Demographic And Health Analysis: Country Report & Analysis Overview

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Working With Different Stakeholders

Peter J. Winch, MD, MPH Johns Hopkins University

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Stakeholders

Section A

Stakeholders

 Who are the stakeholders?

 What do we mean by stakeholders?

 How have perspectives on different types of stakeholders in international health and their respective roles changed since World War II?  1945–1970  1970–2000

Who Are the Stakeholders?

 “… individuals, groups and organizations who have an interest (stake)”

 “… and the potential to influence the actions and aims of an organization, project or policy direction”

Sources: Mason, R. O., & Mitroff, I. I. (1981). Challenging Strategic Planning Assumptions: Theory, Cases, and Techniques. John Wiley & Sons Incorporated. Crosby, B. (1992). Stakeholder Analysis: A Vital Tool for Strategic Managers. USAID’s Implementing Policy Change Project. Walt, G. (1994). Health Policy: An Introduction to Process and Power. Johannesburg : London ; Atlantic Highlands, N.J: Witwatersrand University Press; Zed Books. [Cited in: Varvasovszky, Z., & Brugha, R. (2000). A stakeholder analysis. Health Policy and Planning, 15(3), 338–345.] 4

“Clarkson (1995) defines stakeholders as ‘persons or group that have, or claim, ownership, rights or interests in a corporation and its activities, past, present, or future.’”

—Varvasovszky and Brugha (2000)

Who Are the Stakeholders?

Source: Varvasovszky, Z., & Brugha, R. (2000). A stakeholder analysis. Health Policy and Planning, 15(3), 338–345. [Referencing: Clarkson, M. E. (1995). A Stakeholder framework for analyzing and evaluating corporate social performance. Academy of Management Review, 20(1), 92–117.] 5

Other Related Terms

 Actors  “Actors may be individuals or groups and even states …”

• Walt, Buse, and Harmer, p. 853

 Partners  Note that the term development partners is usually restricted to multilateral and

bilateral organizations

 Representatives

Source: Walt, G., Buse, K., & Harmer, A. Chapter 17: Cooperation in Global Health. In: Merson, M., Black, R. E., & Mills, A., eds. Global Health: Diseases, Programs, Systems, and Policies. (2012) (3rd edition). Burlington, MA: Jones & Bartlett Learning. 6

Engagement With Stakeholders During Three Periods

1945–1970  Vertical representation and “international health”

1970–2000  Decline of vertical representation  Emergence of horizontal partnerships

2000–present  Horizontal partnerships and “global health”

Engagement With Stakeholders During Three Periods

1945–1970  Vertical representation and “international health”

1970–2000  Decline of vertical representation  Emergence of horizontal partnerships

2000–present  Horizontal partnerships and “global health”

“Vertical representation describes the relationship between the state and international organizations that make up the United Nations system, which was established in the mid-1940s to represent the interests of all states and promote cooperation between them.”

—Walt, Buse, and Harmer, p. 853

Vertical Representation

Yalta Conference: February 1945

Source: US Government photographer. (1945). "'Big Three' met at Yalta." Via Wikimedia Commons: https://commons.wikimedia.org/wiki/File:Yalta_ Conference_(Churchill,_Roosevelt,_Stalin)_(B%26 W).jpg. Public domain. Accessed July 21, 2015. 10

Question One

 Who are these men?

1. Winston Churchill, Theodore Roosevelt, Vladimir Lenin 2. Winston Churchill, Theodore Roosevelt, Joseph Stalin 3. Winston Churchill, Franklin Roosevelt, Joseph Stalin 4. Tony Blair, Eleanor Roosevelt, Vladimir Putin

Question One

 Who are these men?

1. Winston Churchill, Theodore Roosevelt, Vladimir Lenin 2. Winston Churchill, Theodore Roosevelt, Joseph Stalin 3. Winston Churchill, Franklin Roosevelt, Joseph Stalin  4. Tony Blair, Eleanor Roosevelt, Vladimir Putin

Post-War Period

1944 Dumbarton Oaks Conference—preliminary UN plans 1945 Yalta Conference—Russia agrees to enter UN

1945 United Nations Conference on International Organization in San Francisco—UN Charter written

1946 Constitution of WHO signed at UN 1947 Partition and independence of India, Pakistan 1948 WHO formed

1948–1949 Berlin Blockade 1949 Independence of Indonesia, Chinese Revolution

1950–1953 Korean War 1956 Hungarian Revolution, Suez Crisis 1957 Independence of Ghana 1960 Independence of Nigeria

