policy solutions like 'pay for performance' (Magrath & Nichter, 2012) and the use of rights regimes in securing access to medicines within national health systems (Biehl, Petryna, Gertner, Amon, & Picon, 2009). ...
... Very little anthropological enquiry has been done on the immunization policy-making process itself. Anthropologists tend to define policies as context, or macro structures which influence people's lives (Justice, 1987;Shore & Wright, 1997). ...
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IntroductionUntil recently immunization as object of investigation was limited to public health researchers and historians of science and medicine (Basch, 1994; Greenough, 1980). Immunization became a more popular topic for anthropological enquiry in the 1970s, when global immunization programs aimed at “universal coverage” were launched. Anthropologists were invited by global health agencies such as the World Health Organization (WHO) to help identify structural and cultural barriers to achieving increased immunization coverage. More recently there has been attention to broader issues, including the processes through which immunization comes to be institutionalized as a routine practice in public health management, at the global, national, and local levels; and there are wider issues pertaining to popular conceptions of immunity, the role of global institutions, and notions of citizenship and consent (Das, Das, & Coutinho, 2000).The History of Immunization
... While often focused on 'local' experiences, anthropologists are increasingly turning their attention to the internal dynamics of the global health enterprise itself, including those shaping public-private partnerships like the Glona Fund to Fight AIDS etc rather than HIV, Tuberculosis and Malaria (Kapilashrami & McPake, 2012). Building on earlier analyses of international health bureaucracies (Foster, 1977;Justice, 1987), anthropologists have begun to study the politics of global health evidence production and research (Béhague & Storeng, 2008;Geissler & Molyneux, 2011;Lambert, 2013) and the discourses underpinning global health work (Lakoff, 2010). These include how the rise of 'audit culture' and business-oriented approaches shape global-level debates about health systems (Storeng & Behague, 2014), the popularity of neoliberal policy solutions like 'pay for performance' (Magrath & Nichter, 2012) and the use of rights regimes in securing access to medicines within national health systems (Biehl, Petryna, Gertner, Amon, & Picon, 2009). ...
Article
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Over the past decade, growing recognition that weak health systems threaten global health progress has galvanised renewed global and national commitment to strengthening health systems (Hafner & Shiffman, 2012). Global health leaders from the World Health Organization to the GAVI Alliance, national governments and donors today endorse the goal of health system strengthening (HSS), though there is little, if any consensus on what this entails. Mirroring the business-oriented and technical bias of dominant global health actors (Birn, 2006), HSS is often approached as a technical challenge, focused on efforts to strengthen implementation and management structures within health service delivery, with little attention to the politics and social relations that shape health systems. This special issue aims to demonstrate the potential of ethnographic enquiry to reinvigorate a political – rather than technical – debate about ‘health systems’.
... This absolves the capacity of the system to adapt to emerging complexity. Similar observations on public health bureaucracy have been made by other studies that looked at targetdriven top-down implementation of public health programs in the South-East Asian context [30][31][32]. ...
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Background: Governing immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. In one of the Indian states, Kerala, after routine immunization had reached high coverage in the late 1990s, it started to decline in some of the districts. This paper describes an application of complex adaptive systems theory and methods to understand and explain the phenomena underlying unexpected changes in vaccination coverage. Methods: We used qualitative methods to explore the factors underlying changes in vaccination coverage in two districts in Kerala, one with high and one with low coverage. Content analysis was guided by features inherent to complex adaptive systems such as phase transitions, feedback, path dependence, and self-organization. Causal loop diagrams were developed to depict the interactions among actors and critical events that influenced the changes in vaccination coverage. Results: We identified various complex adaptive system phenomena that influenced the change in vaccination coverage levels in the two districts. Phase transition describes how initial acceptability to vaccination is replaced by a resistance in northern Kerala, which involved new actors; actors attempting to regain acceptability and others who countered it created several feedback loops. We also describe how the authorities have responded to declining immunization coverage and its impact on vaccine acceptability in the context of certain highly connected actors playing disproportionate influence over household vaccination decisions.Theoretical exposition of our findings reveals the important role of trust in health workers and institutions that shape the interactions of actors leading to complex adaptive system phenomena. Conclusions: As illustrated in this study, a complex adaptive system lens helps to uncover the 'real' drivers for change. This approach assists researchers and decision makers to systematically explore the driving forces and factors in each setting and develop appropriate and timely strategies to address them. The study calls for greater consideration of dynamics of vaccine acceptability while formulating immunization policies and program strategies. The analytical approaches adopted in this study are not only applicable to immunization or Kerala but to all complex interventions, health systems problems, and contexts.
... Other critics of the PHC approach point to issues such as the failure of the governments, funding agencies and NGOs to understand the complexity of the task involved in the implementation of PHC (Van Balen, 2004); the emergence of vertical programs for specific diseases undermining the holistic approach of PHC (Macfarlane et al., 2000, Strasser, 2003; the exclusion of clinicians who may be seen as dealing with cure of disease instead of health promoting interventions (Curtale et al., 1995); and a top-down approach more in agreement with the needs and perceptions of the delivery bureaucracies than of the people being served (Justice, 1987). In the presentation of the concept of health district I should not refrain from saying that rural health districts face challenges that are considerably different from those of urban health districts (Grodos andTonglet, 2002, Ministry of Health, 2003). ...
... This paper demonstrates that the absenteeism and unavailability of providers at the right time plague the rural health services. These findings are consistent with many other studies in different parts of the developing world, including Bangladesh (Justice, 1987;Chowdhury, 1990;Lewis, 1996;Chaudhury & Hammer, 2004). In the case of the Bangladesh health care system, the absenteeism and a lack of motivation was documented in a seminal research on rural health workers (Chowdhury, 1990). ...
