5. Investigating Policy and System Change Over Time

India) clearly demonstrate how a range of different 5. Investigating policy decisions and interventions, taken at different times and and system change sometimes with unexpected consequences, accumulate over time to shape the current state and performance of over time health systems. At a household level, meanwhile, longitudinal work allows for the assessment of the Lucy Gilson impacts on livelihoods over time of, for example, health University of Cape Town, South Africa and London School seeking behaviour and the associated cost burdens. of Hygiene and Tropical Medicine, United Kingdom of Great Britain and Northern Ireland But how can change over time be tracked and investi- A considerable body of HPSR work focuses on experience gated? The range of possible approaches include at one point in time (see Part 4: Cross-sectional pers- prospective tracking of events, or phenomena, over time pectives) and studies investigating (describing and and retrospective analysis of past events and experiences. explaining) change over time are more rarely conducted. Historical research, for example, “is unusual in ... asking Yet health policy change and health system development, big questions and in dealing with change” (Berridge, around which many HPSR questions revolve, are pro- 2001:141) and these include “Why and how do we have cesses that occur over time. Therefore the contextual our current health systems? How and why do they differ influences over health policy and system experience are from the past?” or “How and for what reasons have commonly recognized to include historical factors. Health different health professions established their areas of systems never stop developing or evolving and past competence, and how have boundaries been establi- experience influences current development – perhaps by shed?” (Berridge, 2001:141–2). Drawing on documen- limiting or opening possibilities of future change. Indeed, tary, quantitative and oral sources of data, historical ‘path dependency’ is a notion widely applied in institu- work involves interpretive analysis of past experiences tional analysis that suggests that what happened in the and seeks to open up debates rather than to draw direct past directly influences, and limits, the possibilities of lessons. In contrast, fixed longitudinal study designs institutional change today (North, 1998). Policy analysis involve repeated measures on the same variables for the theory, meanwhile, recognizes that policy change is a same group, or groups, on an extended series of dynamic process evolving over considerable periods of occasions and may support prospective analysis of trends time. For example, punctuated equilibrium theory seeks over time (Robson, 2002). to explain how and why policy processes are characterized by largely incremental change for long periods of Rigour in studies of the time, remaining fairly stable, but occasionally producing dynamics of policy change large-scale departures from this pattern of change (True, Jones & Baumgartner, 2007). over time

Longitudinal perspectives are also particularly important The criteria for assessing the rigour and quality of studies in understanding the complex causality embedded in examining the dynamics of policy and system change processes of health policy and health systems change. At over time will vary with the disciplinary perspective or a system level, for example, a recently published volume research strategy adopted and must be appropriate for (Balabanova, McKee and Mills, 2011) demonstrates the the particular discipline and strategy (see also Part 2, and value of taking a long-term perspective in examining the sections in Part 4 relating to the case-study approach health system development. The country experiences and advances in impact evaluation). presented (for example from Thailand, Tamil Nadu and

Part 4 - Empirical Pape rs 317 References Overview of selected papers

Balabanova D, McKee M and Mills A, eds (2011) 'Good The papers in this section were chosen to illustrate some health at low cost' 25 years on. What makes a successful of the different approaches that can be used to investi- health system? London, London School of Hygiene and gate change over time in health policy and systems Tropical Medicine. experience. n Berridge V (2001). Historical research. In: Fulop N et al., Brown, Cueto & Fee (2006) address the changing role of the World Health Organization over time. eds. Studying the organisation and delivery of health Using an historical approach based on documentary services: research methods. London, Routledge:140–153. review, they argue that over time and in response to larger political and historical processes, the World North D (1998). Where have we been and where are we Health Organization has sought to reconstruct itself going? In: Ben-Ner A & Putterman L, eds. Economics, as the coordinator of global health initiatives, rather values and organizations. Cambridge, Cambridge than being the undisputed leader in international University Press:491–508. health. nCrichton (2008) traces the experience over time of a Robson C (2002). Real world research: a resource for particular Kenyan health policy, using the theoretical social scientists and practitioner-researchers, 2nd ed. lens of policy analysis and what is in essence a Oxford, Blackwell Publishing. process tracing approach.

Russell S (2005). Illuminating cases: understanding the nMasanja et al. (2008) use statistical trends, based on economic burden of illness through case study household epidemiological data, to support consideration of the performance of the Tanzanian health system and how research. Health Policy and Planning, 20(5):277–289. and why its development has impacted positively on True JL, Jones BD, Baumgartner FR (2007). Punctuated child survival. equilibrium theory: explaining stability and change in nVan Ginnekan, Lewin & Berridge (2010) use an public policymaking. In: Sabatier P, ed. Theories of the historical approach to examine the evolution over time of the South African community health worker policy process, 2nd ed. Cambridge MA, Westview programme, drawing on data collected through oral Press:155–188. histories and witness seminars.

See also: Russell & Gilson (2006) in the case-study approach section which reports on prospective studies of Sri Lankan case-study households in which change over time in household livelihoods was tracked and analysed, showing how these impacts were affected by the costs associated with seeking health care.

Wang et al. (2009) in the advances in impact evaluation section which reports a before and after, with control group, evaluation of the impact on health status of a community-based insurance scheme in China.

318 Gilson L, ed. (2012). Health Policy and Systems Research: A Methodology Reader Alliance for Health Policy and Systems Research, World Health Organization References for selected papers

Brown TM, Cueto M, Fee E (2006). The World Health Organization and the transition from ‘international’ to ‘global’ public health. American Journal of Public Health. January; 96(1):62–72. http://dx.doi.org/10.2105/AJPH.2004.050831 nReproduced by permission of the American Journal of Public Health. Copyright American Journal of Public Health, 2006.

Crichton J (2008). Changing fortunes: analysis of fluctuating policy space for family planning in Kenya. Health Policy and Planning, 23(5):339–350. http://dx.doi.org/10.1093/heapol/czn020 nReproduced by permission of the Oxford University Press. Copyright Oxford University Press, 2008.

Masanja H et al. (2008).Child survival gains in Tanzania: analysis of data from demographic and health surveys. The Lancet. 371:1276–83. http://dx.doi.org/10.1016/S0140-6736(08)60562-0 nReproduced by permission of Elsevier. Copyright Elsevier, 2008.

Van Ginneken N, Lewin S, Berridge S. (2010). The emergence of community health worker programmes in the late apartheid era in South Africa: an historical analysis. Social Science & Medicine, 71:1110–1118. http://dx.doi.org/10.1016/j.socscimed.2010.06.009 nReproduced by permission of Elsevier. Copyright Elsevier, 2010.

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The World Health Organization and the Transition From “InternationalInternational” to “Global” Public Health

| Theodore M. Brown, PhD, Marcos Cueto, PhD, and Elizabeth Fee, PhD The term “global health” is rapidly replacing the older terminology of “international health.” We describe the EVEN A QUICK GLANCE AT THE provide a critical analysis of the intergovernmental organizations role of the World Health Organization titles of books and articles in re- meaning, emergence, and signifi- and agencies—for example, the (WHO) in both international and global cent medical and public health cance of the term “global health” media, internationally influential health and in the transition from one to literature suggests that an impor- and to place its growing popular- foundations, nongovernmental the other. We suggest that the term tant transition is under way. The ity in a broader historical context. organizations, and transnational terms “global,” “globalization,” In particular, we focus on the role corporations. Logically, the terms “global health” emerged as part of and their variants are every- of the World Health Organization “international,” “intergovernmen- larger political and historical processes, where, and in the specific context (WHO) in both international and tal,” and “global” need not be mu- in which WHO found its dominant role of international public health, global health and as an agent in tually exclusive and in fact can be challenged and began to reposition “global” seems to be emerging as the transition from one concept understood as complementary. itself within a shifting set of power the preferred authoritative term.1 to the other. Thus, we could say that WHO is alliances. As one indicator, the number of Let us first define and differen- an intergovernmental agency that Between 1948 and 1998, WHO entries in PubMed under the tiate some essential terms. “Inter- exercises international functions moved from being the unquestioned rubrics “global health” and “international health” was already a with the goal of improving global leader of international health to being national health” shows that term of considerable currency in health. an organization in crisis, facing budget “global health” is rapidly on the the late 19th and early 20th cen- Given these definitions, it shortfalls and diminished status, rise, seemingly on track to over- tury, when it referred primarily to should come as no surprise that especially given the growing influence take “international health” in the a focus on the control of epi- global health is not entirely an in- near future (Table 1). Although demics across the boundaries vention of the past few years. The of new and powerful players. We argue universities, government agencies, between nations (i.e., “interna- term “global” was sometimes used that WHO began to refashion itself as and private philanthropies are all tional”). “Intergovernmental” well before the 1990s, as in the the coordinator, strategic planner, and using the term in highly visible refers to the relationships be- “global malaria eradication pro- leader of global health initiatives as a ways,2 the origin and meaning of tween the governments of sover- gram” launched by WHO in the strategy of survival in response to this the term “global health” are still eign nations—in this case, with re- mid-1950s; a WHO Public Affairs transformed international political unclear. gard to the policies and practices Committee pamphlet of 1958, context. (Am J Public Health. 2006;96: We provide historical insight of public health. “Global health,” The World Health Organization: Its 62–72. doi:10.2105/AJPH.2004.050831) into the emergence of the termi- in general, implies consideration Global Battle Against Disease3; a nology of global health. We be- of the health needs of the people 1971 report for the US House of lieve that an examination of this of the whole planet above the Representatives entitled The Poli- linguistic shift will yield important concerns of particular nations. tics of Global Health4; and many fruit, and not just information The term “global” is also associ- studies of the “global population about fashions and fads in lan- ated with the growing importance problem” in the 1970s.5 But the guage use. Our task here is to of actors beyond governmental or term was generally limited and its

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use in official statements and doc- dual aspect, one both promising hamstrung by financial constraints uments sporadic at best. Now and threatening. and internal incompetencies, frus- there is an increasing frequency In one respect, there was eas- trated by turf wars and cross- of references to global health.6 Yet ier diffusion of useful technolo- national policies.”9 Given these the questions remain: How many gies and of ideas and values such -realities, Yach and Bettcher’s pro- have participated in this shift in as human rights. In another, there motion of “global public health” terminology? Do they consider it were such risks as diminished so- while they were affiliated with trendy, trivial, or trenchant? cial safety nets; the facilitated WHO was, to say the least, in- Supinda Bunyavanich and marketing of tobacco, alcohol, triguing. Why were these spokes- Ruth B. Walkup tried to answer and psychoactive drugs; the eas- men for the much-criticized and these questions and published, ier worldwide spread of infec- apparently hobbled WHO so up- under the provocative title “US tious diseases; and the rapid beat about “global” public health? Public Health Leaders Shift To- degradation of the environment, ward a New Paradigm of Global with dangerous public health THE WORLD HEALTH “War on the Malaria Mosquito!” Health,” their report of conversa- consequences. But Yach and ORGANIZATION Poster produced by the Division of tions conducted in 1999 with 29 Bettcher were convinced that Public Information, World Health “international health leaders.”7 WHO could turn these risks into The Early Years Organization, Geneva, 1958. Courtesy of the World Health Their respondents fell into 2 opportunities. WHO, they ar- To better understand Yach and Organization. Source: Prints and groups. About half felt that there gued, could help create more effi- Bettcher’s role, and that of WHO Photographs Collection of the was no need for a new terminol- cient information and surveil- National Library of Medicine. ogy and that the label “global lance systems by strengthening its health” was meaningless jargon. global monitoring and alert sys- The other half thought that there tems, thus creating “global early were profound differences be- warning systems.” They believed tween international health and that even the most powerful na- global health and that “global” tions would buy into this new clearly meant something transna- globally interdependent world tional. Although these respon- system once these nations real- dents believed that a major shift ized that such involvement was in had occurred within the previous their best interest. few years, they seemed unable Despite the long list of prob- clearly to articulate or define it. lems and threats, Yach and In 1998, Derek Yach and Dou- Bettcher were largely uncritical as glas Bettcher came closer to cap- they promoted the virtues of turing both the essence and the global public health and the lead- origin of the new global health in ership role of WHO. In an edito- a 2-part article on “The Global- rial in the same issue of the Jour- ization of Public Health” in the nal, George Silver noted that Yach American Journal of Public and Bettcher worked for WHO Health.8 They defined the “new and that their position was similar paradigm” of globalization as “the to other optimistic stances taken process of increasing economic, by WHO officials and advocates. political, and social interdepend- But WHO, Silver pointed out, was ence and integration as capital, actually in a bad way: “The goods, persons, concepts, images, WHO’s leadership role has passed ideas and values cross state to the far wealthier and more in- boundaries.” The roots of global- fluential World Bank, and the ization were long, they said, going WHO’s mission has been dis- back at least to the 19th century, persed among other UN agen- but the process was assuming a cies.” Wealthy donor countries new magnitude in the late 20th were billions of dollars in arrears, century. The globalization of pub- and this left the United Nations lic health, they argued, had a and its agencies in “disarray,

