Accounting for variations on ART program sustainability outcomes in health facilities in Uganda: A comparative case-study analysis

Abstract Background: Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about how and why some health facilities have sustained ART programs and why others have not sustained these interventions. The objective of the study was to identify facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009. Methods: A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers (N = 18) were conducted. Questionnaire data were analyzed (N = 12). Document review augmented respondent data. Based on the data generated, across-case comparative analyses were performed. Data were collected between February and June 2015. Results: Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers’ ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader ‘menu’ of ART services and more stable program leadership compared to the other cases. High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions. Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases. Conclusions: We found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, M &E systems, goal clarity) and external drivers (donors, ARVs supply chain, patient demand). ART program sustainability contexts were distinguished by the size of health facility and ownership-type. The study’s implications for health systems strengthening in resource-limited countries are discussed. Keywords: Sustainability, HIV treatment, Health systems, ART scale-up, Implementation, Case-study Authors: Henry Zakumumpa, Sara Bennett and Freddie Ssengooba FULL TEXT: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1833-4

Idle reflections on Robert Bolt's A Man for all seasons

Last night I stayed up late watching 'A man for all seasons' on Turner Classic Movies. The movie is an adaptation of Robert Bolt's play of the same name which was a set text for my A'level literature class a decade ago. The play is about Thomas More, Lord Chancellor to King Henry, the eighth. He was put to death for being true to his conscience(even under the most trying and unjust persecution) and denying that Henry's second marriage was legitimate. His opposition to King Henry marrying a second wife was out of religious (catholic)conviction. As chief counselor to King Henry, it was expected that he would go along with all the 'kings's men' and rubber stamp the decision to allow Henry a second wife even when it contravened the legal, religious and moral norms of the time. It is utterly amazing how much more meaning and thematic relevance I can now derive from a text I read as a boy to pass my A'levels. Having seen a bit of the world and known how incredibly trying it is to remain true to one's conscience, I appreciate Thomas More's example even more. The price of a life of convenience is a dearly expensive. As a secondary school student one often asks why they are 'forced' to read certain set texts. But yesterday, the answer came through. Some literature texts are an education in character. Being steadfast in upholding your virtues amidst trials and tribulations. Being loyal to truth and justice even at the cost of one's own life. How many times to we fail this test?, in our daily lives, at work, at home, in politics? Thomas More was truly 'A man for all seasons'. He was true to his convictions and beliefs in all the seasons of his life,when he was a great man and when he was banished from office. He never,even once, flinched when he was unjustly imprisoned, tried under sham charges,isolated from his friends and family and even when he was sent to the gallows. He believed in his heart that Henry's second marriage was a nullity and no amount of persecution would bring him to see matters differently. He spoke truth to power.

How Tobacco use deprived Ugandans of the' Father' of Arsenal's brand of football

Many Ugandans are ardent fans of Arsenal FC's style of football and Barcelona's attack-minded blend of Soccer.Many analysts agree this has a lot to do with one man. Johan Cruyff. Arsene Wenger, Frank Rijkaard and Pep Guardiola have variously acknowledged being influenced by Johan Cruyff's football philosophy. The Dutchman had an illustrious stint with the Dutch national football team famously captaining it to the 1974 World Cup final which they lost to West Germany. He later coached Barcelona to unprecedented success. The Dutchman even has a striker's dribbling manouever named after him. The Cruyff turn is a scenario where a striker makes a swift 180 degrees turn away from a defender. Dennis Bergkamp, Arsenal fans recall,executed this move in the twilight of his career there. Johan Cruyff would still be with us today to inspire more Arsenals and Barcelonas if it wasn't for one tragic habit-cigarette smoking. He passed away about two months ago from lung cancer. Tobacco use is responsible for 90% of all lung cancer deaths in men. Johan Cruyff repeatedly admitted that cigarette smoking had a lot to with the cancer that finally claimed his life and a heart bypass operation he underwent when he was still a football coach. '' Football gave me everything but tobacco almost took it all away'' said Johan Cruyff when it seemed that he would beat the lung cancer. Later in life, he emerged as unlikely poster boy for tobacco control causes. As we commemorate World No Tobacco Day today, it is an opportune moment to go beyond regurgitating the statistics of the victims of tobacco to reflect on the human face of the tobacco epidemic and the one billion lives tobacco use is set to claim this century unless action is taken. WHO has selected plain tobacco plain packaging as this year's World No Tobacco Day theme. Australia led the world in implementing a plain tobacco packaging rule. This simply means that if you buy a packet of cigarettes in Australia you will not find the manufacturer's colours and brand displayed on a cigarette packet as is the case in Uganda today. The United Kingdom implemented the plain tobacco packaging rule this month with France and Ireland set to follow suit this year. Clearly, tobacco packaging is a form of advertising and research has determined that glossy cigarette brand packaging makes smoking seem attractive and induces demand especially among impressionable young people. Last year, the Parliament of Uganda passed a Tobacco Control law which was assented to by President Museveni.The Tobacco Control Act(2015) provides for increasing the size of health warnings on tobacco packaging to provide for messages such as ''Smoking harms your health and those around you'' complete with graphic images illustrating tobacco-associated illnesses such as throat cancer. The Uganda Tobacco control law came into force on 19th May 2016 following a 6-months period since it was gazetted.At this year's World No Tobacco Day in Kampala, a ceremony has been organized to mark the coming into force of the new Tobacco control law. The Ministry of Health and CSO partners are in the process of passing regulations to give full effect to the Tobacco Control law to save the next generation of Ugandans. In Kenya, passage of the tobacco control law was greeted with law suits from the tobacco industry and in Uganda the industry is expected to follow a similar template. Johan Cruyff would not approve of such moves. His story is testimony to kind of lives the law seeks to protect in the first place.