Challenges in Newly Independent Countries

 Artificial borders

 Legitimacy of national government not established

 No administrative structures, ministries, or civil service in place

 No service provision in place

 Rebel movements

Key Activities of WHO From 1945 to 1970

 Establishing health systems for ministries of health in newly independent countries

 Working with new ministries of health to determine the locations of health facilities and the level of facility at each location

 Setting up personnel systems in new ministries of health

 Establishing medical and nursing schools

Question Two

 What diseases did WHO work on eradicating from 1945 to 1970? Multiple responses possible:

1. Yaws 2. Polio 3. Measles 4. Malaria 5. Smallpox 6. Dengue

Question Two

 What diseases did WHO work on eradicating from 1945 to 1970? Multiple responses possible:

 1952–1964:

• Yaws, Bejel, Pinta • Global Control of Treponematoses (GCT)

 1955–1969: • Malaria

 1958–1980: • Smallpox

Question Three

 Who were key partners for WHO from 1945 to 1970? Multiple responses possible:

1. Ministries of health 2. Roll Back Malaria 3. UNAIDS 4. USAID 5. Nongovernmental organizations (NGOs) 6. Community-based organizations (CBOs) 7. Human rights organizations 8. UNICEF

Question Three

 Who were key partners for WHO from 1945 to 1970? Multiple responses possible:

1. Ministries of health  2. Roll Back Malaria 3. UNAIDS 4. USAID  5. Nongovernmental organizations (NGOs) 6. Community-based organizations (CBOs) 7. Human rights organizations 8. UNICEF 

Prof. Timothy D. Baker (1925–2013)

 Professor of international health at JHSPH

 Trailblazer during the 1945–1970 period

Image: Professor Timothy Baker. Retrieved July 21, 2015, from http://www.jhsph.edu/departments/international-health/the-globe/summer-2014/timothy-baker.html. 20

Prof. Timothy D. Baker (1925–2013)

 Worked on malaria eradication programs in India and Ceylon during 1950s as assistant chief of the Health Division for US Technical Cooperation Mission (later USAID)

 1959: Appointed assistant dean of JHSPH and associate professor of public health administration

 1960s: Conducted the first health workforce studies across South America, as well as in Korea, Taiwan, Thailand, and Vietnam (e.g., “Health manpower in a developing economy: Taiwan, a case study in planning,” 1967)

 1961: Founded the School’s Division of International Health and served as acting director

 Faculty member and advisor until his death on December 17, 2013

Image: Professor Timothy Baker. Retrieved July 21, 2015, from http://www.jhsph.edu/departments/international-health/the-globe/summer-2014/timothy-baker.html. 21

Engagement With Stakeholders During Three Periods

1945–1970  Vertical representation and “international health”

1970–2000  Decline of vertical representation  Emergence of horizontal partnerships

2000–present  Horizontal partnerships and “global health”

1970–2000: Key Trends in Stakeholder Engagement

 Recognition of limits of Ministry of Health services  You can build it, but they may not come  Ministry of Health seen as bureaucratic, inflexible, and in some countries, prone to

human rights abuses

 Greater interest in community role  Comprehensive Primary Health Care  Alma Ata Declaration

 Emergence of large NGOs  BRAC in Bangladesh  International NGOs

1970s: Attention to Community-Based Provision of Care

 Bryant, Jack. (1969). Health & the Developing World. Ithaca, NY: Cornell University Press.

 Newell, Kenneth. (Ed.). (1975). Health by the People. Geneva: World Health Organization.  WHO document!  http://apps.who.int/iris/bitstream/10665/40514/1/9241560428_eng.pdf

Table of Contents: Health by the People (Newell, 1975)

Source: Newell, K. W. (Ed.). (1975). Health by the People. Geneva: World Health Organization. Available at: http://apps.who.int/iris/bitstream/10665/40514/1 /9241560428_eng.pdf. Accessed July 21, 2015.

Elements of the Emerging Approach to Health Services

 Integrated and comprehensive  All health problems  Multiple sectors (education, agriculture, etc.)