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TABLE 1—Number of Articles Retrieved by PubMed, Using “International Health Organization, began its tionale d’Hygiène Publique, the Health” and “Global Health” as Search Terms, by Decade: 1950 work in 1920.13 This organiza- League of Nations Health Organi- Through July 2005 tion established its headquarters zation, and UNRRA merged into International Global in Geneva, sponsored a series of the new agency. The Pan Ameri- Decade Healtha Healtha international commissions on dis- can Sanitary Bureau—then eases, and published epidemio- headed by Fred L. Soper, a for- 1950s 1 007 54 logical intelligence and technical mer Rockefeller Foundation offi- 1960s 3 303 155 reports. The League of Nations cial—was allowed to retain au- 1970s 8 369 1 137 Health Organization was poorly tonomous status as part of a 1980s 16 924 7 176 budgeted and faced covert oppo- regionalization scheme.14 WHO 1990s 49 158 27 794 sition from other national and in- formally divided the world into a 2000–July 2005 52 169b 39 759b ternational organizations, includ- series of regions—the Americas, aPicks up variant term endings (e.g. “international” also picks up “internationalize” and “internationalization”; ing the US Public Health Service. Southeast Asia, Europe, Eastern “global” also picks up “globalize” and “globalization”). Despite these complications, Mediterranean, Western Pacific, bNumber for 55 months only. which limited the Health Organi- and Africa—but it did not fully more generally, it will be helpful zation ’s effectiveness, both the implement this regionalization to review the history of the or- Office Internationale d’Hygiène until the 1950s. Although an “in- ganization from 1948 to 1998, Publique and the Health Organi- ternational” and “intergovern- as it moved from being the un- zation survived through World mental” mindset prevailed in the questioned leader of international War II and were present at the 1940s and 1950s, naming the health to searching for its place in critical postwar moment when new organization the World the contested world of global the future of international health Health Organization also raised health. would be defined. sights to a worldwide, “global” WHO formally began in 1948, An international conference in perspective. when the first World Health As- 1945 approved the creation of The first director general of sembly in Geneva, Switzerland, the United Nations and also voted WHO, Brock Chisholm, was a ratified its constitution. The idea for the creation of a new special- Canadian psychiatrist loosely of a permanent institution for in- ized health agency. Participants at identified with the British social ternational health can be traced the meeting initially formed a medicine tradition. The United to the organization in 1902 of commission of prominent individ- States, a main contributor to the the International Sanitary Office uals, among whom were René WHO budget, played a contradic- of the American Republics, Sand from Belgium, Andrija Stam- tory role: on the one hand, it sup- which, some decades later, be- par from Yugoslavia, and Thomas ported the UN system with its came the Pan American Sanitary Parran from the United States. broad worldwide goals, but on Bureau and eventually the Pan Sand and Stampar were widely the other, it was jealous of its sov- American Health Organization.10 recognized as champions of social ereignty and maintained the right The Rockefeller Foundation, es- medicine. The commission held to intervene unilaterally in the pecially its International Health meetings between 1946 and Americas in the name of national Division, was also a very signifi- early 1948 to plan the new inter- security. Another problem for cant player in international health national health organization. Rep- WHO was that its constitution in the early 20th century.11 resentatives of the Pan American had to be ratified by nation states, Two European-based interna- Sanitary Bureau, whose leaders a slow process: by 1949, only 14 tional health agencies were also resisted being absorbed by the countries had signed on.15 important. One was the Office In- new agency, were also involved, As an intergovernmental ternationale d’Hygiène Publique, as were leaders of new institu- agency, WHO had to be respon- which began functioning in Paris tions such as the United Nations sive to the larger political environ- in 1907; it concentrated on sev- Relief and Rehabilitation Adminis- ment. The politics of the Cold eral basic activities related to the tration (UNRRA). War had a particular salience, administration of international Against this background, the with an unmistakable impact on sanitary agreements and the first World Health Assembly met WHO policies and personnel. rapid exchange of epidemiologi- in Geneva in June 1948 and for- Thus, when the Soviet Union and cal information.12 The second mally created the World Health other communist countries agency, the League of Nations Organization. The Office Interna- walked out of the UN system and

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therefore out of WHO in 1949, modernization with limited so- He argued that it was now scien- the United States and its allies cial reform.18 tifically feasible, socially desir- were easily able to exert a domi- With the return of the Soviet able, and economically worth- nating influence. In 1953, Union and other communist while to attempt to eradicate Chisholm completed his term as countries in 1956, the political smallpox worldwide.19 The Soviet director general and was replaced balance in the World Health As- Union wanted to make its mark by the Brazilian Marcolino Can- sembly shifted and Candau ac- on global health, and Candau, dau. Candau, who had worked commodated the changed bal- recognizing the shifting balance under Soper on malaria control in ance of power. During the 1960s, of power, was willing to cooper- Brazil, was associated first with malaria eradication was facing se- ate. The Soviet Union and Cuba the “vertical” disease control pro- rious difficulties in the field; ulti- agreed to provide 25 million and grams of the Rockefeller Founda- mately, it would suffer colossal 2 million doses of freeze-dried tion and then with their adoption and embarrassing failures. In vaccine, respectively; in 1959, by the Pan American Sanitary Bu- 1969, the World Health Assem- the World Health Assembly com- reau when Soper moved to that bly, declaring that it was not feasi- mitted itself to a global smallpox agency as director.16 Candau ble to eradicate malaria in many eradication program. would be director general of parts of the world, began a slow In the 1960s, technical im- WHO for over 20 years. From process of reversal, returning once provements—jet injectors and bi- 1949 until 1956, when the Soviet again to an older malaria control furcated needles—made the proc- Union returned to the UN and agenda. This time, however, there ess of vaccination much cheaper, WHO, WHO was closely allied was a new twist; the 1969 assem- easier, and more effective. The with US interests. bly emphasized the need to de- United States’ interest in smallpox In 1955, Candau was charged velop rural health systems and to eradication sharply increased; in with overseeing WHO’s cam- integrate malaria control into gen- 1965, Lyndon Johnson instructed paign of malaria eradication, ap- eral health services. the US delegation to the World proved that year by the World When the Soviet Union re- Health Assembly to pledge Smallpox Vaccination Program Health Assembly. The ambitious turned to WHO, its representa- American support for an interna- in Togo, 1967. Courtesy of the goal of malaria eradication had tive at the assembly was the national program to eradicate small- Centers for Disease Control and been conceived and promoted in tional deputy minister of health. pox from the earth.20 At that Prevention. Source: Public Health the context of great enthusiasm Image Library, CDC. and optimism about the ability of widespread DDT spraying to kill mosquitoes. As Randall Packard has argued, the United States and its allies believed that global malaria eradication would usher in economic growth and create overseas markets for US technology and manufactured goods.17 It would build support for local governments and their US supporters and help win “hearts and minds” in the battle against Communism. Mirroring then-current development theories, the campaign promoted technologies brought in from outside and made no attempt to enlist the participation of local populations in planning or implementation. This model of development assistance fit neatly into US Cold War efforts to promote

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time, despite a decade of marked interests of international players, the 1950s, with the civil rights progress, the disease was still en- the intellectual and ideological movement and other social demic in more than 30 countries. commitments of key individuals, movements forcing changes in In 1967, now with the support and the way that all of these national priorities. of the world’s most powerful factors interact with the health This changing political envi- players, WHO launched the policymaking process. ronment was reflected in corre- Intensified Smallpox Eradication During the 1960s and 1970s, sponding shifts within WHO. In Program. This program, an inter- changes in WHO were signifi- the 1960s, WHO acknowledged national effort led by the Ameri- cantly influenced by a political that a strengthened health infra- can Donald A. Henderson, context marked by the emer- structure was prerequisite to the would ultimately be stunningly gence of decolonized African na- success of malaria control pro- successful.21 tions, the spread of nationalist grams, especially in Africa. In and socialist movements, and 1968, Candau called for a com- The Promise and Perils of new theories of development prehensive and integrated plan Primary Health Care, that emphasized long-term socio- for curative and preventive care 1973–1993 economic growth rather than services. A Soviet representative Within WHO, there have al- short-term technological inter- called for an organizational study ways been tensions between so- vention. Rallying within organiza- of methods for promoting the de- cial and economic approaches to tions such as the Non-Aligned velopment of basic health serv- population health and technology- Movement, developing countries ices.23 In January 1971, the Exec- or disease-focused approaches. created the UN Conference utive Board of the World Health These approaches are not neces- on Trade and Development Assembly agreed to undertake sarily incompatible, although (UNCTAD), where they argued this study, and its results were they have often been at odds. vigorously for fairer terms of presented to the assembly in The emphasis on one or the trade and more generous financ- 1973.24 Socrates Litsios has dis- Alma Ata Conference, 1978. other waxes and wanes over ing of development.22 In Wash- cussed many of the steps in the Courtesy of the Pan American time, depending on the larger ington, DC, more liberal politics transformation of WHO’s ap- Health Organization. Source: Office of Public Information, PAHO. balance of power, the changing succeeded the conservatism of proach from an older model of health services to what would become the “Primary Health Care” approach.25 This new model drew upon the thinking and experiences of nongovernmental organizations and medical mis- sionaries working in Africa, Asia, and Latin America at the grass- roots level. It also gained saliency from China’s reentry into the UN in 1973 and the widespread interest in Chinese “barefoot doctors,” who were reported to be transforming rural health conditions. These experiences underscored the urgency of a “Primary Health Care” perspective that included the training of community health workers and the resolution of basic economic and environmental problems.26 These new approaches were spearheaded by Halfdan T. Mahler, a Dane, who served as director general of WHO from

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1973 to 1988. Under pressure the World Bank, the vice presi- from the Soviet delegate to the dent of the Ford Foundation, the The Declaration of Primary Health Care executive board, Mahler agreed administrator of USAID, and the and the goal of “Health for All in the Year to hold a major conference on executive secretary of UNICEF.30 the organization of health serv- The Bellagio meeting focused 2000” advocated an “inter-sectoral” and ices in Alma-Ata, in the Soviet on an alternative concept to that “ multidimensional approach to health Union. Mahler was initially reluc- articulated at Alma-Ata—“Selec- and socioeconomic development, emphasized tant because he disagreed with tive Primary Health Care”—which the Soviet Union’s highly central- was built on the notion of prag- the use of “appropriate technology,” and ized and medicalized approach to matic, low-cost interventions that urged active community participation in health the provision of health services.27 were limited in scope and easy to care and health education at every level. The Soviet Union succeeded in monitor and evaluate. Thanks hosting the September 1978 con- primarily to UNICEF, Selective ference, but the conference itself Primary Health Care was soon growth, thus providing a good ar- reflected Mahler’s views much operationalized under the gument for social sector spend- ” more closely than it did those acronym “GOBI” (Growth moni- ing. As the Bank began to make of the Soviets. The Declaration of toring to fight malnutrition in direct loans for health services, it Primary Health Care and the children, Oral rehydration tech- called for more efficient use of goal of “Health for All in the niques to defeat diarrheal dis- available resources and discussed Year 2000” advocated an “inter- eases, Breastfeeding to protect the roles of the private and public sectoral” and multidimensional children, and Immunizations).31 sectors in financing health care. approach to health and socioeco- In the 1980s, WHO had to The Bank favored free markets nomic development, emphasized reckon with the growing influ- and a diminished role for na- the use of “appropriate technol- ence of the World Bank. The tional governments.34 In the con- ogy,” and urged active commu- bank had initially been formed in text of widespread indebtedness nity participation in health care 1946 to assist in the reconstruc- by developing countries and in- and health education at every tion of Europe and later ex- creasingly scarce resources for level.28 panded its mandate to provide health expenditures, the World David Tejada de Rivero has ar- loans, grants, and technical assis- Bank’s promotion of “structural gued that “It is regrettable that af- tance to developing countries. At adjustment” measures at the very terward the impatience of some first, it funded large investments time that the HIV/AIDS epi- international agencies, both UN in physical capital and infrastruc- demic erupted drew angry criti- and private, and their emphasis ture; in the 1970s, however, it cism but also underscored the on achieving tangible results in- began to invest in population con- Bank’s new influence. stead of promoting change . . . led trol, health, and education, with In contrast to the World to major distortions of the original an emphasis on population con- Bank’s increasing authority, in concept of primary health care.”29 trol.32 The World Bank approved the 1980s the prestige of WHO A number of governments, agen- its first loan for family planning was beginning to diminish. One cies, and individuals saw WHO’s in 1970. In 1979, the World sign of trouble was the 1982 idealistic view of Primary Health Bank created a Population, vote by the World Health Care as “unrealistic” and unattain- Health, and Nutrition Depart- Assembly to freeze WHO’s able. The process of reducing ment and adopted a policy of budget.35 This was followed Alma-Ata’s idealism to a practical funding both stand-alone health by the 1985 decision by the set of technical interventions that programs and health components United States to pay only 20% could be implemented and mea- of other projects. of its assessed contribution to all sured more easily began in 1979 In its 1980 World Development UN agencies and to withhold its at a small conference—heavily in- Report, the Bank argued that both contribution to WHO’s regular fluenced by US attendees and malnutrition and ill health could budget, in part as a protest policies—held in Bellagio, Italy, be countered by direct govern- against WHO’s “Essential Drug and sponsored by the Rockefeller ment action—with World Bank Program,” which was opposed Foundation, with assistance from assistance.33 It also suggested that by leading US-based pharma- the World Bank. Those in atten- improving health and nutrition ceutical companies.36 These dance included the president of could accelerate economic events occurred amidst growing