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A key aim of the health policy of the Government of Bangladesh (GoB) has been to provide quality health services to all its citizens. In line with the policy objective, the GoB has adopted the primary health care (PHC) approach as a health development strategy. Inspired by the Alma Ata Declaration on PHC, the GoB health policy and programmes aim at ensuring “health for all” (Perry, 2000), with special focus on rural population and the poor. There is now a common mistrust of the public health services in the country and the perceived poor quality of health services push the higher socio-economic groups to seek health services abroad (Mahdy, 2009). I used a narrative interview method to better understand the user perspectives on the quality of PHC to register patients’ voices missed in previous predominantly quantitative studies (e.g., Sohail, 2005). Data for the research came from 10 ex-patients who sought primary health services in a health centre in a sub-district in Bangladesh. This paper demonstrates that lack of adequate health professionals, misuse of resources, provider absenteeism, provider-centric consultations result in patient dissatisfaction and ineffectiveness of services. I argue that there is a need for proper maintenance of resources, better monitoring and supervision and address process-related quality issues to ensure better quality health services for the rural people.
... If northern NGOs, as suggested by Dubash and Oppenheimers (1992) and Ahmad (2006), are primarily concerned with framing the problem and advancing policy solutions, then southern NGOs failure to contribute to a public good with these NGOs is troublesome. As Justice (1987) showed, policymaking by donor agencies and international health coalitions that does not have substantial input from recipients can lead to poor implementation outcomes. So, this leads us to consider the question, why are there more likely to be ties from NGOs in the global north to the global south than by chance alone but not visa versa? ...
Article
Globalization and communication scholars have argued that technology is transforming the “third sector”, the set of organizations that are not-for-profit and non-governmental (NGOs). This research examines the local and global linkages among a hyperlink network of 248 HIV/AIDS NGOs. This research examines the north/south NGO divide in the context of these new technology-based associations. Results suggest that the north/south divide is as great a concern in the virtual world as it is in the physical one. This research implies that globalization theorists’ argument that communication technologies break down economic and geographic barriers may be overstating the empirical reality.
... Social scientists, especially medical anthropologists, have contributed to the study of primary health care by examining the presumably problematic health-related behaviors of poor populations, the social world of national primary health care providers, and even the bureaucracies of international agencies (cf. Foster, 1977; Coreil & Mull, 1990; Justice, 1987; Nichter, 1996). However, little research on primary health care has examined the interface between expatriate foreign health agency workers in the field and the poor communities they are supposed to serve. ...
Article
In keeping with the neo-liberal emphasis on privatization, international aid has been increasingly channeled through non-governmental organizations (NGOs) and their expatriate technical experts to support primary health care (PHC) in the developing world. Relationships between international aid workers and their local counterparts have thus become critical aspects of PHC and its effectiveness. However, these important social dynamics of PHC remain understudied by social scientists. Based on three years of participant-observation in Mozambique, this paper presents an ethnographic case study of these relationships in one central province. The Mozambique experience reveals that the deluge of NGOs and their expatriate workers over the last decade has fragmented the local health system, undermined local control of health programs, and contributed to growing local social inequality. Since national health system salaries plummeted over the same period as a result of structural adjustment, health workers became vulnerable to financial favors offered by NGOs seeking to promote their projects in turf struggles with other agencies. It is argued that new aid management strategies, while necessary, will not be sufficient to remedy the fragmentation of the health sector. A new model for collaboration between expatriate aid workers and their local counterparts in the developing world is urgently needed that centers on the building of long-term equitable professional relationships in a sustainable adequately funded public sector. The case study presented here illustrates how the NGO model undermines the establishment of these relationships that are so vital to successful development assistance.
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This paper analyzes capacity building in practice, addressing the expectations, imaginaries and experiences of health researchers from Mozambique and Angola. The empirical data stems from the Erasmus+ funded project “Uni-versity Development and Innovation – Africa (UDI-A)”, a consortium established between European and African institutions to promote the mobility and empowerment of African academics, the establishment of North/South research partnerships and the strengthening of African institutions. Through qualitative research methods – semi-structured interviews and a focus group with African participants, and participant observation – this article analyzes the experiences of African academics working in the health field, their perceptions of capacity building and aspirations during their stay in Portugal in 2018. By addressing some of their concerns and achievements, this paper reflects on the performativity of capacity building methodologies, exploring a wide range of issues that emerge within the framework of North/South partnerships, inquiring whether it would be possible to decolonize capacity-building methodologies
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Many authorities recognize the concept that sensitivity to a recipient people's culture during the formulation and implementation of international health programs is a basic component to the success of those programs. Nevertheless, international health agencies have consistently failed in realizing truly successful projects in recipient countries by their neglect to fully take culture into account. The reasons are complex, and their comprehension involves a understanding of who is involved in international health programs, the history of those programs, and the conflicts that arise when outside agencies fail to understand--or be understood by--those who are on the receiving end of programs. This paper will scrutinize international health care assistance and development from the points of view of both donor agencies and recipient countries. Examples are presented from countries and regions worldwide. The challenges in maintaining cultural sensitivity will be described, analyzed, and potential solutions will be offered.
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Nepal's Assistant Nurse-Midwife program demonstrates some of the consequences of ignoring social and cultural information in health planning. Partly in response to national and international pressures to develop careers for women, the program was designed to train young women to provide maternal and child health care in rural areas. But traditional expectations about women, which are widely known, have impaired the program's effectiveness. Thus, even when cultural information is relevant and available--in fact, common knowledge--it still may not influence health planning. This case study pinpoints crucial planning issues in primary health care and recommends changes that could make the Assistant Nurse-Midwife's role more appropriate to its social and cultural setting.
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