 Horizontal, not vertical  Planning and implementation at local level  Selection of locally appropriate approaches

 Make use of local resources  Traditional healers, traditional birth attendants  Community health workers / village health workers (CHWs/VHWs)  Local leaders

International Conference on Primary Health Care, Almaty (Formerly Alma-Ata), Kazakhstan, September 6–12, 1978

 Alma Ata Declaration

 Reaffirmed WHO definition of health:  “A state of complete physical, mental and social well-being and not merely the

absence of disease or infirmity”

 Health for All

 Primary Health Care

Carl E. Taylor (1916–2010)

 First chair of JHSPH Department of International Health

 Key mover behind Alma Ata Declaration

 Lifetime proponent of Comprehensive Primary Health Care

 Considered arrogance and lack of humility to be key barriers to implementation

Image: Carl E. Taylor 1916-2010. Retrieved July 21, 2015, from http://www.jhsph.edu/news/stories/2010/carl-taylor.html. 28

Emergence of Stakeholder Analysis as Key Tool

 Need to consider not only Ministry of Health, but also:  Researchers and universities  International and national NGOs  Donors and development banks  Community-based organizations  Municipalities and local governments

 Stakeholder analysis began to be required component for many grant applications

Changing Roles

Section B

Changing Roles

 How have perspectives on different types of stakeholders in international health and their respective roles changed since World War II?  2000–present

 How have the roles of NGOs changed over time?

 Aid effectiveness

Engagement With Stakeholders During Three Periods

1945–1970  Vertical representation and “international health”

1970–2000  Decline of vertical representation  Emergence of horizontal partnerships

2000–present  Horizontal partnerships and “global health”

2000–Present: Key Developments in Stakeholder Analysis

 2002—founding of Global Fund  Stakeholder analysis hardwired into the grant application process  Country Coordinating Mechanisms (CCMs)

 Continued growth of civil society organizations (CSOs) / international NGOs  Questions about their role and accountability

 2005—Paris Declaration on Aid Effectiveness

CSOs and Founding of the Global Fund for AIDS, Tuberculosis, and Malaria

 Many events happening at once  See “The Global Fund to Fight AIDS, Tuberculosis and Malaria” in Wikipedia

 In the late 1990s, various NGOs/CSOs …  Engaged in the fight against AIDS  Protested injustice of lack of HIV treatment in countries most affected  Lobbied for lower prices for HIV drugs

 Role for CSOs was written into funding guidelines

 Initial idea was a broad antipoverty development fund, but focus was narrowed to diseases

Source: “The Global Fund to Fight AIDS, Tuberculosis and Malaria.” (Updated July 8, 2015). In Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/wiki/The_Global_Fund_to_Fight_AIDS,_Tuberculosis_and_Malaria#Creation. Accessed July 21, 2015. 5

Global Fund: Country Coordinating Mechanisms (CCMs)

 Fight against AIDS, tuberculosis, and malaria to be multisectoral

 Each country to have a CCM  CCM to bring together government ministries, community-based organizations

(CBOs), CSOs, and development partners around the table

 Principal Recipient for Global Fund grant can be Ministry of Health, but also Ministry of Finance, UN Development Program (UNDP), international NGO, etc.

Growing roles for NGOs: Good thing or bad thing?

Impacts of NGOs on Health Systems (Pfeiffer, et al., 2008)

Negative impact Positive impact

Manage- ment

Burden  Multiple projects to oversee  Divergent financial and program

reporting requirements  Diversion of planning to meet NGO

needs

Support  Support for management capacity

building  Support for financial coordination

and harmonized program reporting  Support for integrated planning

Oper- ations

Fragmentation of services, vertical technical assistance  Showcase projects with limited

sustainability  Imbalances in geographic and

programmatic resource allocation  Vertical programs that undermine

service integration  Concentration of scarce MOH human

resources within NGO-related projects

Technical assistance, innovation, pilot projects  New, innovative programs to meet

Ministry of Health (MOH) priorities  Contribution of resources to MOH

technical assistance priorities  Innovative methods to channel

vertical funds into integrated services  Allocation of human resources to

MOH for innovative projects

Human resources

Shortages  “Brain drain” to NGOs  Lack of sustainability for new

programs  Lower morale among health workers  Weakened management through loss

of skilled staff

Capacity building  On-the-job training for MOH staff  Funding for additional MOH workforce

for new program needs  Advocacy to improve work

conditions, capacity, and workloads  Provision of management training and

funding for new management tools

Source: Pfeiffer, J., Johnson, W., Fort, M., Shakow, A., Hagopian, A., Gloyd, S., & Gimbel- Sherr, K. (2008). Strengthening health systems in poor countries: a code of conduct for nongovernmental organizations. American Journal of Public Health, 98(12), 2134–2140. http://doi.org/10.2105/AJPH.2007.125989