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tensions between WHO and reliance on WHO’s “regular assessment: “WHO is caught in a UNICEF and other agencies budget”—drawn from member cycle of decline, with donors ex- and the controversy over Selec- states’ contributions on the basis pressing their lack of faith in its tive versus Comprehensive Pri- of population size and gross na- central management by placing mary Health Care. As part of a tional product—to greatly in- funds outside the management’s rancorous public debate con- creased dependence on extrabud- control. This has prevented ducted in the pages of Social getary funding coming from WHO from [developing] . . . inte- Science and Medicine in 1988, donations by multilateral agen- grated responses to countries’ Kenneth Newell, a highly placed cies or “donor” nations.39 By the long term needs.”41 WHO official and an architect period 1986–1987, extrabud- In the late 1980s and early of Comprehensive Primary getary funds of $437 million had 1990s, the World Bank moved Health Care, called Selective Pri- almost caught up with the regular confidently into the vacuum cre- mary Health Care a “threat . . . budget of $543 million. By the ated by an increasingly ineffec- [that] can be thought of as a beginning of the 1990s, extra- tive WHO. WHO officials were counter-revolution.”37 budgetary funding had overtaken unable or unwilling to respond to In 1988, Mahler’s 15-year the regular budget by $21 mil- the new international political tenure as director general of lion, contributing 54% of WHO’s economy structured around ne- WHO came to an end. Unexpect- overall budget. oliberal approaches to economics, edly, Hiroshi Nakajima, a Japanese Enormous problems for the or- trade, and politics.42 The Bank researcher who had been director ganization followed from this maintained that existing health of the WHO Western Pacific Re- budgetary shift. Priorities and systems were often wasteful, inef- gional Office in Manila, was policies were still ostensibly set ficient, and ineffective, and it ar- elected new director general.38 by the World Health Assembly, gued in favor of greater reliance which was made up of all mem- on private-sector health care pro- Crisis at WHO, 1988–1998 ber nations. The assembly, how- vision and the reduction of public The first citizen of Japan ever ever, now dominated numerically involvement in health services elected to head a UN agency, by poor and developing coun- delivery.43 Nakajima rapidly became the tries, had authority only over the Controversies surrounded the most controversial director gen- regular budget, frozen since the World Bank’s policies and prac- eral in WHO’s history. His nomi- early 1980s. Wealthy donor na- tices, but there was no doubt that, nation had not been supported tions and multilateral agencies by the early 1990s, it had be- by the United States or by a like the World Bank could largely come a dominant force in interna- number of European and Latin call the shots on the use of the tional health. The Bank’s greatest American countries, and his per- extrabudgetary funds they con- “comparative advantage” lay in its formance in office did little to as- tributed. Thus, they created, in ability to mobilize large financial suage their doubts. Nakajima did effect, a series of “vertical” pro- resources. By 1990, the Bank’s try to launch several important grams more or less independent loans for health surpassed WHO’s initiatives—on tobacco, global of the rest of WHO’s programs total budget, and by the end of disease surveillance, and and decisionmaking structure. 1996, the Bank’s cumulative public–private partnerships— The dilemma for the organization lending portfolio in health, nutri- but fierce criticism persisted that was that although the extrabud- tion, and population had reached raised questions about his auto- getary funds added to the overall $13.5 billion. Yet the Bank recog- cratic style and poor manage- budget, “they [increased] difficul- nized that, whereas it had great ment, his inability to communities of coordination and continu- economic strengths and influence, cate effectively, and, worst of all, ity, [caused] unpredictability in fi- WHO still had considerable tech- cronyism and corruption. nance, and a great deal of nical expertise in matters of Another symptom of WHO’s dependence on the satisfaction of health and medicine. This was problems in the late 1980s was particular donors,”40 as Gill Walt clearly reflected in the Bank’s the growth of “extrabudgetary” explained. widely influential World Develop- funding. As Gill Walt of the Lon- Fiona Godlee published a se- ment Report, 1993: Investing in don School of Hygiene and Tropi- ries of articles in 1994 and 1995 Health, in which credit is given to cal Medicine noted, there was a that built on Walt’s critique.41 WHO, “a full partner with the crucial shift from predominant She concluded with this dire World Bank at every step of the

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preparation of the Report.”44 Cir- cumstances suggested that it was to the advantage of both parties for the World Bank and WHO to work together.

WHO EMBRACES “GLOBAL HEALTH”

This is the context in which WHO began to refashion itself as a coordinator, strategic planner, and leader of “global health” initiatives. In January 1992, the 31-member Executive Board of the World Health Assembly decided to appoint a “working group” to recommend how WHO could be most effective in Current Director General Jong-wook international health work in light for analyses of “global health Diseases: A Strategy for the 21st Lee with three former Directors- of the “global change” rapidly interdependence.”47 In the same Century appeared, followed in General at the celebration to overtaking the world. The execu- year, Milton and Ruth Roemer 2001 by the Institute of Medi- mark the 25th Anniversary of the Alma Ata Declaration. From left: tive board may have been re- argued that further improvements cine’s Perspectives on the Depart- G. H. Brundtland, H. Mahler, sponding, in part, to the Chil- in “global health” would be de- ment of Defense Global Emerging H. Nakajima, Lee JW. Courtesy of dren’s Vaccine Initiative, pendent on the expansion of pub- Infections Surveillance and Re- the World Health Organization. perceived within WHO as an at- lic rather than private health sponse System.52 Best-selling Source: Media Center, WHO. tempted “coup” by UNICEF, the services.48 Another strong source books and news magazines were World Bank, the UN Develop- for the term “global health” was full of stories about Ebola and ment Program, the Rockefeller the environmental movement, es- West Nile virus, resurgent tuber- Foundation, and several other pecially debates over world envi- culosis, and the threat of bioter- players seeking to wrest control ronmental degradation, global rorism.53 The message was clear: of vaccine development.45 The warming, and their potentially there was a palpable global dis- working group’s final report of devastating effects on human ease threat. May 1993 recommended that health.49 In 1998, the World Health WHO—if it was to maintain lead- In the mid-1990s, a consider- Assembly reached outside the ership of the health sector—must able body of literature was pro- ranks of WHO for a new leader overhaul its fragmented manage- duced on global health threats. In who could restore credibility to ment of global, regional, and the United States, a new Centers the organization and provide it country programs, diminish the for Disease Control and Preven- with a new vision: Gro Harlem competition between regular and tion (CDC) journal, Emerging In- Brundtland, former prime minis- extrabudgetary programs, and, fectious Diseases, began publica- ter of Norway and a physician above all, increase the emphasis tion, and former CDC director and public health professional. within WHO on global health is- William Foege started using the Brundtland brought formidable sues and WHO’s coordinating phrase “global infectious disease expertise to the task. In the role in that domain.46 threats.”50 In 1997, the Institute 1980s, she had been chair of the Until that time, the term of Medicine’s Board of Interna- UN World Commission on Envi- “global health” had been used tional Health released a report, ronment and Development and sporadically and, outside WHO, America’s Vital Interest in Global produced the “Brundtland Re- usually by people on the political Health: Protecting Our People, port,” which led to the Earth left with various “world” agendas. Enhancing Our Economy, and Summit of 1992. She was familiar In 1990, G. A. Gellert of Interna- Advancing Our International with the global thinking of the en- tional Physicians for the Preven- Interests.51 In 1998, the CDC’s vironmental movement and had a tion of Nuclear War had called Preventing Emerging Infectious broad and clear understanding of

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the links between health, environ- eases in the world’s poorest na- from a narrow emphasis on Requests for reprints should be sent to ment, and development.54 tions, mainly through vaccines malaria eradication to a broader Elizabeth Fee, PhD, History of Medicine 58 Division, National Library of Medicine, Brundtland was determined to and immunization programs. interest in the development of 8600 Rockville Pike, Bethesda, MD position WHO as an important Within a few years, some 70 health services and the emerging 20974 (e-mail: elizabeth_fee@ player on the global stage, move “global health partnerships” had concentration on smallpox eradi- nlm.nih.gov). This article was accepted January 11, beyond ministries of health, and been created. cation. In the 1970s and 1980s, 2005. gain a seat at the table where de- Brundtland’s tenure as director WHO developed the concept of 55 cisions were being made. She general was not without blemish Primary Health Care but then Contributors wanted to refashion WHO as a nor free from criticism. Some of turned from zealous advocacy to All authors contributed equally to the re- “department of consequence”55 the initiatives credited to her ad- the pragmatic promotion of Se- search and writing. able to monitor and influence ministration had actually been lective Primary Health Care as other actors on the global scene. started under Nakajima (for ex- complex changes overtook intra- Acknowledgments She established a Commission on ample, the WHO Framework and interorganizational dynam- The authors are grateful to the Joint Learning Initiative of the Rockefeller Macroeconomics and Health, Convention on Tobacco Control), ics and altered the international Foundation, which initially commis- chaired by economist Jeffrey Sachs others may be looked upon today economic and political order. In sioned this article, and to the Global of Harvard University and includ- with some skepticism (the Com- the 1990s, WHO attempted to Health Histories Initiative of the World Health Organization, which has provided ing former ministers of finance mission on Macroeconomics and use leadership of an emerging a supportive environment for continuing and officers from the World Bank, Health, Roll Back Malaria), and concern with “global health” as our research. the International Monetary Fund, still others arguably did not re- an organizational strategy that the World Trade Organization, ceive enough attention from her promised survival and, indeed, References and the UN Development Pro- administration (Primary Health renewal. 1. A small sampling of recent titles: gram, as well as public health Care, HIV/AIDS, Health and But just as it did not invent David L. Heymann and G. R. Rodier, leaders. The commission issued a Human Rights, and Child Health). the eradicationist or primary “Global Surveillance of Communicable Diseases,” Emerging Infectious Diseases report in December 2001, which Nonetheless, few would dispute care agendas, WHO did not in- 4 (1998): 362–365; David Wood- argued that improving health in the assertion that Brundtland suc- vent “global health”; other, ward, Nick Drager, Robert Beaglehole, developing countries was essential ceeded in achieving her principal larger forces were responsible. and Debra Lipson, “Globalization and 56 Health: A Framework for Analysis and to their economic development. objective, which was to reposition WHO certainly did help pro- Action,” Bulletin of the World Health The report identified a set of dis- WHO as a credible and highly mote interest in global health Organization 79 (2001): 875–881; ease priorities that would require visible contributor to the rapidly and contributed significantly to Gill Walt, “Globalisation of Interna- tional Health,” The Lancet 351 (Febru- focused intervention. changing field of global health. the dissemination of new con- ary 7, 1998): 434–437; Stephen J. Brundtland also began to cepts and a new vocabulary. In Kunitz, “Globalization, States, and the strengthen WHO’s financial posi- CONCLUSION that process, it was hoping to ac- Health of Indigenous Peoples,” Ameri- can Journal of Public Health 90 (2000): tion, largely by organizing “global quire, as Yach and Bettcher sug- 1531–1539; Health Policy in a Global- partnerships” and “global funds” We can now return briefly to gested in 1998, a restored coor- ising World, ed. Kelley Lee, Kent Buse, to bring together “stakeholders”— the questions implied at the be- dinating and leadership role. and Suzanne Fustukian (Cambridge, England: Cambridge University Press, private donors, governments, and ginning of this article: how does Whether WHO’s organizational 2002). bilateral and multilateral agen- a historical perspective help us repositioning will serve to 2. For example, Yale has a Division of cies—to concentrate on specific understand the emergence of the reestablish it as the unques- Global Health in its School of Public targets (for example, Roll Back terminology of “global health” tioned steward of the health of Health, Harvard has a Center for Health and the Global Environment, and the Malaria in 1998, the Global Al- and what role did WHO play as the world’s population, and how London School of Hygiene and Tropical liance for Vaccines and Immu- an agent in its development? this mission will be effected in Medicine has a Center on Global nization in 1999, and Stop TB in The basic answers derive from practice, remains an open ques- Change and Health; the National Insti- tutes of Health has a strategic plan on ■ 2001). These were semiau- the fact that WHO at various tion at this time. Emerging Infectious Diseases and Global tonomous programs bringing in times in its history alternatively Health; Gro Harlem Brundtland ad- substantial outside funding, often led, reflected, and tried to ac- dressed the 35th Anniversary Sympo- About the Author sium of the John E. Fogarty Interna- in the form of “public–private commodate broader changes Theodore M. Brown is with the Department tional Center on “Global Health: A partnerships.”57 A very significant and challenges in the ever- of History and the Department of Commu- Challenge to Scientists” in May 2003; player in these partnerships was shifting world of international nity and Preventive Medicine, University of the Centers of Disease Control and Pre- Rochester, Rochester, NY. Marcos Cueto is vention has established an Office of the Bill & Melinda Gates Founda- health. In the 1950s and 1960s, with the Facultad de Salud Pública, Uni- Global Health and has partnered with tion, which committed more than when changes in biology, eco- versidad Peruana Cayetano Heredia, Lima, the World Health Organization (WHO), $1.7 billion between 1998 and nomics, and great power politics Peru. Elizabeth Fee is with the History of the World Bank, UNICEF, the US Medicine Division, National Library of Agency for International Development, 2000 to an international pro- transformed foreign relations Medicine, National Institutes of Health, and others in creating Global Health gram to prevent or eliminate dis- and public health, WHO moved Bethesda, Md. Partnerships.