Vergiss mein nicht: 'Forget me not' A German film review

An adult son takes a few days from work to visit his parents' home to relieve his caretaker father from the grueling task of looking after his 71 year old mother who has end-stage Alzheimer disease. From this simple plot flows an intimate family portrait of the effects of Alzheimer on a German family.On a more sophisticated level, Vergiss mein nicht, which is German for 'Forget me not' is a introspective tale of mortality and human transition and how we negotiate this journey in the intersection of a family setting. We see first hand how a elderly woman loses her memory to the point of being unable to tell the difference between her own husband of 30 years her adult son. The pain of being forgotten in an instant by a loved out of mental disability brought on from an advanced disease couldn't be more stark. The almost complete memory loss by the filmaker's mother, except for a few flickers of memory such as being able to recognise her father, tell an intimate story of the struggle of a family to come to terms with a mother who can longer identify the closest people in her life or even recall the use of the most basic domestic tools. A painful moment in the film shows the filmaker's mother being told how to use a fork to pick on a tomato in a food bowl. The films provides some rich background of the filmaker's mother when she was a very pretty, young, politically-active wife of a young German mathematics lecturer in Zurich, Switzerland flashbacks from the 1960s and 1970s and cuts to the image of an elderly woman suffering from dementia who is much more at ease in sleep than awake with the inevitable outcome all but clear. The story touches on the interesting subject of monogamy in married unions. We learn from the filmaker's narration that her mother and father agreed on an 'open' relationship where they allowed each other to see other people when they were a young idealistic couple. From the woman's long-kept diary we learn she wasnt as tolerant of this open union as she let on. The unfairness of fates comes into play when we learn that 71-year old woman's mother in law (who is several years older) appears in better command of her physical and (certainly)mental faculties her being in a retirement home notwithstanding. The family debates whether to institutionalize their mother or to look after her at home with some very painful moral choices. Vergiss mein nicht will make you cry and laugh at the same time.

Intriguing perspective from Alex de Waal-' A social science in Africa Fit for Purpose'