Elements of an NGO Code of Conduct for Health System Strengthening (Pfeiffer, et al., 2008)

1. Hiring practices that ensure long-term health system sustainability  Limit hiring out of public systems  Obtain consent from the local Ministry of Health (MOH) for any hiring from public

systems

2. Compensation practices that strengthen the public sector  Limit pay inequity between the public and private sectors, and compensate

community health workers  Support pay incentives for rural service  Grant similar privileges to expatriate and national employees

3. Human resources support for local health systems  Support increases in the number and capacity of health professionals  Support training to build management and service capacity in MOHs

4. NGO management support for MOHs  Commit to joint planning  Follow MOH geographic, administrative, and personnel norms  Advocate for flexible donor funding to mitigate effects of vertical funding

5. Health system community support  Support communities’ linkages to health systems while promoting government

accountability  Help protect oppressed populations

6. Advocacy to eliminate wage bill caps and limitations on health system investment promoted by international financial institutions

Question Four

 Which of these will be most difficult for NGOs to implement? One response only

1. Limit hiring out of public systems 2. Limit pay inequity between public and private sectors 3. Grant similar privileges for expatriate and national employees 4. Follow Ministry of Health geographic, administrative, and personnel norms

“One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners; One National HIV/AIDS Coordinating Authority, with a broad-based multi- sectoral mandate; One agreed HIV/AIDS country-level Monitoring and Evaluation (M&E) System.”

Three Ones: UNAIDS 2004

Source: UNAIDS. “Three Ones Principles.” Available at: www.unaids.org.ua/un_support/strategies/ThreeOnes. Accessed July 21, 2015. 11

Aid Effectiveness

 Concern that foreign aid …  Does not achieve its objectives  Undermines rather than strengthens governance  Promotes kleptocracy and corruption  Promotes aid dependence  Lets countries avoid tough decisions  Often goes back (through contracts, etc.) to donor countries

Paris Declaration on Aid Effectiveness, 2005

 Sought to institutionalize:  Recommendations similar to those of Pfeiffer, et al. (2008) for NGOs and the Three

Ones of UNAIDS  Similar recommendations made for donor organizations

 Five major principles

Source: “Aid effectiveness.” (Updated April 11, 2015). In Wikipedia, the free encyclopedia. Available at: https://en.wikipedia.org/wiki/Aid_effectiveness#Paris_Declaration_on_Aid_Effectiveness.2C_February_2005. Accessed July 21, 2015. 13

Paris Declaration on Aid Effectiveness, 2005

1. Ownership:  Developing countries must own, lead, and manage their development work  Funds should go to established country plans and priorities

2. Alignment:  Donors should fund activities that align with country plans and priorities

3. Harmonization:  Donors coordinate their procedures and reporting mechanisms to lessen administrative

burden on countries

4. Managing for results:  Establish objectives and indicators, and evaluate on the basis of achievement of

objectives

5. Mutual accountability:  Donors and recipient countries account transparently to each other for use of aid funds,

and to citizens and parliaments for impact of aid

Stakeholder Analysis, Example 1: Response to the Anti-Homosexuality Act in Uganda

Section C

What we mean by stakeholder analysis

Stakeholder Analysis

 Evolution since 1945  From:

• Why do it, given that only stakeholder is Ministry of Health?  To current situation:

• Essential to appreciate the complex role of different partners • Requirement as part of grant application process for many donors

Twelve-Step Guidelines for Future Health Systems (Hyder, et al., 2010)

1. Articulate clear problem statement 2. Identify health policy or strategy 3. Consider 11 categories of stakeholders 4. Identify groups within organizations with different perspectives 5. Rate level of influence of each on five-point scale 6. Articulate type of power/influence 7. Rate current level of agreement with proposal 8. Identify concerns 9. Classify into one of five categories 10. Articulate strategies to deal with stakeholders 11. Plan for each stakeholder, taking into account main concerns 12. Plan for repeat stakeholder analysis

4 Source: Hyder, A., Syed, S., Puvanachandra, P., et al. (2010). Stakeholder analysis for health research: case studies from low- and middle-income countries. Public Health, 124(3), 159–166. http://doi.org/10.1016/j.puhe.2009.12.006