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3. Albert Deutsch, The World Health Retrospective Memoir,” Perspectives in World Health Organization 76 (1998): 114–140. UNICEF was created in 1946 Organization: Its Global Battle Against Biology and Medicine 11 (1968): 233–235; Donald A. Henderson, “Erad- to assist needy children in Europe’s war Disease (New York: Public Affairs Com- 273–285. ication: Lessons From the Past,” Bulletin ravaged areas. After the emergency mittee, 1958). 13. Frank G. Bourdreau, “International of the World Health Organization 76 ended, it broadened its mission and con- 4. Randall M. Packard, “ ‘No Other Health,” American Journal of Public (Supplement 2) (1998): 17–21; Frank centrated resources on the needs of chil- Logical Choice’: Global Malaria Eradica- Health and the Nation’s Health 19 Fenner, Donald A. Henderson, Issao dren in developing countries. Arita, Zdenek Jevek, and Ivan Dali- tion and the Politics of International (1929): 863–878; Bourdreau, “Interna- 31. UNICEF, The State of the World’s novich Ladnyi, Smallpox and its Eradica- Health in the Post-War Era,” Parassitolo- tional Health Work,” in Pioneers in Children: 1982/1983 (New York: Oxford tion (Geneva: WHO, 1988). gia 40 (1998): 217–229, and The Poli- World Order: An American Appraisal of University Press, 1983). See also Cueto, tics of Global Health, Prepared for the the League of Nations, ed. Harriet Eager 22. The New International Economic “Origins of Primary Health Care.” Subcommittee on National Security Policy Favis (New York: Columbia University Order: The North South Debate, ed. 32. Jennifer Prah Ruger, “The Chang- and Scientific Developments of the Com- Press, 1944), 193–207; Norman Jagdish N. Bhagwati (Cambridge, Mass: ing Role of the World Bank in Global mittee on Foreign Affairs, US House of Howard-Jones, International Public Health MIT Press, 1977); Robert L. Rothstein, Health in Historical Perspective,” Ameri- Representatives (Washington, DC: US Between the Two World Wars: The Orga- Global Bargaining: UNCTAD and the can Journal of Public Health 95 (2005): Government Printing Office, 1971). nizational Problems (Geneva: WHO, Quest for a New International Economic 60–70. 5. For example, T W. Wilson, World 1978); Martin David Dubin, “The Order (Princeton, NJ: Princeton Univer- Population and a Global Emergency League of Nations Health Organisation,” sity Press, 1979). 33. World Development Report 1980 (Washington, DC: Aspen Institute for in International Health Organisations and 23. Socrates Litsios, “The Long and (Washington, DC: World Bank, 1980). Movements, 1918–1939, ed. Paul Wein- Humanistic Studies, Program in Environ- Difficult Road to Alma-Ata: A Personal 34. Financing Health Services in Devel- dling (Cambridge, England: Cambridge ment and Quality of Life, 1974). Reflection,” International Journal of oping Countries: An Agenda for Reform University Press, 1995), 56–80. 6. James E. Banta, “From Interna- Health Services 32 (2002): 709–732. (Washington, DC: World Bank, 1987). 14. Thomas Parran, “The First 12 tional to Global Health,” Journal of Com- 24. Executive Board 49th Session, 35. Fiona Godlee, “WHO in Retreat; Is Years of WHO,” Public Health Reports munity Health 26 (2001): 73–76. WHO document EB49/SR/14 Rev It Losing Its Influence?” British Medical 73 (1958): 879–883; Fred L. Soper, (Geneva: WHO, 1973), 218; Organiza- Journal 309 (1994): 1491–1495. 7. Supinda Bunyavanich and Ruth B. Ventures in World Health: The Memoirs of Walkup, “US Public Health Leaders Shift tional Study of the Executive Board on Fred Lowe Soper, ed. John Duffy (Wash- Methods of Promoting the Development of 36. Ibid, 1492. Toward a New Paradigm of Global ington, DC: Pan American Health Orga- Basic Health Services, WHO document 37. Kenneth Newell, “Selective Primary Health,” American Journal of Public nization, 1977); Javed Siddiqi, World EB49/WP/6 (Geneva: WHO, 1972), Health Care: The Counter Revolution,” Health 91 (2001): 1556–1558. Health and World Politics: The World 19–20. Social Science and Medicine 26 (1988): Health Organization and the UN System 8. Derek Yach and Douglas Bettcher, 903–906 (quote on p. 906). “The Globalization of Public Health, I: (London: Hurst and Co, 1995). 25. Socrates Litsios, “The Christian Medical Commission and the Develop- 38. Paul Lewis, “Divided World Health Threats and Opportunities,” American 15. “Seventh Meeting of the Executive ment of WHO’s Primary Health Care Organization Braces for Leadership Journal of Public Health 88 (1998): Committee of the Pan American Sani- Approach,” American Journal of Public Change,” New York Times, May 1, 1988, 735–738, and “The Globalization of tary Organization,” Washington, DC, Health 94 (2004): 1884–1893; Litsios, p. 20. Public Health, II: The Convergence of May 23–30, 1949, Folder “Pan Ameri- Self-Interest and Altruism,” American “The Long and Difficult Road to Alma- can Sanitary Bureau,” RG 90–41, Box Ata.” 39. Gill Walt, “WHO Under Stress: Im- Journal of Public Health 88 (1998): 9, Series Graduate School of Public plications for Health Policy,” Health Pol- 738–741. Health, University of Pittsburgh 26. John H. Bryant, Health and the De- icy 24 (1993): 125–144. 9. George Silver, “International Archives. veloping World (Ithaca, NY: Cornell Uni- versity Press, 1969); Doctors for the Vil- 40. Ibid, 129. Health Services Need an Interorganiza- 16. WHO, “Information. Former Direc- lages: Study of Rural Internships in Seven 41. Fiona Godlee, “WHO in Crisis,” tional Policy,” American Journal of Public tors-General of the World Health Organi- Indian Medical Colleges, ed. Carl E. Tay- British Medical Journal 309 Health 88 (1998): 727–729 (quote on zation. Dr Marcolino Gomes Candau,” lor (New York: Asia Publishing House, (1994):1424–1428; Godlee, “WHO in p. 728). available at http://www.who.int/archives/ 1976); Kenneth W. Newell, Health by the Retreat”; Fiona Godlee, “WHO’s Special 10. Pro Salute, Novi Mundi: Historia de wh050/en/directors.htm, accessed People (Geneva: WHO, 1975). See also Programmes: Undermining From la Organización Panamericana de la July 24, 2004; “In memory of Dr M. G. Marcos Cueto, “The Origins of Primary Above,” British Medical Journal 310 Salud (Washington, DC: Organización Candau,” WHO Chronicle 37 (1983): Health Care and Selective Primary (1995):178–182 (quote on p. 182). Panamericana de la Salud, 1992). 144–147. Health Care,” American Journal of Public 42. P. Brown, “The WHO Strikes Mid- 11. See John Farley, To Cast Out Dis- 17. Randall M. Packard, “Malaria Health 94 (2004): 1864–1874; Litsios, Life Crisis,” New Scientist 153 (1997): ease: A History of the International Health Dreams: Postwar Visions of Health and “The Christian Medical Commission.” 12; “World Bank’s Cure for Donor Fa- Division of the Rockefeller Foundation Development in the Third World,” Med- 27. See Litsios, “The Long and Difficult tigue [editorial],” The Lancet 342 (July (1913–1951) (Oxford: Oxford University ical Anthropology 17 (1997): 279–296; Road to Alma-Ata,” 716–719. 10, 1993): 63–64; Anthony Zwi, “Intro- Press, 2003); Anne-Emmanuelle Birn, Packard, “No Other Logical Choice” duction to Policy Forum: The World “Eradication, Control or Neither? Hook- Parassitologia 40 (1998): 217–229. 28. “Declaration of Alma-Ata, Interna- Bank and International Health,” Social worm Versus Malaria Strategies and tional Conference on Primary Health 18. Randall M. Packard and Peter J. Science and Medicine 50 (2000): 167. Rockefeller Public Health in Mexico,” Care, Alma-Ata, USSR, 6–12 September, Brown, “Rethinking Health, Develop- 1978,” available at http://www.who.int/ Parassitologia 40 (1996):137–147; Mis- 43. World Bank, Financing Health Ser- ment and Malaria: Historicizing a Cul- hpr/NPH/docs/declaration_almaata.pdf, sionaries of Science: Latin America and tural Model in International Health,” vices in Developing Countries. the Rockefeller Foundation, ed. Marcos accessed April 10, 2004. Medical Anthropology 17 (1997): 44. World Development Report, 1993: In- Cueto (Bloomington: Indiana University 29. David A. Tejada de Rivero, “Alma- 181–194. vesting in Health (Washington, DC: World Press, 1994). Ata Revisited,” Perspectives in Health 19. Ian and Jennifer Glynn, The Life Bank, 1993), iii–iv (quote on pp. iii–iv). 12. Vingt-Cinq Ans d’Activité de l’Office Magazine: The Magazine of the Pan and Death of Smallpox (New York: Cam- 45. For a full account, see William Internationale d’Hygiène Publique, American Health Organization 8 (2003): bridge University Press, 2004), Muraskin, The Politics of International 1909–1933 (Paris: Office Internationale 1–6 (quote on p. 4). 194–196. Health: The Children’s Vaccine Initiative d’Hygiène Publique, 1933); Paul F. 30. Maggie Black, Children First: The 20. Ibid, 198. and the Struggle to Develop Vaccines for Basch, “A Historical Perspective on Inter- Story of UNICEF, Past and Present (Ox- the Third World (Albany: State Univer- national Health,” Infectious Disease Clin- 21. William H. Foege, “Commentary: ford: Oxford University Press; 1996), and sity of New York Press, 1998). ics of North America 5 (1991):183–196; Smallpox Eradication in West and Cen- The Children and the Nations: The Story of W.R. Aykroyd, “International Health—A tral Africa Revisited,” Bulletin of the UNICEF (New York: UNICEF, 1986), 46. Bo Stenson and Göran Sterky,

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“What Future WHO?” Health Policy 28 54. Lawrence K. Altman, “US Moves to Fighting Global Blindness (1994): 235–256 (quote on p. 242). Replace Japanese Head of WHO,” New 47. G. A. Gellert, “Global Health Inter- York Times, December 20, 1992, p. 1. Improving World Vision dependence and the International Physi- 55. Ilona Kickbusch, “The Develop- Through Cataract Elimination cians’ Movement,” Journal of the Ameri- ment of International Health Priorities— can Medical Association 264 (1990): Accountability Intact?” Social Science & By Sanduk Ruit, MD, 610–613 (quote on p. 610). Medicine 51 (2000): 979–989 (quote Charles C.Wykoff, MD, D.Phil., MD, 48. Milton Roemer and Ruth Roemer, on p. 985). Geoffrey C.Tabin, MD “Global Health, National Development, 56. Commission on Macroeconomics and the Role of Government,” American and Health, Macroeconomics and Health: Journal of Public Health 80 (1990): Investing in Health for Economic Develop- 1188–1192. ment (Geneva: WHO, 2001); see also 49. See, for example, Andrew J. Howard Waitzkin, “Report of the WHO Haines, “Global Warming and Health,” Commission on Macroeconomics and British Medical Journal 302 (1991): Health: A Summary and Critique,” The 669–670; Andrew J. Haines, Paul R. Lancet 361 (February 8, 2003): Epstein, and Anthony J. McMichael, 523–526. “Global Health Watch: Monitoring Im- 57. Michael A. Reid and E. Jim Pearce, pacts of Environmental Change,” The “Whither the World Health Organiza- Lancet 342 (December 11, 1993): tion?” The Medical Journal of Australia 1464–1469; Anthony J. McMichael, 178 (2003): 9–12. “Global Environmental Change and 58. Michael McCarthy, “A Conversation Human Population Health: A Concep- With the Leaders of the Gates Founda- tual and Scientific Challenge for Epide- tion’s Global Health Program: Gordon miology,” International Journal of Epide- Perkin and William Foege,” The Lancet miology 22 (1993): 1–8; John M. Last, 356 (July 8, 2000): 153–155. “Global Change: Ozone Depletion, Greenhouse Warming, and Public noperated cataract is the cause of millions Health,” Annual Review of Public Health of cases of visual impairment and 14 (1993): 115–136; A. J. McMichael, U Planetary Overload, Global Environmental blindness in poor populations throughout Change and the Health of the Human both the developing and the developed world. Species (Cambridge, England: Cambridge This wonderfully written volume shares the University Press, 1993); Anthony J. experiences of a team of surgeons who have McMichael, Andrew J. Haines, R. Sloof, demonstrated how the surgical procedures can and S. Kovats, Climate Change and be simplified and made more efficient, Human Health (Geneva: WHO, 1996); accessible, and far less expensive. Anthony J. McMichael and Andrew ISBN 0-87553-067-2 • spiral bound • 2006 Haines, “Global Climate Change: The $31.50 APHA Members • $45.00 Nonmembers Potential Effects on Health,” British Med- ical Journal 315 (1997): 805–809. American Public Health 50. Stephen S. Morse, “Factors in the Association Emergence of Infectious Diseases,” 800 I Street, NW, Emerging Infectious Diseases 1 (1995): Washington, DC 20001 7–15 (quote on p. 7). www.apha.org 51. Institute of Medicine, America’s Vital Interest in Global Health: Protecting TO ORDER: web www.aphabookstore.org Our People, Enhancing Our Economy, and email [email protected] Advancing Our International Interests fax 888.361.APHA (Washington, DC: National Academy phone 888.320.APHA M-F 8am-5pm EST Press, 1997). 52. Emerging Infections: Biomedical Re- search Reports, ed. Richard M. Krause (San Diego: Academic Press, 1998); Pre- venting Emerging Infectious Diseases: A Strategy for the 21st Century (Atlanta: Centers for Disease Control and Preven- tion, 1998); Perspectives on the Depart- ment of Defense Global Emerging Infec- tions Surveillance and Response System, ed. Philip S. Brachman, Heather C. O’- Maonaigh, and Richard N. Miller (Wash- ington, DC: National Academy Press, 2001). 53. For example, Laurie Garrett, The Coming Plague: Newly Emerging Diseases in a World Out of Balance (New York: Farrar, Straus and Giroux, 1994).

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330 The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact [email protected] Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine Health Policy and Planning 2008;23:339–350 ß The Author 2008; all rights reserved. Advance Access publication 24 July 2008 doi:10.1093/heapol/czn020 Changing fortunes: analysis of fluctuating policy space for family planning in Kenya

Joanna Crichton*

Accepted 22 June 2008

Policies relating to contraceptive services (population, family planning and reproductive health policies) often receive weak or fluctuating levels of commitment from national policy elites in Southern countries, leading to slow policy evolution and undermining implementation. This is true of Kenya, despite the government’s early progress in committing to population and reproductive health policies, and its success in implementing them during the 1980s. This key informant study on family planning policy in Kenya found that policy space contracted, and then began to expand, because of shifts in contextual factors, and because of the actions of different actors. Policy space contracted during the mid-1990s in the context of weakening prioritization of reproductive health in national and international policy agendas, undermining access to contraceptive services and contributing to the stalling of the country’s fertility rates. However, during the mid-2000s, champions of family planning within the Kenyan Government bureaucracy played an important role in expanding the policy space through both public and hidden advocacy activities. The case study demonstrates that policy space analysis can provide useful insights into the dynamics of routine policy and programme evolution and the challenge of sustaining support for issues even after they have reached the policy agenda.

Keywords Policy analysis, family planning, health policy, contraception

KEY MESSAGES

Policy space for the issue of family planning in Kenya contracted during the late 1990s, and has since begun to expand, due to changing contextual factors and the actions of different individuals.