Alex de Waal A Social Science in Africa Fit for Purpose Introduction In this presentation I will argue that African scholarship on Africa is operating at only a fraction of its true potential, and that it is hampered by the preferences, policies and politics of the western academy. I will make three major points. First, the state of knowledge about African economics and politics is poor because in the higher reaches of the western academies, the focus is not on generating accurate information, but on inferring causal associations at a high level of abstraction, from datasets. And that those datasets are in fact far too weak for any such conclusions to be drawn. Second, the structure of academic rewards and careers systematically disadvantages those who either do not have the skills or capacities for this kind of high-end quantitative endeavor (although it is profoundly flawed), or have serious misgivings about it. One result of this is a severe dissonance between actual lived experience, and academic work validated by the academy. Third is what I call ‘Occidentalism’ in theory and policy. Occidentalism is the variant of Orientalism, it is the tendency to ascribe a cogency to the intellectual and cultural products of the west, that it does not in fact possess. Despite sustained critique by historians and anthropologists, the western experience of state formation remains the standard against which the rest of the world is indexed. African Data There’s a long-standing joke that 87.7% of Sudanese statistics are made up on the spot. This is not a laughing matter. Too much social scientific ‘fact’ about Africa is actually fiction because it is not based on real data. We are all familiar with the way in which a foreign researcher relates to his or her research assistant. It can be mutually respectful, or it can be exploitative. Fundamentally it is unequal. It corresponds to the designation of knowledge as either ‘expert’ or ‘local knowledge’. Let me give three examples of how this is reflected at a macro level to the detriment of both scholarship and policy. First, macroeconomics. I highly recommend a recent book by Morten Jerven: Africa: Why Economists Get it Wrong. His starting point is that the economic data used for the study of African econometrics are highly unreliable. Econometricians have tried to compensate for this deficiency by using sophisticated statistical techniques. This cannot legitimately be done. Much of African econometrics is simply a vast exercise in garbage in, garbage out. For example, economists have spent much time and effort trying to explain the supposed African chronic growth deficit. They take governance data from the late 1990s or early 2000s and use it to try to explain why Africa grew more slowly than the global average over the last fifty years. But, as Morten points out, cause should come first and, effect later. Because of lack of data—and lack of awareness of the deficits of the data—econometricians have made a simple error. They are trying to explain something that didn’t actually happen. Africa’s chronic growth deficit didn’t happen. What happened—as everyone who lived in the continent knows—was that African economies grew in the 1960s and early 70s, stalled in the 1980s and early 1990s, then grew again, albeit in a different fashion. Africa’s story isn’t one of chronic slow growth, but of boom, bust and boom again. There was a time-specific economic crisis—deeper and more protracted in Africa than elsewhere in the world—and that is what needs to be explained. The dominant feature of African economies is their extremely high sensitivity to global economic conditions. That conclusion would lead to radically different economic policy prescriptions at the World Bank and other international financial institutions and donors. My second example concerns wars. Everyone knows that there are no inter-state conflicts in Africa, only internal wars. Look at the databases of the Correlates of War and UCDP/PRIO databases: they have zeroes for the number of inter-state wars in Africa for most years. So there is an academic industry explaining civil wars, and why state formation has not needed to worry about borders. So the policy requirement is internal governance not inter-state relations. But hold on a moment. Anyone who follows politics and conflict knows this is false. Countries regularly invade one another, or have border conflicts, or sponsor proxies to fight against their neighbors. In the Horn of Africa alone I have enumerated 35 of these conflicts over the last 55 years. If we expand the dataset to include conflicts across borders among their immediate neighbors too the number goes up to 92. Once again, political science is trying to explain something that didn’t happen. A third example is from politics, namely governance indicators and failed/fragile states index. Did anyone notice how Mali still performed on the Failed States Index even while it fell apart during 2011-12? We all know the story of that period: Mali faced a near-perfect storm of corruption and institutional collapse at the center that left the state eviscerated and penetrated by international drug trafficking cartels, with parts of its territory surrendered—with state complicity—to criminal gangs and Al Qa’ida in the Islamic Maghreb, which avowed extremist and separatist agendas. A military coup by a junior officer and the near total evaporation of state authority followed, leading to first a rescue plan by neighboring African countries, quickly overtaken by a French military intervention, which despite some battlefield successes, became bogged down in an intractable conflict. There are datasets and indices specially designed to predict such crises. Specialists on Mali certainly predicted the crisis, in some detail. But if we turn to the most prominent of these measures, the Foreign Policy/Fund for Peace index of failed states, and turn to the data published in 2012—the year the crisis struck, based on the values of the indicators as they stood in 2011, we note something quite striking. The index ranks countries in reverse order: head of the list at number one is Somalia, and 191st out of 191 is Finland. In 2012, Mali stood at number 78, more or less the same as India and China. In