Step 6: Articulate Types of Power/Influence

 Opinion leader

 Advisor to policy maker

 Decision maker

Step 9: Classify Into One of Five Categories of Stakeholders

 Drivers

 Blockers

 Supporters

 Bystanders

 Abstainers

Stakeholder Analysis Example 1:

Response to the Anti-Homosexuality Act in Uganda

Background on Uganda

 Hard-hit by HIV in early 1990s

 Steady decrease in HIV prevalence through 1990s

 HIV transmission increasing again by 2005

 Most at-risk populations / key populations:  Commercial sex workers  Men who have sex with men, male sex workers  Truck drivers, fisherfolk, military, police

External Funding for Health Sector

 ~40% of health spending

 Heavily influenced by Paris Declaration

 Example:  See page 5 of Health Spending in Uganda: The Impact of Current Aid Structures and

Aid Effectiveness (2010)

9 Source: Action for Global Health, German Foundation for World Population. (2010). Health Spending in Uganda: The Impact of Current Aid Structures and Aid Effectiveness. Available at: http://www.actionforglobalhealth.eu/fileadmin/AfGH_Intranet/AFGH/Publications/PolicyBriefing1_Final1_LoRes_02.pdf. Accessed July 23, 2015.

Top Funders to Health Sector

1. USAID

2. Global Fund

3. International Development Association (IDA) / World Bank

4. United Kingdom

5. Ireland

6. Sweden

7. African Development Fund (AfDF) / African Development Bank

8. Global Alliance for Vaccines and Immunization (GAVI)

9. Belgium

10. United Nations Population Fund (UNFPA)

Source: OECD Database 2006–2008. 10

Anti-Homosexuality Act

 More than 80 countries have laws making homosexuality illegal  Most are not enforced

 Uganda  Had preexisting colonial-era law  New law introduced in 2009

• Private member’s bill • Penalties up to capital punishment • Not signed into law

Source: LGBT rights by country or territory. (Updated July 22, 2015). In Wikipedia, the free encyclopedia. Available at: https://en.wikipedia.org/w/index.php?title=LGBT_rights_by_country_or_territory&oldid=672542301. Accessed July 23, 2015. 11

Decriminalization by Country

Same-sex marriage Other type of partnership (or

unregistered cohabitation) Foreign same-sex marriages

recognized Limited recognition of same-sex

marriages at the federal level, no state-level recognition

No recognition of same-sex couples Laws restricting freedom of

expression and association De jure penalty that is de facto not

enforced Imprisonment Imprisonment (up to life sentence) Up to death

Anti-Homosexuality Act

 Modified version was introduced in 2013

 Other laws were introduced around same time:  Antipornography Act  HIV/AIDS prevention/control

 Confrontations with Uganda MPs at international meetings strengthened local support for the Act

 Passed in Parliament in December 2013

 President signed it into law in February 2014

Popular Support for the Law

Source: Agence France-Presse. (March 31, 2014). “Ugandan President Museveni leads rally backing new anti-gay laws.” Available at: http://www.rawstory.com/2014/03/ugandan- president-museveni-leads-rally-backing-new-anti- gay-laws/. Accessed July 21, 2015. 14

Initial Question for World Bank

 Uganda Health Systems Strengthening Project:  Proceed with next round of financing by June 30, 2014?

• Yes • No

Provisions of the Anti-Homosexuality Act

 Criminalizes consensual sexual activities between adults of the same sex with a sentence of life imprisonment (sect. 2)

 Makes same-sex activities between persons living with HIV and persons with disability and aggravating circumstance to the offence of homosexuality punishable by life imprisonment (sect. 3 [1] [b], and [e])

 Provides for mandatory HIV testing of persons charged with homosexuality (sect. 3 [3])  Criminalizes attempts to commit the offence of homosexuality with a seven-year jail term (sect. 4)  Provides for the offence of aiding, abetting, counseling, and procurement of homosexuality and

punishment of seven years in jail upon conviction  Criminalizes keeping a house, set of rooms, or any place for the purpose of homosexuality (sect. 11

[1])  Criminalizes under the broad heading of promotion publication, dissemination, procuring of any

pornographic materials for the purposes of promoting homosexuality; funding or sponsorship of homosexuality or related activities; offering premises and other related fixed and moveable assets for the purpose of homosexuality, or promoting homosexuality; use of electronic devices including mobile phones, films, the internet for the purpose of promoting homosexuality (sect. 13)