Proponents of family planning within two government ministries played an important role in expanding the policy space through both public and intra-government advocacy activities.

Policy space analysis can provide useful insights into the dynamics of routine policy and programme evolution and the challenge of sustaining support for issues after they have made it onto the policy agenda.

Introduction policies during the 1960s and in contraceptive service provision during the 1970s and 1980s, yet where resource allocations and In many parts of the world policies relating to contraceptives implementation subsequently declined (Chimbwete and Zulu tend to receive weak or fluctuating levels of commitment from 2003). In Kenya, as elsewhere in sub-Saharan Africa, the past national policy elites, leading to slow policy evolution and decade has seen a weakening prioritization of contraceptive undermining implementation. This is true of Kenya, where the programmes in national and international policy agendas government made early progress in committing to population (Cleland et al. 2006), undermining access to services and progress towards the Millennium Development Goals. *African Population and Health Research Center, PO Box 10787, 00100-GPO, Nairobi, Kenya. Tel: þ254 20 272 0400/1/2. Fax: þ254 20 272 0380. This key informant study examines factors affecting the E-mail: [email protected] fluctuating level of prioritization of contraceptive service

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provision among Kenyan government policy-makers since the mid-1990s. Contraceptive services are usually referred to as ‘family planning’ in national policy debates in Kenya and are framed as cutting across reproductive health and population concerns (Ministry of Health 2000, 2007; NCPD 2000, 2003, 2005, 2006a). Based on key informant interviews and a review of academic and official publications and reports, the paper focuses on the strategies and actions taken by a range of actors to ‘reposition’ family planning in government policy and to ensure the incorporation of contraceptive commodities in the national government budget of 2005, for the first time in the country’s history. The problem of sustaining political and bureaucratic commitment for the implementation and evolution of policies affects a variety of policy issues (Grindle and Thomas 1991; Buse et al. 2005). Waning commitment can lead to stagnation in implementation, and can undermine the likelihood that political and bureaucratic actors create new policies and strategies to adapt to changing contexts, such as shifts in external funding trends. Figure 1 Factors affecting policy space In Southern countries and elsewhere, reproductive health policies are particularly vulnerable to weak political commit- and have limited resources for dealing with them (Shiffman ment, because they do not tend to have strong national support 2007). External actors and international structural trends bases and have historically been controversial and perceived as have a critical influence on national health policy processes, driven by external actors (Jain 1998; Chimbwete and Zulu with increasing diversity and fragmentation of international 2003). Thomas and Grindle (1994), in their review of popu- actors and sources of funding (Walt and Buse 2000; Cerny lation reforms in 16 countries, explain that sustained commit- 2002). These international factors often have contradictory ment to the implementation of population policies tends to be influences, particularly in contexts characterized by national constrained by two main factors: the dispersed and long-term government dependence on external funds, aid conditionalities, nature of their impacts, and the lack of mobilized support from shifting funding priorities, and persistence in vertical program- users of contraceptive services. Reproductive health and ming (Walt and Buse 2000; Cerny 2002; Mayhew et al. 2005). population policies have therefore been vulnerable to depriori- The background characteristics of policy elites are also tization and neglect in many Southern countries, especially in important pre-existing factors that shape policy space; for the context of the shift in international attention and official example the values, level of expertise, experience, degree of development assistance to HIV and AIDS programmes during influence and loyalties of elites influence both their receptive- the 1990s (Cleland et al. 2006). ness to policy change, and their success in championing In this paper, I contend that policy space analysis provides particular policies. a useful framework for understanding why commitment to A second area affecting policy space is that of ‘policy existing policies often fluctuates over time, and for mapping the circumstances’, or the ways in which policy makers’ perceptions room for manoeuvre that advocates of particular policies have for about a policy issue shape the dynamics of decision making. addressing policies that are being neglected. Policy elites can be The extent to which a policy issue is perceived by policy elites to thought of as operating within a ‘policy space’, which influences be a matter of crisis or ‘politics-as-usual’ affects the level at the degree of agency they have for reforming and driving policy which decisions are taken, the urgency with which decisions implementation, but which can be expanded by the exercise of are made, and the extent of risk taking (Grindle and Thomas that agency. These concepts are drawn from Grindle and Thomas 1991; Walt and Gilson 1994). Policy crises involve strong (1991), who suggest that the scope of policy space is influenced by pressure on policy makers to act, as well as high political the way in which policy elites manage the interactions between stakes, and can lead to radical shifts in the prioritization of (1) national and international contextual factors, (2) the issues. When policies are not perceived as urgent, decision circumstances surrounding the policy process, and (3) the making may be dominated by concerns about micropolitical acceptability of the policy’s content. Figure 1 represents policy and bureaucratic costs and benefits. Policy circumstances differ space as a balloon, which can be expanded, constrained or from contextual factors because of their dynamic element: contracted by shifts in these factors and by peoples’ actions. Firstly, contextual factors are the pre-existing circumstances How particular circumstances are perceived by policy elites within which policy processes occur. They can act as opportu- [...] serves as a bridge between the ‘‘embedded orienta- nities and constraints for policy elites’ prioritization of a policy tions’’ of individuals and societies and the kinds of changes issue, and include historical, social, cultural, political, economic considered by decision makers confronted with specific and demographic characteristics of a country and situational policy choices. (Thomas and Grindle 1994, p.53) or focusing events, like epidemics, droughts or media coverage of issues (Kingdon 1984; Grindle and Thomas 1991). Policy- Lastly, the policy’s characteristics are themselves influenced by makers are confronted with a multitude of competing issues policy elites’ decisions, but also affect the scope policy makers

332 POLICY SPACE FOR FAMILY PLANNING IN KENYA 341 have for introducing a policy and prioritizing it. The acceptability in Kenya.1 Interviews were recorded in shorthand during the of a policy is influenced by policy characteristics such as the interview and then typed up by the interviewer immediately distribution of the costs and benefits associated with its afterwards. The notation I1, I2, IX is used in the results section implementation across policy actors and society, which in turn as a code for the various key informants. I also reviewed official affects the level of support or opposition to the policy from various and academic publications and grey material on family stakeholders (Kingdon 1984). Characteristics of a policy that planning policy in Kenya, reports of relevant meetings, and affect its acceptability include its implications for vested interests, the theoretical literature on budget and policy processes. the level of public participation it involves, the resources required I investigated the factors affecting the policy space for reform for implementation and the length of time needed for its impacts using the framework developed by Grindle and Thomas (1991). to become visible (Grindle and Thomas 1991). I also carried out textual analysis (Ulin et al. 2005) of interview In Grindle and Thomas’ model, the various factors interrelate transcripts to gain insights into the experiences of the different in the following ways. Contextual factors shape the circum- individuals who played key roles in the policy process, and the stances of decision making by policy elites concerning particular narratives they used to explain the importance of family policies at particular times. These decisions in turn shape the planning as a policy issue. characteristics of the policy, and public and bureaucratic While carrying out the analysis, I compared and triangulated incentives to support or oppose it. These incentives in turn data from different key informant interview transcripts with shape decisions by policy makers and policy managers about written resources to assess their validity and to mitigate the resource allocation, and explain how prioritization and imple- impact of biased or partial testimony from key informants. mentation may fluctuate over time. Though the framework was Where discrepancies and information gaps were found, I carried initially developed for analysing processes of agenda setting, out further investigation through telephone interviews with key decision-making circumstances directly affect policy makers’ informants and grey literature investigations, to resolve incon- and managers’ decisions about subsequent implementation, for sistencies and address omissions. example where shifts in perceptions of the issue among policy elites affect decisions about resource allocation. Importantly, as Figure 1 illustrates, policy makers can widen the policy space Results they operate within by taking actions to influence the different This section begins with an overview of family planning policy factors, for example by building consensus or by forming in Kenya. The remainder of the section examines each of the coalitions in support of an issue. factors affecting the policy space for family planning, analysing Indeed, analysis of agenda setting across different contexts the ways in which they helped to expand or contract policy space. shows that individual politicians and bureaucrats often play a Box 1 summarizes Kenya’s long history of population central role in championing issues and getting them onto the and reproductive health programmes. The first Population policy agenda, in addition to non-government advocates Policy was introduced in 1967, however government involvement (Grindle and Thomas 1991; Shiffman 2007). Such analyses in contraceptive service provision did not begin in earnest until also show that the level of success of advocacy initiatives the 1980s (Chimbwete and Zulu 2003). During the 1980s depends on a combination of factors including: clear indicators and early 1990s, the Kenyan government demonstrated consider- to show the extent of the problem, the presence of political able commitment to family planning, through the development entrepreneurs to champion the cause, and the organization of of national policies and guidelines, involvement of high-level attention-generating focusing events; as well as the political politicians, the establishment of the National Council for acceptability of policies (Shiffman 2007). Successful advocacy Population and Development (NCPD) in the Office of the Vice may also require the ‘framing’ of contested or neglected issues President, and support for increased distribution of contra- in a way that legitimizes them as an important issue for ceptives through governmental and non-governmental health governments to address (Scho¨n and Rein 1991; Joachim 2003), facilities, and extensive information, education and communica- appealing to prevailing social norms (Shiffman 2007) and tion (IEC) campaigns (Ajayi and Kekovole 1999; Blacker 2006). employing policy narratives, or stories, that simplify issues and Service provision expanded impressively during this period, persuade others of their importance (Roe 1991; Keeley 2001). and the contraceptive prevalence rate in Kenya increased from This case study has implications for government and non- 7 to 27% between 1980 and 1989 (Ajayi and Kekovole 1999). governmental advocates aiming to sustain commitment to International factors played a leading role in this original existing policies in shifting national and international contexts, expansion of policy space for family planning, with external particularly policies relating to contraceptive services and other actors advocating for and supporting the implementation of the neglected sexual and reproductive health issues. population policy. At this time, donors covered the costs of all government and non-government contraceptives and IEC campaigns. During the second half of the 1990s, however, external funding for services and IEC declined, in the context Methods of a shift in priorities to HIV and AIDS and donor fatigue The material for this case study is based on 13 semi-structured (Aloo-Obunga 2003; NCPD 2003; I5; I13). interviews and three unstructured discussions carried out The Kenyan government was slow to respond to the shifting during 2006 and 2007 with high-level officials and programme international aid allocations. Combined with poor management staff from government ministries and agencies, international of commodity procurement between the Ministry of Health and non-governmental organizations (NGOs), national NGOs, a the Kenya Medical Supplies Agency (KEMSA)2 (I13; I4), the bilateral donor and an academic with expertise in demography unreliable and dwindling international funds were a cause of a

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Box 1 The history of family planning policy and programmes in Kenya

1962 Family Planning Association of Kenya (FPAK) established 1967 Government of Kenya’s first population policy, but contraceptive services and Information, Education and Communication (IEC) mainly provided by the private sector 1975 The government launched a 5 year Family Planning Programme 1982 The National Council for Population and Development was established in the Office of the Vice President 1984 First National leader’s Population Conference in Nairobi 1994 United Nations International Conference on Population and Development (ICPD), Cairo 1996 NCPD published its National Population Advocacy and IEC Strategy for Sustainable Development 1996–2010 1997 National Reproductive Health Strategy published 2000 NCPD published the second Population Policy for Sustainable Development 2003 Kenya Demographic and Health Survey generates deteriorating indicators (published in 2004) 2004 NCPD became a semi-autonomous agency under the Ministry of Planning and Economic Development, the National Coordinating Agency for Population and Development (NCAPD) 2005 The budget for 2005/6 presented to parliament and passed, allocating Kenyan government funds to family planning for the first time 2007 National Reproductive Health Policy published

Sources: Ajayi and Kekovole (1998); Blacker et al. (2005); Aloo-Obunga (2000); NCPD (2000).

considerable weakening of government and voluntary sector as a result of these efforts, government funds were allocated to contraceptive services (I2; I7; I4). In 1996, the NCPD launched contraceptives for the first time in Kenya’s history. The incor- a National Population Advocacy and IEC strategy for poration of contraceptive programmes into the national budget Sustainable Development 1996–2010, but this strategy floun- demonstrates national commitment (Shiffman 2006), and dered when funding from UNFPA was withdrawn in 2000 (I5; enhances the potential for sustaining public programmes in I6; The Global Gag Rule Project 2006). Some clinics suffered the face of potential fluctuations in external funding. The from commodity stock outs and lack of method choice during government allocation for this line increased to 300 million the early 2000s, while others closed altogether (I2; I4; I7). The Kenyan shillings, or US$4.17 million, in the 2006/7 budget.4 Kenya Service Provision Assessment Survey of 2004 found that However, it should be noted that this is still only around one- in the 5 years preceding the survey, the proportion of health third of the cost of Kenya’s public sector provision of family facilities offering any method of family planning declined from planning commodities according to 2000 projections (Ministry 88 to 75% (NCAPD et al. 2005). of Health 2003), and proponents of family planning continue to The 2003 Kenya Demographic and Health Survey (KDHS) seek public funding from increased national allocations and results revealed a stall in fertility decline at 4.8 in 1998–2003, from devolved government funds. and the rate actually rose for women who had not completed primary education (Blacker et al. 2005; CBS et al. 2005; Westoff Factors affecting policy space and Cross 2006). The 2003 KDHS revealed increases in unmet This section examines how policy elites interacted with each of need for contraception and high contraception discontinuation the three sets of factors in the policy space framework, to assess rates (Blacker et al. 2005). These trends caused concern among how each influenced the contraction and expansion of policy national and international actors about the implications for the space over time, ultimately leading to the inclusion of contra- rate of population growth in Kenya.3 In 2004, UN predictions of ceptive commodities in Kenya’s 2005 budget. Table 1 sum- Kenya’s population by mid-2050 were revised from 48 to 70 marizes contextual factors, policy circumstances and policy million, based on these new figures (Cleland et al. 2006). characteristics, comparing their impact on policy space during Various societal, economic and demographic factors may have the second half of the 1990s with the years since 2000. contributed to the worsening fertility and contraceptive use trends, and there are differences of opinion among analysts about the impact of declining donor resource allocations for (1) Contextual factors contraceptives and weakening service delivery (Blacker et al. Changes over time in the political, bureaucratic, national and 2005; Bongaarts 2005; Westoff and Cross 2006). But in any international context had a major impact on the room for case, the new data provided powerful evidence for reproductive manoeuvre open to proponents of family planning within the health proponents, and catalysed a series of advocacy initiatives bureaucracy. Table 1 shows how, during the mid-2000s, there with the aim of influencing the government to prioritize were shifts in all these areas that either increased opportunities contraceptive services and allocate public funding to contra- for family planning to be prioritized within government, or ceptive commodities. The advocacy initiatives included meetings reduced the contextual constraints against this occurring. The with parliamentarians and informal advocacy in government role played by policy actors in working with these shifts and budget meetings. A line item for contraceptive commodities was building on them is outlined in the text, below. eventually included in the 2005 national budget, allocating 200 million Kenyan Shillings, or US$2.62 million.4 Influences on policy elites The new budget line signifies a widening of policy space after Analysts of the national political environment for family planning its contraction in the 1990s. Advocates had mobilized concern policy in Kenya contend that commitment to the issue by policy among key decision-makers about the KDHS 2003 results and elites tended to be ambivalent during the 1960s and 1970s,