the 2013 index, Mali came crashing up this list, reaching 39. But still it barely reaches into the quintile of the most at-risk states, assessed as far more stable than, for example, Ethiopia (ranked at 19). We may have concerns about Ethiopia’s human rights record, but few would dispute that it should rank as a far more effective and stable state than Mali. Where is the ‘real politics’ of political management in all this? African scholars first destination is history or political ethnography: documenting what actually happens. This is vital but grossly undervalued. It is done principally by country experts working for think-tanks like the International Crisis Group and the Carnegie Endowment. For sure, these institutions do some superb analysis, and their senior staff can move into academic positions. But it is extraordinarily hard to build a career based on knowing what is really happening a country, especially if it happens to be your own country. What Knowledge is Valued The structure of academic careers is in need of serious attention and reform. We are all familiar with the biases in academic reward and promotion, that undervalues teaching, and that rewards peer reviewed publication, biased towards high-ranking journals that prefer certain methodologies and questions. Those methods are typically quantitative, building beautiful castles in the air, or palaces on foundations of sand. This career structure marginalizes the African scholar. Supervisors in foreign universities rarely have the subject matter expertise and so tend to guide students towards more theoretical approaches. Examiners and peer reviewers likewise reward and reinforce their own disciplinary biases. On the other hand, it is common to see junior western scholars doing rather uninteresting quantitative studies, or superficial case studies, which they nonetheless are able to publish. This means that they thereby becoming the peer group that undertakes peer review. A lot of substandard material comes out, particularly on fashionable subjects. The African scholar of political science may be compelled to adopt a schizoid personality. In order to become an academic in a western university, she or he may be obliged to unlearn important knowledge, and learn frameworks and skills that are actually irrelevant to the situation at hand, but necessary for being considered a professional academic. Occidentalism in Theory and Practice "Occidentalism" is an inverse variant of Orientalism, which was western scholars’ exoticization of eastern (and by extension) African societies. It is the tendency to ascribe a cogency to the intellectual and cultural products of the west, that it does not in fact possess. Occidentalism persists in scholarship and in policy. One prime example of Occidentalism is the concept of ‘the state’. Despite the best attempts of historians and anthropologists to problematize this concept, it nonetheless carries with it a strong teleology: a one-way process of state formation and state-building. It is a process of turning robber barons to barons to constitutional government, moving from a traditional patronage-based political order toward a Weberian state, which means essentially an imitation of a north-west European state, or France, or the U.S.—all countries that established their modern statehood at the zenith of imperialism. The rise of Asia will challenge this for sure. We will see a diversity of destinations for the consolidation of governance, sharing only the common factor of international recognition. This diversity reflects the fact that the vernacular in most countries doesn’t contain a word for ‘state’—but rather for power, authority, government, the regime of the day, etc. It is the same in Africa: political vernaculars have words for many things, but if we are to talk about ‘states’ it must be in English or French, in the domain of scholarship or the practice of international law and international relations. Occidentalism also occurs in policy engagement. We shape our analysis to suit our audience, and end up speaking their language. Rather than evidence-based policy, we have policy-based evidence-making. The paradigm of this is engaging with western governments, the World Bank or the United Nations. Much of the policy-related discourse on good governance, post-conflict reconstruction, development, etc., takes place in a fantasy land that exists only in the minds of international civil servants. It is very welcome that we are here in Addis Ababa. The African Union has in important respects deviated from the standard international practices. But we need to guard against treating the African Union as just a regional institution under Chapter VIII of the UN Charter. The AU’s legitimacy derives from the extent to which it reflects the aspirations of the African people, not its juridical and financial relationship with international bodies outside Africa. The Need for an African Academy Everything I have said does not lessen the need for rigor. To the contrary, it is more difficult to produce first rate scholarship by being true to the realities of this continent, than it is to slot into the established track. Generating accurate data about African economies, African conflicts, and African political systems is hard. It is harder than pretending that the datasets that actually exist are good enough. It requires doing fieldwork, gathering information in a thorough and painstaking way. Writing and publishing good quality, fact-heavy accounts of African realities is also not easy. Detailed accounts of what is actually happening don’t fit neatly into 5,000-8,000 word journal articles, and the market for books is very small, so that there is not much chance of publishing the kinds of local histories or detailed political memoirs that are commonplace in Europe. Constructing frameworks for explaining how societies actually function, is intellectually demanding. It involves challenging the dominant frameworks and replacing them with better ones. I am confident that these things will happen, and as they do, that scholars in this continent will feel less divided between their real selves and their scholarly selves.

Intriguing perspective from Dr Alex De Waal-Full Length article

From Alex De Waal