Potential Health Impacts

 Arrest, detention and prosecution of health care practitioners for the provision of health and related services to the LGBTI community, under the guise of the overly broad and undefined promotion clause in the Anti-Homosexuality Act  The Act prohibits the aiding, abetting, or promoting of homosexuality

 Owners/proprietors of premises could be liable to prosecution for the provision of premises for any health service provider offering services to the LGBTI community

 Compulsion through a court order, or upon request by the police to disclose medical related information (including patients’ details)

 Provision of funds, or sponsoring of activities related to homosexuality can be construed as an offence under the promotion of homosexuality clause in the Act

 Under the clause on aiding and abetting, counseling an LGBTI person “to engage in acts of homosexuality” is construed to be equivalent to aiding and abetting the offence of homosexuality

Stakeholders Contacted

Category Organizations or individuals contacted Government agencies/officials

 Ministry of Health (Minister of State, Principal Secretary, staff of AIDS Control Program)

 Uganda AIDS Commission Development partners  UNAIDS, USAID, US State Department, Unicef, DANIDA, Irish Aid, SIDA

 AIDS Partnership Group Service providers, researchers

 MARPS Network, Mulago National STI clinic/MARPI, AIDS Information Centre, TASO

 Joint Clinical Research Centre (JCRC)  Inter Religious Council of Uganda (IRCU), Uganda Catholic Medical

Bureau, Uganda Protestant Medical Bureau  Uganda Medical and Dental Practitioners Council

Advocacy organizations  Uhuru Institute, Health GAP (Global Access Project), Health Gap

Political and religious leaders

 Members of Parliament  Retired bishop

LGTBI people  Names withheld 18

Question Five

 Who wants World Bank, USAID, and other development partners to halt further financing? (Multiple responses possible)

1. Ministry of Health 2. Uganda AIDS Commission 3. Development partners 4. Secular NGO service providers 5. Religious service providers 6. Advocacy organizations 7. Members of parliament who introduced the bill 8. LGTBI people

Question Six

 What should World Bank, USAID, and other development partners demand? (One response allowed)

1. Repeal of law by Parliament 2. Suspension of implementation of all aspects of the law 3. Mitigation measures by Ministry of Health to blunt the impact of the law

Question Six

 What should World Bank, USAID, and other development partners demand? (One response allowed)

1. Repeal of law by Parliament 2. Suspension of implementation of all aspects of the law 3. Mitigation measures by Ministry of Health to blunt the impact of the law 

Question Seven

 Which risks in health service provision were of greatest concern? (Multiple responses possible)

1. Discriminatory behavior by health workers 2. Closure of specialized centers that could be accused of “aiding homosexuality” 3. Violence, harassment, or arrest of patients 4. Discrimination against patients by staff and by other patients

Research Finds Strengthened Our Hand to Make Recommendations

 Respondent-driven sampling study on 300 MSM in Kampala published in 2009

 “In multivariate analysis, MSM reporting ever having been exposed to homophobic abuse (verbal, moral, sexual, or physical abuse; aOR 5.38, 95% CI 1.95-14.79) were significantly more likely to be HIV infected.”

• MSM = men who have sex with men; aOR, adjusted odds ratio;

and CI, confidence interval

Source: Raymond, H. F., Kajubi, P., Kamya, M. R., Rutherford, G. W., Mandel, J. S., & McFarland, W. (2009). Correlates of unprotected receptive anal intercourse among gay and bisexual men: Kampala, Uganda. AIDS and Behavior, 13(4), 677–681. http://doi.org/10.1007/s10461-009-9557-7 23

Mitigation of Risks in Health Service Provision

1. Discriminatory behavior by health workers  Preparing and disseminating guidelines and training for health workers across the

health system

2. Closure of specialized centers that could be accused of “aiding homosexuality”  Confirming the legitimacy and existence of specialized clinics for most at-risk

populations

Mitigation of Risks in Health Service Provision

3. Violence, harassment, or arrest of patients  Creating a system to safely escort patients to clinics and to reduce frequency of

patient visits to clinics by increasing the volume of antiretroviral drugs provided at each visit

4. Discrimination against patients by staff and by other patients  Strengthening the grievance mechanism to address cases of discrimination or

harassment

What We Concluded

 There is a definite need to take action

 Action needs to be taken in a low-key way that does not inflame the press or encourage members of the public to take matters into their own hands