334 POLICY SPACE FOR FAMILY PLANNING IN KENYA 343

Table 1 Factors affecting policy space for family planning in Kenya Mid to late 1990s, Policy space contracting Early 2000s, Policy space expanding 1. Contextual factors Influences on policy elites # Lack of response to negative donor " Religious opposition becoming less vocal funding trends by high-level politicians # Religious opposition to contraceptives " Government consensus building with religious groups

Change of government in 2002 # Shortage of government resources " New government increasing allocated to health sector resources to the health sector " Passive support from high-level politicians

Bureaucratic # Conservative budget officials " Mandate and influence of NCAPD # Intra- and inter-sectoral competition " Concern about weak service delivery for resources within Ministry of Health # Conservative budget officials # Intra- and inter-sectoral competition for resources " Introduction of the MTEF

International # Vertical HIV and AIDS funding " Financial and technical support for # Prioritization of HIV and AIDS family planning advocacy from international # Reduced donor funding for NGOs and donors contraceptive services and IEC

Availability of policy evidence " Availability of new evidence of a decline in family planning

2. Policy circumstances # HIV and AIDS became a policy crisis, " HIV and AIDS policy is making a gradual transition drawing attention and funding away from ‘crisis’ policy making to ‘politics-as-usual’ from family planning

3. Policy characteristics # Lack of mobilized support from users # Lack of mobilized support from users of of contraceptive services contraceptive services # Some religious sensitivity about " Decreasing religious sensitivity about contraceptive contraceptive services services # Vested interests undermining policy # Vested interests undermining policy implementation implementation

#: Factors constraining or contracting policy space. ": Factors expanding policy space.

and that this was strongly influenced by contextual factors such international population funding than out of genuine conviction as prevailing cultural and religious attitudes. During this period, (Chimbwete and Zulu 2003). there was considerable popular opposition to contraceptives and During the 1980s, President Daniel Arap Moi appears to have to population control in Kenyan society, especially outside the been less troubled than his predecessor by religious and cultural narrow class of urban ‘modernising elites’ (Ajayi and Kekovole reservations about family planning, which enabled him to take 1999; Chimbwete and Zulu 2003). This included opposition to important measures to ensure effective implementation of the the use of contraceptives from religious groups and from pro- population policy. Moi appears to have been more influenced natalist attitudes associated with tribal politics. During this by neo-Malthusian arguments, using them in a number of public period, some technocrats were convinced by arguments from the statements in support of the issue (Ajayi and Kekovole 1999; international population control lobby about the beneficial Chimbwete and Zulu 2003; Blacker 2006). In addition, concerns impacts of lowering fertility rates for economic development, about economic stagnation and heightened pressure from donors but key policy elites expressed scepticism about family planning such as the World Bank also pushed Moi’s government into on cultural, religious and pro-natalist grounds (Ajayi and prioritizing family planning (Ajayi and Kekovole 1999; Kekovole 1999; Chimbwete and Zulu 2003). President Jomo Chimbwete and Zulu 2003). The government-led services and Kenyatta is said to have never fully reconciled contraception IEC campaigns sparked a backlash from some religious orga- with his cultural and religious attitudes, and believed that nizations and community leaders, who made public statements of Kenyan society was too opposed to contraceptives for the opposition to the policy. However, the government and repro- government to openly promote them or directly provide services. ductive health NGOs worked to create a supportive environment Instead, he introduced the population policy more to impress and for family planning and population policies by sensitizing build links with the international community and access religious organizations, the public and the media to the issue

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(I5; I7; I14; I17). When multi-party elections were reintroduced Memorandum tabled by NCAPD in the same year, which called in the early 1990s, all political parties included population for the government to make renewed efforts in family planning. issues in their manifestos (Ajayi and Kekovole 1999), demon- In addition, one senior official in the Ministry of Health and strating the success of these campaigns. one donor argued that the change of administration allowed However, Moi’s commitment had significant limits, as family increasing government allocations to the health sector and planning commodities remained totally funded by donors while made it more likely that politicians would take public health he was in power, and his government failed to take action in issues such as reproductive health more seriously (I13; I17). response to declining resource allocations from donors, allowing implementation and policy evolution to stagnate (NCAPD 2003). This lends weight to the assertion by some key Bureaucratic culture, capacity and institutional arrangements informants from donor agencies and NGOs (I14; I16; I17) Conservatism, lack of transparency and concentration of deci- that policy elites in Kenya had never fully taken ownership of sion-making power in the budget process were factors constrain- family planning policy, even during the 1980s. ing the policy space throughout the period examined. These By the 2000s, pro-natalist attitudes appear to have much less were significant in preventing the government from allocating influence on Kenyan politicians than in the past (I2; I6; I8; I14; resources to contraceptives until 2005. One key informant I15; NCAPD 2006a). The influence of organized religious described budget officers in the ministries of health and finance opposition to contraceptives has also considerably decreased as being opposed to any display of creativity or decisions that are (I5; I6; I3; I4; I15). Efforts by the Kenyan government to build perceived as ‘radical’ (I6). Budget officials had to be convinced consensus with religious groups during the 1990s appear to of the need to innovate by introducing government funding for have helped to reduce the opposition. The 2000 Population an item that was already funded by donors: Policy was a milestone in this process, with religious coalitions being actively involved in the drafting of the policy before it Health indicators such as IMR [infant mortality rates] and MMR was adopted in parliament (I5). [maternal mortality rates] are declining in Kenya. Our strategic The increasing visibility of HIV and AIDS-related illness and plan 2005–2010 shows the need to reverse these trends. FP is mortality over the past decade or so may also have helped to important for reducing MMR. One third of IMR is neonatal make opposition less vocal. One key informant argued that HIV mortality. Economists understood this. But there was a feeling that and AIDS have led religious groups to reconsider their partners were already supporting adequately. So why put money to opposition to family planning, especially the use of condoms: this not drugs or infrastructure? (I4)

’... no one has not been affected by HIV/AIDS. Religious groups However, other bureaucratic factors helped to facilitate the new have decided to lay low and remain silent’. (I5) budget line in 2005. One example is the existence of planning units in each sectoral ministry, which supported the transfer Although religious organizations continue to influence the of knowledge, information and skills between the Ministry of government to exercise caution in their policy making in Planning and the Ministry of Health. The head of the Planning persistently controversial areas such as abortion, emergency Unit, who was seconded from the Ministry of Planning, had been contraception and sexuality education, key informants did not involved in the production of the 2003 KDHS, and therefore had a consider general family planning policy to be affected by good understanding of population and contraceptive use trends, religious opposition. In addition, high-level politicians in the and a personal stake in the issue (I12). This official was formally 2002–07 government appear to have strong personal convictions responsible for the initial drafting of the Ministry of Health about family planning. President Mwai Kibaki is known to be budget. The introduction of the Medium Term Expenditure convinced by economic arguments for limiting population Framework (MTEF) in 1999 (Ministry of Health 2005) may also growth (Ajayi and Kekovole 1998; Chimbwete and Zulu have been a supporting factor. Since the MTEF allows for annual 2003), and the ministers of health and finance during that increases in resources for existing budget lines, allocations period were considered to be sympathetic to reproductive health for family planning were much easier to pass in 2006 than in issues (I4; I6; I17). 2005 (I1; I4; I7; I12; I13). Since its creation as an agency in 2004, the existence of Change of government in 2002 NCAPD has been an important factor expanding the policy Moi’s government failed to address the declining implementa- space for family planning prioritization in Kenya. One key tion of family planning policy during the 1990s, and it seems informant emphasized that the transformation of the National that the change of administration in 2002 may have brought an Council for Population and Development into the agency impetus of change that helped to mobilize action to address this NCAPD led to a considerable improvement in its effectiveness issue. The new government may have helped to expand policy and policy influence. NCAPD is part of the Ministry of space by bringing politicians who were more supportive of Planning, but is semi-autonomous, so has greater operational family planning into key positions. The arrival of the new flexibility than its predecessor (I1; I7). Unlike the Division of government certainly precipitated two actions that indicate Reproductive Health, NCAPD has a mandate to conduct high- high-level sympathy for the issue. These were the creation of level advocacy (I2; I6, I14; NCAPD 2005). In 2003, shortly the National Coordinating Agency for Population and before NCPD made its transition to an agency, a new Director Development (NCAPD) through an act of parliament in 2004, was appointed, who was charismatic and influential within with its new advocacy mandate, and the issuing of a Cabinet government and with donors, enabling him to take advantage

336 POLICY SPACE FOR FAMILY PLANNING IN KENYA 345 of this mandate to mobilize resources for family planning commodity stockouts. The ministry did not understand the donor’s advocacy, and to sell the issue in high-level meetings (I9; I14). cycle. (I14) The experience of poor implementation within the Ministry of Health during the late 1990s and early 2000s was also A senior government official on the other hand, argued, an important factor creating concern about the issue within the ministry and triggering action to address it. In the Division Donors have no idea of our procurement schedule. You would find of Reproductive Health and among NGO service providers, lorries arriving at KEMSA without any storage space. (I13) the policy problem was identified because of stock outs of family planning commodities from health facilities, leading to While external assistance for service delivery and IEC has a concern that family planning policy implementation was dropped, international actors have increased their support to ineffective and action needed to be taken to improve service ‘behind the scenes’ advocacy campaigns to reposition family delivery. One official in the ministry stated that, planning. This includes the provision of financial and technical assistance for advocacy on family planning from donors such as The Ministry of Health had a general feeling that FP implementa- USAID, and of technical assistance from international NGOs tion was not good enough. (I3) such as the Futures Group and the African Population and Health Research Center (I2; I14). Since 2000, UNFPA has been funding improvements in the division of responsibility and International influences coordination between the Ministry of Health and NCAPD, Population first made it onto the Kenyan government’s agenda which may have helped them to carry out joint advocacy for because of the influence of external actors, and even at the family planning (I5). In the past few years, some donors have height of prioritization of the issue during the 1980s and early been working with the Ministry to strengthen procurement 1990s, the government always relied on external resources to policy, though it is too early to assess the impacts of these fund policy implementation (Ajayi and Kerkovole 1998; efforts (I6; I14). A key shift in international engagement Chimbwete and Zulu 2003). As with the national government, between the 1980s and recent years is, therefore, that external many international donors shifted their priorities to HIV and actors are now trying to create local ownership for family AIDS during the 1990s, leading to declining foreign aid planning by supporting national advocates of the issue, allocations for family planning (Aloo-Obunga 2003; NCPD particularly government officials and parliamentarians. 2003). The strong external pressure that had influenced political elites to prioritize population and reproductive health Availability of policy evidence issues during the 1980s and early 1990s declined. In addition, The availability of new data in 2003 demonstrating that a some key informants described a situation of donor fatigue ‘policy problem’ existed was a catalyst for alerting policy brought on by frustration with poor planning and lack of entrepreneurs to the need for family planning to be reprior- ownership for family planning in the Ministry of Health. itized. Key informants from the NCAPD, Ministry of Health, USAID and NGOs pointed to the importance of the 2003 KDHS Donors got fed up with the lack of planning. DRH used to say, data in identifying and persuading others about the importance ‘‘we have a shortage of pills. UNFPA can give us an emergency of the issue. drop’’. UNFPA would do this, but 6 months later they’d come back and ask for another bail out. (I14) The plateau [of contraceptive use and fertility rates] was a critical turning point. (I1) Some key informants stated that donor agencies consider IEC The results showed clearly that unmet need for FP had not to be expensive and lack conviction in its importance and changed for over 10 years. Contraceptive prevalence was the effectiveness (I6; I2). There appears to have been complacency same. The TFR was beginning to show an increase. among donors as well as national actors about fertility These figures rang a bell. So we did further analysis. Our finding transition, and a belief that it would happen naturally without was that there was a shortage of commodities. [...] We needed a the need for sustained interventions. broad program of high-level advocacy to lobby government, partners and donors. (I2) Implementation disappeared in the 1990s. There was an expecta- tion that the transition would continue automatically. Resources Contrary to the previous quotation, those working on the were moved away. (I1) issue in government had already expressed concern about Donors no longer wanted to support community-based distribution, declining prioritization of family planning and decreasing donor questioning its impact. (I2) funding before the KDHS funding before the KDHS results were available (Ministry of Health 2000; NCAPD 2003). The Government and donor key informants unsurprisingly dif- publication of this data provided an opportunity and a resource fered as to where they put the blame for poor coordination and for champions of family planning to use in their advocacy. commodity stockouts, with a USAID official stating that: (2) Policy circumstances [...] there was a major problem when the Germans picked up the Since the time of Kenya’s first population policy in the 1960s, bulk of procurement, but there was a 6 month gap between projects family planning has consistently been regarded by policy elites which the ministry had not picked up on, so there were almost as an issue of ‘business as usual’ rather than a crisis issue.

