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Thinking about stakeholder risk and accountability in pilot experiments

Heather Lanthorn's picture

ACT malaria medicationHeather Lanthorn describes the design of the Affordable Medicines Facility- malaria, a financing mechanism for expanding access to antimalarial medication, as well as some of the questions countries faced as they decided to participate in its pilot, particularly those related to risk and reputation.

I examine, in my never-ending thesis, the political-economy of adopting and implementing a large global health program, the Affordable Medicines Facility – malaria or the “AMFm”. This program was designed at the global level, meaning largely in Washington, DC and Geneva, with tweaking workshops in assorted African capitals. Global actors invited select sub-Saharan African countries to apply to pilot the AMFm for two years before any decision would be made to continue, modify, scale-up, or terminate the program. One key point I make is that implementing stakeholders see pilot experiments with uncertain follow-up plans as risky: they take time and effort to set-up and they often have unclear lines of accountability, presenting risk to personal, organizational, and even national reputations. This can lead to stakeholder resistance to being involved in experimental pilots.

It should be noted from the outset that it was not fully clear what role the evidence from the pilot would play in the board’s decision or how the evidence would be interpreted. As I highlight below, this lack of clarity helped to foster feelings of risk as well as a resistance among some of the national-level stakeholders about participating in the pilot. Several critics have noted that the scale and scope and requisite new systems and relationships involved in the AMFm disqualify it from being considered a ‘pilot,’ though I use that term for continuity with most other AMFm-related writing.
 
In my research, my focus is on the national and sub-national processes of deciding to participate in the initial pilot (‘phase I’) stage, focusing specifically on Ghana. Besides being notable for the project scale and resources mobilized, one thing that stood out about this project is that there was a reasonable amount of resistance to piloting this program among stakeholders in several of the invited countries. I have been lucky and grateful that a set of key informants in Ghana, as well as my committee and other reviewers, have been willing to converse openly with me over several years as I have tried to untangle the reasons behind the support and resistance and to try to get the story ‘right’.

What you don't know can hurt you: Malaria edition

Markus Goldstein's picture
You are feeling not so well.   You go to the doctor.   She is a good doctor.   She runs some tests, tells you nothing is wrong with you and you leave, ready to get back to work.   Why are you so much more ready to work now then you were before you saw your doctor?  
 

Malaria, Ebola, and Saving Lives

Quentin Wodon's picture

Last week, Mali announced a national strategic plan to scale up Community Health Workers in every region of the country. This initiative has the potential to save tens of thousands of lives, including significantly reducing the risk of an Ebola epidemic.
 
How was this achieved? Roll back a few years and meet Djeneba, a young girl living in Yirimadjo. Today she goes to school but her life was once threatened. Djeneba started getting high fevers but her parents did not have enough money to pay for care. They tried to break the fever by bathing her in herbal remedies and buying unregulated pharmaceuticals but the fevers persisted and became increasingly severe.

How Can Complexity and Systems Thinking End Malaria?

Duncan Green's picture

This is complexity week on the blog, pegged to the launch of Ben Ramalingam’s big new book ‘Aid on the Edge of Chaos’ at the ODI on Wednesday (I get to be a discussant – maximum airtime for least preparation. Result.)

So let’s start with a taster from the book that works nicely as a riposte to all those people who say (sometimes with justification, I admit) that banging on about complexity is just a lot of intellectual self-indulgence (sometimes they’re not so polite). We know what works, why complicate things? Hmmm, read on:

‘Kenya’s Mwea region is especially prone to malaria because it is an important rice-growing region, and large paddies provide an ideal breeding ground and habitat for mosquitoes. The application of insecticides and anti-malarial drugs has been widespread, but there has been a marked rise in resistance among both mosquitoes and the parasites themselves.

A multidisciplinary team developed and launched an eco-health project, employing and training community members as local researchers, whose first task was to conduct interviews across four villages in the region, to give a first view of the malaria ‘system’ from the perspective of those most affected by it.

The factors involved were almost dizzyingly large in number—from history, to social background, to political conflicts. A subsequent evaluation of the programme referred to this as an admirable feat of analysis.