 Research results prove invaluable in a delicate situation

 Mitigation measures work better than outright repeal of the law  Generate less negative publicity  Can be phrased as positive actions  May have other long-term benefits

What We Concluded

 Structures put in place as condition of Global Fund and PEPFAR funding to bring different stakeholders together prove invaluable to resolution of problems:  Uganda AIDS Commission and its various committees  AIDS Development Partners group  Inter-Religious Council of Uganda

Stakeholder Analysis, Example 2: Cholera in Angola

Section D

Cholera in Angola

 Cholera transmission in Angola is continuous, punctuated by large epidemics every few years (e.g., 2006 epidemic centered on Luanda)

 Concern about risk for Ebola  Cholera and Ebola transmission thrive under similar conditions

Reproductive Health and Female Literacy for Countries With Top Ten Under-Five Mortality Rates

TFR Contraceptive prevalence

Adjusted maternal mortality

rate

Lifetime risk maternal mortality:

1 in X

Female literacy, ages

15-24

Sierra Leone 4.8 11 890 23 52 Angola 6.0 – 450 39 66 Chad 6.4 5 1,100 15 42 Somalia 6.7 15 1,000 16 – DR Congo 6.0 17 540 30 53 Guinea-Bissau 5.0 14 790 25 59 Central African Republic 4.5 15 890 26 67 Mali 6.9 10 540 28 39 Nigeria 6.0 18 630 29 58 Niger 7.6 14 590 23 23

Data: United Nations Children’s Fund (UNICEF). (2014). The State of the World’s Children 2014: Every Child Counts : Revealing Disparities, Advancing Children’s Rights. New York, NY: United Nations Children’s Fund (UNICEF). 3

Quick History of Angola

1483 Portuguese started trading

1700s–1800s Huge source of slaves to Brazil

1961–1974 Liberation war against Portuguese

November 11, 1975 Independence

1975–2002 Civil war

2008 National elections

2010 New constitution

Demographics and Economy

 Population of 19 million

 Land area of 1.2 million km2 (two times the size of Texas)

 Per capita GDP US$ 6,484

 From 2001–2010, world’s highest GDP growth rate at 11.1% per year

 Oil and diamonds are 60% of economy

 Ranked near bottom for Human Development Index

Legacy of 40 Years of War

 Very high rate of urbanization (45%)

 Serious humanitarian crisis  Result of war and refugees from DR Congo  “Musseques”—internally displaced

 Abundance of minefields

 “The general situation for Angolans remains desperate”

Legacy of 40 Years of War

 Level of professional training of health workers is minimal

 Many Ministry of Health employees “learned on the job”

 Many government employees are decommissioned soldiers and former rebel fighters, with no formal qualifications

 There is low capacity to plan, collect data, and interpret data

Angola

Image: Vick, V., for The New York Times. In: Lafraniere, S. (June 16, 2006). In oil-rich Angola, cholera preys upon poorest. The New York Times. Available at: http://www.nytimes.com/2006/06/16/world/africa/16cholera.html. Accessed July 23, 2015. 8

Angola

9 Image: Vick, V., for The New York Times. In: Lafraniere, S. (June 16, 2006). In oil-rich Angola, cholera preys upon poorest. The New York Times. Available at: http://www.nytimes.com/2006/06/16/world/africa/16cholera.html. Accessed July 23, 2015.

2006 Cholera Epidemic

Source: Lafraniere, S. (June 16, 2006). In oil-rich Angola, cholera preys upon poorest. The New York Times. Available at: http://www.nytimes.com/2006/06/16/world/afric a/16cholera.html. Accessed July 23, 2015. 10

Controlling Cholera in Luanda Province

Constraints on Engagement of Development Partners

 Monthly rent for accommodation for expatriate staff in Luanda is $10K to $35K

 Some organizations cannot work in Angola because it is no longer a low-income country

 Portuguese speakers are in short supply

Categories of Action: Prevention and Control of Cholera

1. Case management in hospitals and clinics

2. Immunization

3. Promotion of water and sanitation behaviors  Chlorination of water  Handwashing  Building/maintaining latrines

4. Build water supply and sewer systems

We will focus on No. 3 for this example

Question Eight

 Who are the key stakeholders?