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Government officials repeatedly stated that a difficulty for of supporters for the policy among users of contraceptive securing prioritization of family planning in the Ministry of services, or the Kenyan public in general (I2; I6; I15; I16). The Health is that it is not considered to be an emergency, unlike issue of family planning has therefore tended to involve low other health issues such as epidemics (I6; I3; I4). During political stakes for the Kenyan Government, focusing the costs the 1990s, the policy space for family planning narrowed and benefits of the policy in the bureaucratic domain. further, when HIV and AIDS was perceived as a crisis issue In the bureaucracy, there seem to be no significant incentives (Aloo-Obunga 2003; NCPD 2003). to oppose family planning programmes among government officials, with the issue being treated as relatively uncontro- FP has become routine. It has been overrun by other activities like versial (I2; I6). As with other health services, contraceptives HIV/AIDS. (I4) have relatively intense administrative requirements because of the need for continuous administrative resources to be allocated This was exacerbated by a perception that family planning to procurement, storage and distribution of contraceptive and HIV and AIDS are competing issues that can be traded off commodities, and the technical skills required for effective against each other. This narrowed the policy space for family service delivery. The capacity of the government to distribute planning by diverting resources away and undermining contraceptives beyond the district level to the facility level is acknowledgement of the interdependence between the two weak (I17). As with other areas of the health sector, entrenched services and the need for integrated policies and programmes. vested interests associated with procurement of family planning One government official commented that: . commodities play an influential role in undermining the implementation of family planning services (I14). These There was the occasional minister who would prioritize HIV over interests continue to frustrate efforts to address inefficiencies FP. (I2) in procurement and distribution by improving the effectiveness of KEMSA. During the 1990s, the deprioritization of family planning seems to have been reinforced by complacency among government Procurement is worth billions [of Kenyan shillings]. KEMSA officials and politicians about increasing contraceptive use rates became independent recently. But the Ministry of Health [still] and declining fertility. There seems to have been a perception that wants it. How to let go of a cash cow? The previous minister the fertility transition would continue without the need for selected a board chairman, but there is still no board. So there are continuous government intervention, further undermining the many vested interests. It has become a donor issue. [Donors] keep sense of importance of family planning as a policy issue. saying, ‘let KEMSA go!’. (I17)

People did not realise what was happening when the decline in FP The role of advocacy strategies: expanding policy funding started. For a long time, FP had been doing very well. It space during the mid-2000s was at the peak of its success when HIV/AIDS became a crisis issue. [The decline in government prioritization of FP] was an The previous section has outlined how shifts in context, policy involuntary decrease. (I5) circumstances and policy characteristics leading up to the mid- 2000s widened the policy space for family planning. This As demonstrated in Table 1, changing perceptions of policy section focuses on the ways in which policy actors took makers during the first half of the 2000s helped to create a more advantage of these shifts and widened policy space still further supportive decision-making environment for family planning. through advocacy initiatives. It also examines strategies that This involved both an increase in concern among policy makers were used effectively by these advocates in order to influence about the issue, and an opening up of policy space because of key decision-makers. changing attitudes to HIV and AIDS as a policy issue. By 2003, HIV From 2003 onwards, advocacy activities led by bureaucrats, and AIDS was no longer seen as such an urgent crisis, opening the with support from political, international and civil society policy space for policy makers to focus more on family planning. actors, led to increased recognition of the importance of contraceptive services among key policy-makers and ultimately resulted in the introduction of the new budget line for (3) Policy characteristics contraceptive commodities in 2005. Certain advocacy strategies As shown in Table 1, the policy content had an important appear to have been effective in encouraging increased impact on the nature of the policy space for family planning, prioritization of the issue, including combining public and but did not present a major change during the period examined intra-government advocacy, organizing focusing events, and by this case study. The decreasing religious opposition to family using a variety of policy narratives to ‘reframe’ family planning. planning during the 1990s may have helped to increase the The advocacy process involved a range of actors, loosely acceptability of family planning policy among the electorate, coordinated through family planning and reproductive health thus expanding policy space slightly. There appears to be committees chaired by the Ministry of Health, with member- insufficient knowledge about how far family planning is ship including NCAPD, NGOs and donors. The aims were accepted by individual Kenyans, but generally it is unlikely to multifaceted. They included ‘repositioning’ family planning by meet strong opposition, although there are high levels of myth raising its profile as a government development priority, by and suspicion about particular methods in some communities making it genuinely multi-sectoral, and enhancing integration (Feldblum et al. 2001; I12; I15; 16). However, a defining feature with HIV and AIDS and other reproductive health issues such of family planning policy is the lack of a mobilized constituency as maternal and child health (I1).

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When preliminary results from the KDHS were circulated budget officials in the Ministries of Health and Finance to support by the Central Bureau of Statistics (CBS, since renamed the public funding of contraceptive commodities (I1). NCAPD Kenyan National Bureau of Statistics) in January 2004,5 the provided data and other support to the DRH in this process. deteriorating trends were immediately noted, and the NCAPD A line of advocacy was necessary through government hierar- carried out further analysis of the KDHS findings, with support chies, where the Head of the DRH took advantage of routine from USAID, and held stakeholders’ meetings to discuss how to meetings to persuade Ministry of Health budget officials and react (I12). A reproductive health working group, of govern- senior administrators such as the Director of Medical Services of ment officials, NGOs and donors, chaired by the Ministry the importance of adding family planning to the budget (I8; I17). of Health, identified a specific goal to address donor depen- In turn, these senior officials had to convey this message to dency by ensuring the government allocated national resources the Ministry of Finance and during multi-sectoral planning to family planning for the first time. meetings such as MTEF meetings. Agenda setting to incorporate family planning in the 2005 budget process involved two advocacy processes. The first was [The Division of Reproductive Health (DRH)] needs to be able to a public process to influence parliamentarians, senior bureau- push the DMS [Director of Medical Services] who oversees the crats and the wider public, led by NCAPD. The second budget under the PS [Permanent Secretary] to make these involved internal government advocacy to influence the decisions. There is a line of command from DRH to DMS to PS budget process within the Ministry of Health and between to the Ministry of Finance. If Kibaru [Head of the DRH] is not the Ministry of Health, the Ministry of Planning and the shouting enough to the DMS, the DMS will not be shouting to the Ministry of Finance. PS, and so on. (I8) The public efforts centred on the budget process. In April and July 2005, two advocacy workshops were convened by NCAPD, The decision-making process to allocate government resources with support from national and international NGOs and donors to contraceptive commodities began when bureaucrats in (NCAPD 2005, 2006b). Presentations and speeches on the NCPAD, DRH and the Ministry of Health Planning Unit importance of family planning and the deteriorating trends variously identified the need for the budget line (I4; I1; I2; were delivered by NCAPD, the African Inter-Parliamentary I7). The process encompassed ministerial budget meetings and Network on Reproductive Health and the Ministry of Health. the Medium Term Expenditure process and culminated in the Advocacy materials and presentations (APHRC 2005; NCAPD acceptance of the budget by the Minister of Finance. The 2005) drew both from KDHS data and from evidence on the Planning Unit in the Ministry of Health started the process correlation between higher contraceptive prevalence rates, lower officially, tabling arguments to the Ministerial Budget fertility rates, and increased maternal and infant survival Committee charged with formulating the budget. Officials in published by UNFPA (2003). These workshops targeted ministers, the Planning Unit presented key budget decision-makers in the senior administrators and budget officials from the Ministries of Ministry of Health, including the Director of Medical Services Finance, Planning and Health, and parliamentarians (I3; I4; I7). and the Permanent Secretary, with arguments about the need The workshops were reported in the press, and key informants for the new budget line based on shortfalls in family planning argue that this public profile of the event helped to persuade key funding from donors and the implications of declining KDHS officials in the bureaucracy to accept and support the allocation indicators for health and development. In turn, the Ministry of of national resources to family planning (I1; I2; I6; I7; I14). Health Budget Committee inserted the budget line into the The exact role played by the parliamentarians is hard to ministerial budget and defended it to the cross-sector MTEF pinpoint. Key informants involved in the advocacy argued that Secretariat in the Ministry of Finance (I12; I13). the ultimate aim of targeting MPs was to make them become This intra-government advocacy can be seen as a strategy to active in the budget process, advocating for resources to be create a sense of urgency about family planning as a policy allocated to contraceptives (I6, I14). However, the parliamen- problem, in order to create more favourable decision-making tarians’ direct impact on the budget is extremely small in dynamics. The KDHS data played an important role, and Kenya, limited only to simply passing or rejecting the whole government economists were said to be receptive to arguments budget (Mwenda and Gachocho 2003; Gomez et al. 2004; IPAR about the importance of access to contraceptives for improving 2004). Overall, targeting the parliamentarians may have a more maternal health and child health indicators (I2; I4; I12; I13; I17). long-term effect through strengthening networks of support for The Public Expenditure Review, carried out by the Planning Unit, reproductive health among politicians and paving the way for provided evidence of the fluctuating resources for family plan- future work with parliamentarians (NCAPD 2006b), rather than ning, which was presented to the Minister and other senior directly affecting the budget line. However, it is possible that policy-makers in the Ministry of Health to demonstrate that the parliamentary workshops may have catalysed the budget donor funds were unreliable and inadequate without national line decision from the Ministry of Health, by putting senior allocations (I13). officials in the ministry under scrutiny about their response to In addition to the use of statistics, a wide range of policy the deteriorating KDHS indicators. In this way, the workshops narratives were employed by different actors in their bid to can be regarded as ‘focusing events’, which raised the profile of reframe family planning as an important issue for economic the issue, strengthened networks of sympathetic individuals, growth, development and health, which should be prioritized in and mobilized action. public policy-making. Arguments were made to counter a In the parallel, hidden advocacy process, officials within the general perception among policy-makers that sustained fertility Division of Reproductive Health (DRH) worked to influence transitions occur automatically due to socio-economic change,

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without requiring government intervention (I2; I6). One key Discussion and conclusion informant stated that ‘without continual family planning IEC, This paper examines the challenge of sustaining commitment to acceptance will decline’ (I6). Another key informant argued existing policies in politics-as-usual circumstances, rather than that argued that, focusing on the agenda-setting phase of policy reform, as is more common in the field of policy analysis. Policy space for There is a tendency for poor communities to continually reduce the issue of family planning in Kenya contracted during the late their acceptance of FP [...]. FP is not readily accepted by the poor 1990s, and subsequently began to expand, due both to except if they receive information and community-based distribu- changing contextual factors and the ways in which advocates tion. Hence the need for continuous IEC provision. (I2) within and outside government worked with these factors. The case study approach brings certain limitations to this Particular individuals used various policy narratives, targeting paper. In particular, it limits the potential for developing arguments to particular audiences. Key informants explained concrete assertions about causality in the policy process or for how the Head of the Division of Reproductive Health used generalizing about results. However, the paper does support ‘government language’ and internal advocacy within the lessons on policy processes from other contexts, and also Ministry of Health to make sure the issue did not seem radical provides suggestions for how policy space analysis could be or part of an external agenda (I7, I6). Advocates appealed to utilized more widely in health policy analysis. nationalism (I2; I3): Firstly, the paper demonstrates the potential for the use of NCAPD’s argument to the government is: ‘‘don’t allow the life of policy space analysis to identify the challenges and opportunities your citizens to hang on the whims of donors’’. We must have a for sustaining or increasing commitment to existing policies in politics-as-usual circumstances. This is particularly useful for Plan B – of government money for family planning. (I2) cases involving ‘unplanned drift’ of policies in response to trends The slogan ‘Planning our families is Planning for our Nation’s such as political pressures or opportunities or shifts in funds Development’ was used in advocacy materials distributed at the provided by global initiatives (Buse et al. 2005). advocacy workshops (NCAPD 2005). In advocacy initiatives to Policy space analysis can be used both as an analytical influence government officials and parliamentarians, propo- framework and as a tool that proponents of a policy issue can nents of family planning focused on the importance of use to map the boundaries of policy space and identify the family planning for economic and social development and actions that could be undertaken to expand it. Key advantages poverty reduction, and specifically for achievement of the of the policy space analysis framework include its explicit focus Millennium Development Goals (APHRC 2005; NCAPD 2005, on the dynamics of decision-making circumstances, the influ- 2006a,b). ence of vested interests in shaping policy outcomes, and the There were also attempts to transform attitudes among policy agency of policy elites (Walt and Gilson 1994). In this way, elites about the beneficiaries of contraception, highlighting the policy space is a powerful and under-utilized tool for analysis of benefits for men, children, low-income families, and the nation the political economy of public health policies. at large, countering popular assumptions that contraception is a The case study reveals the important role government officials ‘women’s issue’ (APHRC 2005). Some key informants for this can play in sensitizing colleagues within and between ministries study described the importance of presenting family planning to neglected SRH issues. In Kenya this was dependent on the as uncontroversial and in line with national Kenyan aspirations existence of highly motivated individuals in both the Ministry and prevailing gender norms. of Planning and the Ministry of Health, and the existence of With a couple of notable exceptions, reproductive health rights the NCAPD, which had the independence and mandate to carry were very rarely used in advocacy materials (APHRC 2005; out advocacy on population-related issues. NCAPD 2005), and remain controversial even among some This case study provides support for Thomas and Grindle’s senior government officials (I17). However, population and observation that the ‘policy content’ of population policies, sexual and reproductive health narratives were adeptly combined involving sustained bureaucratic demands, dispersed benefits by some key informants, without explicitly referring to and low political stakes, is a likely reason why policies relating to rights. One example was the argument that high quality contraceptive services tend to evolve slowly and are often poorly contraceptive services based on a choice of methods are implemented (Thomas and Grindle 1994). In Kenya, the advocacy essential for acceptance of contraception by the Kenyan public around family planning and the 2005 budget involved attempts to and for lowering total fertility rates. Shortages of family planning counter this tendency by securing political commitment and commodities in clinics and poor quality of service delivery government resources for the issue and addressing complacency were blamed for causing discontinuation of contraceptive by feeding new evidence from the 2003 KDHS into policy. use and decreasing acceptance of contraceptive methods (I1, The public advocacy events involving parliamentarians and the I2, I8). media organized by NCPAD and other partners could be seen as an attempt to move the issue from the purely bureaucratic In the 1990s, there was unmet need for FP. Many women had arena into the public domain. The case study demonstrates that unintended children. When they went to a facility, they did not find research examining policy processes would benefit from investi- the contraceptive of their choice. They went away, meaning to come gating budget processes in more detail, because of their role back another time, but did not [...] When there are shortfalls in in intra-government negotiation and advocacy for planning and FP commodities, fertility goes up automatically. (I1) prioritizing policy issues.