Using a systems analysis approach that placed malaria in the wider ecological context was a critical part of the programme design:

Mosquito Nets in Kenya: Driving Africa’s Fastest Reduction in Infant Mortality

Kavita Watsa's picture


Growing up in India, mosquito nets were an essential part of life. I slept under them as a child in Bangalore, with their ropes tied to bedposts, doors, closets, window grills—anything that would offer support at the right height. It was like pitching a tent every night, and the occasional dramatic collapse would result in much helpless laughter. Later, going to college on the banks of the slow-flowing Koovam river in Madras (now Chennai), I tucked myself under a net in my dormitory at about 6 p.m. to avoid the twilight assault of mosquitos from the water. In fact, particularly after a bad attack of malaria when I was a child, a lot of my life was lived perforce under a mosquito net, until electric repellent gadgets reached the market and nets somewhat lost their popularity.

Recently, sitting in Halima Ibrahim’s house in Majengo, a neighborhood in the coastal city of Mombasa, and talking about the new mosquito nets her family had just received from the Kenyan government, I felt instantly at home in her tiny living room. It was packed from corner to corner with family and friends, all brimming with opinions about nets old and new. Everybody talked about malaria and what a problem the disease was in the community. The nets that had just been distributed to them free of cost would make a huge difference, they said, protecting them from being bitten by mosquitos, and saving them considerable expense. Many of the families on the street simply could not afford to buy durable and effective nets at the prices they commanded in the local market.

Weekly Wire: the Global Forum

Kalliope Kokolis's picture

These are some of the views and reports relevant to our readers that caught our attention this week.

SciDev
Cell Phones can speed up malaria treatment in remote areas

“Mobile phones along with local knowledge and field support, can help to ensure the effective diagnosis and treatment of malaria in remote rural areas, according to a study in Bangladesh.

Researchers examined almost 1,000 phone calls to report suspected cases of malaria that were made over two years by inhabitants of a hilly and forested part of the country bordering Mynamar. This area, called the Chittagong Hill Tracts, has Bangladesh’s highest malaria rates.”  READ MORE

Dying from malaria in the market for lemons

Markus Goldstein's picture

We know malaria is a big problem and we know fake drugs are a big problem.   What do you get when you put them together?   Bad news.   A recent paper by Martina Bjorkman-Nyqvist, Jakob Svensson and David Yanagizawa-Drott (ungated version here) shows how bad this problem is in Uganda, and provides an innovative way to deal with it.

How does Africa fare? Findings from the Global Burden of Disease Study

Patricio V. Marquez's picture

The Global Burden of Disease Study 2010 (GBD 2010), a systematic effort to assess the global distribution and causes of major diseases, injuries, and health risk factors, was launched last week in London. 

And a special issue of The Lancet has published its results (http://www.thelancet.com/themed/global-burden-of-disease).

What are some of the main findings for Africa that can be drawn from the GBD 2010?

  • Since 1990, the largest gains in life expectancy worldwide occurred in sub-Saharan African countries, especially in Angola, Ethiopia, Niger and Rwanda, where life expectancy increased by 12-15 years for men and women. Overall, male life expectancy increased from 48.8 in 1990 to 53.2 years in 2010 in central sub-Saharan Africa, 50.9 to 59.4 years in eastern sub-Saharan Africa, and 53.0 to 57.9 years in western sub-Saharan Africa. 

Weekly Wire: the Global Forum

Kalliope Kokolis's picture

These are some of the views and reports relevant to our readers that caught our attention this week.

CIPE
Closing the Implementation Gap

“In every country, sound laws are a key foundation of democratic governance and economic development. Crafting such laws, however, is only part of the path to success. The other half is making sure that the laws are properly implemented – which is often more challenging.

When laws and regulations are not properly adopted, such discrepancy creates an implementation gap – the difference between laws on the books and how they function in practice. This gap can have very negative consequences for democratic governance and the economic prospects of countries and communities. When laws are not properly implemented, that undermines the credibility of government officials, fuels corruption, and presents serious challenges for business, which in turn hampers economic growth.”  READ MORE

Health Costs and Benefits of DDT Use in Malaria Control and Prevention

Susmita Dasgupta's picture

Photo: Istockphoto.comMalaria, a life threatening mosquito-borne infectious disease, poses a risk to approximately 3.3 billion people, approximately half of the world’s population. Most malaria cases occur in Sub-Saharan Africa, but they also occur in Asia, Latin America, and to a lesser extent the Middle East and parts of Europe. In 2010, malaria was found in 106 countries and territories, with an estimated 216 million cases and nearly 0.7 million deaths – mostly among children living in Africa. In addition to its health toll, malaria places a heavy economic burden on many countries with high disease rates, with estimates of as much as a 1.3 percent reduction in GDP in those countries.


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