World Health Organization Private providers

UNICEF Community-based organizations

National Ministry of Health Informal community groups

Provincial government Government of Cuba

Armed forces Government of Brazil

International NGOs Eduardo dos Santos Foundation

USAID School of Public Health

Oil companies

WHO and UNICEF

 Because of 40 years of war, Angolans have yet to learn that the era of “vertical representation and international health” is over

WHO and UNICEF

Perspectives

 Eager to have an impact, because health and indicators are so poor in Angola

 Concerned that poor performance in Angola makes it difficult to reach goals for the Region

Potential roles

 Dissemination of global guidelines for control and prevention

 Training and capacity building

 Sharing of lessons learned between countries

 Bring together partners to work on new initiatives

Sources: http://www.afro.who.int/en/angola/who-country-office-angola.html http://www.unicef.org/infobycountry/angola_latest.html 16

National Ministry of Health

Perspectives

 Eager to take actions, but: concern about health worker shortages, limited skill level of many health workers

 Respect for UN agencies: WHO, UNAIDS, UNICEF

Potential roles

 Setting health priorities o Capacity building o Implementation o Research

 Coordinating actions of donors, indicating sites and health facilities in need of support

Source: Health in Angola. (Updated July 21, 2015). In Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/wiki/Health_in_Angola. Accessed July 23, 2015. 17

Provincial Government

Perspectives

 Eager for technical input and capacity building

 Under new national health plan, much responsibility for implementation of health services transferred to provincial and municipal levels

Potential roles

 Defining activities of control program

 Identifying staff/field workers for training

 Monitoring progress in implementation of program

Source: Luanda Province. (Updated November 16, 2014). In Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/wiki/Luanda_Province. Accessed July 23, 2015. 18

Armed Forces

Perspectives

 Perhaps largest and best organized armed forces in any African country

 Large, well-structured health systems that deliver some public services

 Need to demonstrate relevance by assisting in response to health problems of national significance

Potential roles

 Response to epidemics, especially logistics and coordination

 Preparedness and planning for epidemics

 Education and treatment for cholera of members of the armed forces and their families

Source: Angolan Armed Forces. (Updated May 28, 2015). In Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/wiki/Angolan_Armed_Forces. Accessed July 23, 2015. 19

USAID

Perspectives

 Want to help with capacity building, but high cost structure limits what they can do

 Have access to expertise on disease prevention and control: CDC, NIH, etc.

Potential roles

 Production of guidelines and materials

 Training courses  Organizing meetings  Sharing of lessons learned

from other countries

Source: USAID. “Where We Work: Angola.” Available at: http://www.usaid.gov/angola. Accessed July 23, 2015. 20

Oil Companies

Perspectives

 Need to demonstrate “corporate social responsibility” → beneficial to address a visible public problem o Good example is

work of Exxon/Mobil on malaria

 Considerable resources

Potential roles

 Sponsor courses, transport, training materials

 Implementation of programs in communities/ provinces where oil is produced, like Kabinda

For Chevron, see: Chevron Corporation. (Updated July 16, 2015). In Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/wiki/Chevron_Corporation#Upstream. Accessed July 23, 2015. 21

CBOs and Community Groups

Perspectives

 Relatively little involvement in the past

 Would like capacity building

Potential roles

 Implementation of community-level actions

Government of Cuba

Perspectives

 Long history of support of Government of Angola, and health services in Angola throughout the entire civil war

 Want to continue collaboration and support

Potential roles

 Input on organization of control programs

 Help with community mobilization

Government of Brazil

Perspectives

 Large health system with considerable capacity

 Established record in improving health status in low-income and marginalized populations

 Want to demonstrate solidarity with other Portuguese-speaking countries

Potential roles

 Input on organization of control programs

 Adaptation of community and training materials from Brazil

 Participation/support from Brazilian health workers based in Angola

Eduardo dos Santos Foundation

Perspectives

 Largest health foundation in Angola

 Wants visible role in responding to major public problems

Potential roles

 Bring together various stakeholders

 Convening and hosting international meetings

 Training and capacity- building

Source: José Eduardo dos Santos. (Updated May 29, 2015). In Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/wiki/Jos%C3%A9_Eduardo_dos_Santos. Accessed July 23, 2015. 25

Augustinho Neto University

Perspectives

 Wants to build capacity of university in public health

 Wants training and opportunities for faculty and students

 Wants opportunities to collaborate with and establish relationships with foreign organizations and institutions

Potential roles

 Training and capacity building

 Operational research to improve the functioning of the control program

Source: Agostinho Neto University. (May 17, 2015). In Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/wiki/Agostinho_Neto_University. Accessed July 23, 2015. 26

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