340 POLICY SPACE FOR FAMILY PLANNING IN KENYA 349

3 In accordance with Walt and Buse (2000), Buse et al. (2005) The KDHS 2003 results were published in 2004 but were discussed in and Cerny (2002), UNFPA, USAID, other bilateral donors and meetings during late 2003 within the Ministry of Planning and with other stakeholders. international NGOs played a vital role in shaping the domestic 4 This figure is based on the conversion rate between Kenyan Shillings policy process, first helping to contract, then to expand the policy and US Dollars in June 2005. space for family planning through international support to 5 Although the specific agenda to use advocacy to ‘reposition family local advocacy activities. However, while the original expansion planning’ began to appear in government documents during 2005, of policy space during the 1980s was to a large degree led by the agenda appears to have its roots among actors in the then NCPD and supporting US agencies from before the KDHS figures emerged. international actors, national government officials and resources A 2003 document that does not feature KDHS results cites the have played a greater role during the expansion since 2003, need for ‘renewed high-profile public commitment by high-level providing some evidence of increased national ownership of leaders to reinvigorate FP in Kenya’ (NCPD 2003). the issue. The case study supports Shiffman’s assertion of the importance of both the availability of reliable indicators to demonstrate Acknowledgements the policy problem and the organization of focusing events The author expresses her appreciation for the financial support (Shiffman 2007). As predicted by Thomas and Grindle (1994), (Grant HD4) to this study provided by the UK Department for technical analyses of population problems played a central role International Development (DfID) for the Realising Rights in persuading policy elites of the need for reform. Research Programme Consortium. The views expressed are not The government officials and politicians who support family necessarily those of DfID. planning appear to have been skilled at selecting from the range I am grateful to the key informants from the Ministry of of policy narratives and tailoring their arguments for different Health, Kenya National Bureau of Statistics, National audiences. Advocates’ use of arguments to reframe contraceptive Coordinating Agency for Population and Development, Futures services as non-radical and in tune with national development Group, KAPAH, UNFPA, USAID, Marie Stopes International, goals and prevailing gender norms can be seen as a useful strategy International Planned Parenthood Federation, and London for increasing recognition of the importance of these services and School of Hygiene and Tropical Medicine for taking the time to tackling sources of scepticism about them (Scho¨n and Rein 1991; be interviewed and providing invaluable insights and information Joachim 2003). Grindle and Thomas (1991) focus on the impli- for this study. I would like to thank Frederick Mugisha for his cations of policy characteristics for the distribution of costs contributions to the study design and methodology, and Gill and benefits to key stakeholders. However, where policy issues Walt, Lucy Gilson, Sally Theobald, and Eliya Zulu and other staff that are highly influenced by social and cultural values are at APHRC for their helpful advice and comments on previous concerned, including sexual and reproductive health policies, drafts of the paper. the ways in which policies are framed to stakeholders may be equally important. Despite the significant expansion of policy space identified in this case study, very few of the key informants interviewed were References of the opinion that contraceptive service delivery and information Ajayi A, Kekovole J. 1998. Kenya’s population policy: from apathy to campaigns have returned to the levels of success experienced effectiveness. In Jain A (ed.). Do population policies matter? Fertility during the 1980s. Proponents of family planning in Kenya and politics in Egypt, India, Kenya and Mexico. New York: Population continue with their efforts to promote family planning as a Council, pp. 113–56. priority in Kenya and to secure further resources for implementa- Aloo-Obunga C. 2003. Country analysis of family planning and HIV/AIDS: tion. However, they may not be able to achieve major improve- Kenya. Washington, DC: the Policy Project. ments in service delivery without successfully tackling the African Population and Health Research Center (APHRC), City Council weaknesses in government procurement and distribution of of Nairobi, Ministry of Health, and National Coordinating Agency contraceptive commodities. for Population and Development. 2005. Repositioning population and reproductive health for the attainment of National and Millennium Development Goals. Report of the Meeting of Parliamentarians, Development Partners and Key Stakeholders in Endnotes Population and Reproductive Health in Kenya, 19 April 2005, Nairobi. 1 The key informants were from the Ministry of Health [one official in Blacker J, Opiyo C, Jasseh M, Sloggett A, Ssekamatte-Ssebuliba J. 2005. the ministry’s Planning Unit and two officials in the Division of Fertility in Kenya and Uganda: a comparative study of trends and Reproductive Health (I3; I4; I13)], the National Coordinating determinants. Population Studies 59: 355–73. Agency for Population and Development (NCAPD) (I1; I2; I7), Bongaarts J. 2005. The causes of stalling fertility transitions. New York: the Kenyan National Bureau of Statistics (I12), the donors USAID and UNFPA (I14; I17), and the NGOs Planned Parenthood Population Council. Working Paper No. 204. Federation of America, Futures Group, Kenyan Association for Buse K, Mays N, Walt G. 2005. Making health policy. Maidenhead, UK: the Promotion of Adolescent Health (KAPAH), and Marie Stopes Open University Press. International (I5; I6; I8; I15; I16). Additional unstructured Campbell J. 1998. Institutional analysis and the role of ideas in political discussions were carried out with an international adviser to the economy. Theory and Society 27: 3. Ministry of Health (I10), an NGO representative (I11), and a demographer with expertise on family planning in Kenya (I9). Central Bureau of Statistics, Kenya, Ministry of Health, Kenya and ORC 2 The public sector Medical Supplies Coordinating Unit (MSCU) was Macro. 2004. Kenya Demographic and Health Survey 2003. Nairobi: transformed into a parastatal and renamed KEMSA in 2000. CBS, and Calverton, MD: ORC Macro.

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Cerny P. 2002. Globalizing the policy process: from ‘iron triangles’ Ministry of Health. 2007. National Reproductive Health Policy: Enhancing to ‘golden pentangles’? Paper presented at the annual convention reproductive health status for all Kenyans. Nairobi: Ministry of Health, of the International Studies Association, New Orleans, 24–27 Republic of Kenya. March 2002. Mwenda A, Gachocho M. 2003. Budget transparency: Kenyan perspec- Chimbwete C, Zulu EM. 2003. The evolution of population policies in tive. Nairobi: Institute of Economic Affairs, Research Paper Series Kenya and Malawi. Nairobi: African Population and Health No. 4. Online at: http://www.internationalbudget.org/resources/ Research Center, Working Paper No. 27. library/Kenyatransp.pdf. Cleland J, Bernstein S, Ezeh A et al. 2006. Family planning: the National Council for Population and Development (NCPD). 2000. Family unfinished agenda. The Lancet 368: 1810–27. Planning Financial Analysis and Projections for 1995 to 2020. Druce N, Dickinson C, Attawell K, Campbell White A, Standing H. 2006. Nairobi: NCPD, Division of Primary Health Care, Ministry Strengthening linkages for sexual and reproductive health, HIV and AIDS: of Health, Government of Kenya and the POLICY Project. progress, barriers and opportunities for scaling up. London: DFID Health National Council for Population and Development (NCPD). 2003. Family Resource Centre. Planning Achievements and Challenges. Nairobi: NCPD, Ministry Feldblum P, Kuyoh MA, Bwayo JJ et al. 2001. Female condom of National Planning and Development, Division of Reproductive introduction and sexually transmitted infection prevalence: results Health, Ministry of Health, Government of Kenya, Family Planning of a community intervention trial in Kenya. AIDS 15: 1037–44. Association of Kenya and The POLICY Project. The Global Gag Rule Project. 2006. Access denied: the impact of the NCAPD. 2005. ‘Calling the Nation to Action’. Fact sheet distributed Global Gag Rule in Kenya. 2006 Updates. The Global Gag Rule at the parliamentary meeting on ‘Repositioning Population Project. and Reproductive Health for the Attainment of National and Gomez P, Friedman J, Shaprio I. 2004. Opening budgets to public Millennium Development Goals’, 19 April 2005, Nairobi. understanding and debate: results from 36 countries. Washington, DC: NCAPD. 2006a. Proposed Workshop of Parliamentary Network on International Budget Project. Population and Development to be held on 5–6 May 2006: Government of Kenya. 2006. The Health Sector MTEF 2006/7–2008/9. A summary of initiatives to work with MPs to lobby for support Sector Working Group Report (Final Draft), February 2006. to population and development issues. Nairobi: NCAPD. Nairobi: Government of Kenya. Online at: http://www.treasury. NCAPD. 2006b. Launch and Agenda Setting Workshop, Summary of go.ke/docs/sreports0506/HealthSectorReport.pdf. Proceedings. Nairobi: NCAPD. Grindle MS, Thomas JW. 1991. Public choices and policy change: the political NCAPD, Ministry of Health (MoH), Central Bureau of Statistics (CBS), economy of reform in developing countries. Baltimore and London: The ORC Macro. 2005. Kenya Service Provision Assessment Survey 2004. John Hopkins University Press. Nairobi: NCAPD, MoH, CBS and ORC Macro. Institute of Policy Analysis and Research (IPAR). 2004. Budgetary Scho¨n DA, Rein M. 1994. Frame reflection: toward the resolution of process in Kenya: enhancement of its public accountability. IPAR intractable policy controversies. New York: Basic Books. Policy Brief 10(1). Nairobi: IPAR. Shiffman J. 2007. Generating political priority for maternal mortality Jain A. 1998. Do population policies matter? Fertility and politics in Egypt, reduction in 5 developing countries. American Journal of Public India, Kenya and Mexico. New York: Population Council. Health 97: 796–803. Joachim J. 2003. Framing issues and seizing opportunities: the Thomas JW, Grindle MS. 1994. Political leadership and policy UN, NGOs, and Women’s Rights. International Studies Quarterly 47: characteristics in population policy reform. Population and 247–74. Development Review 20 (Supplement: The new politics of population: Keeley JE. 2001. Influencing policy processes for sustainable livelihoods: conflict and consensus in family planning): 51–70. strategies for change. Lessons for Change in Policy and Organisations, Ulin P, Robinson E, Tolley E. 2005. Qualitative methods in public health: No. 2. Brighton: Institute of Development Studies. a field guide in applied research. San Francisco, CA: Jossey-Bass. Kingdon JW. 1984. Agendas, alternatives and public policies. New York: Walt G, Buse K. 2000. Partnership and fragmentation in international Harper Collins. health: threat or opportunity? Tropical Medicine and International Mayhew S, Walt G, Lush L, Cleland J. 2005. Donor agencies’ Health 5: 467–71. involvement in reproductive health: saying one thing and doing Walt G, Gilson L. 1994. Reforming the health sector in developing another? International Journal of Health Services 35: 579–601. countries: the central role of policy analysis. Health Policy and Ministry of Health. 2000. Family planning and reproductive health commodities Planning 9: 353–70. in Kenya: background information for policymakers. Nairobi: Division of Westoff CF, Cross A. 2006. The stall in the fertility transition in Kenya. DHS Primary Health, Ministry of Health, Government of Kenya. Analytical Studies No. 9. Calverton: ORC Macro. Ministry of Health. 2003. Contraceptive Commodities Procurement Plan 2003–2006. Nairobi: Reproductive Health Advisory Board, Ministry of Health, Government of Kenya.

342 Articles

Child survival gains in Tanzania: analysis of data from demographic and health surveys

Honorati Masanja, Don de Savigny, Paul Smithson, Joanna Schellenberg, Theopista John, Conrad Mbuya, Gabriel Upunda, Ties Boerma, Cesar Victora, Tom Smith, Hassan Mshinda

Summary Lancet 2008; 371: 1276–83 Background A recent national survey in Tanzania reported that mortality in children younger than 5 years dropped Ifakara Health Research and by 24% over the 5 years between 2000 and 2004. We aimed to investigate yearly changes to identify what might have Development Centre, Ifakara, contributed to this reduction and to investigate the prospects for meeting the Millennium Development Goal for child Tanzania (H Masanja PhD, survival (MDG 4). Prof D de Savigny PhD, P Smithson MPH, J Schellenberg PhD, Methods We analysed data from the four demographic and health surveys done in Tanzania since 1990 to generate H Mshinda PhD); Swiss Tropical estimates of mortality in children younger than 5 years for every 1-year period before each survey back to 1990. We Institute, Basel, Switzerland estimated trends in mortality between 1990 and 2004 by ﬁ tting Lowess regression, and forecasted trends in mortality (D de Savigny, Prof T Smith PhD); London School of Hygiene and in 2005 to 2015. We aimed to investigate contextual factors, whether part of Tanzania’s health system or not, that Tropical Medicine, London, UK could have aﬀ ected child mortality. (J Schellenberg); World Health Organization, Dar es Salaam, Findings Disaggregated estimates of mortality showed a sharp acceleration in the reduction in mortality in children Tanzania (T John MSc); Ministry of Health and Social Welfare, younger than 5 years in Tanzania between 2000 and 2004. In 1990, the point estimate of mortality was 141·5 (95% CI Dar es Salaam, Tanzania 141·5–141·5) deaths per 1000 livebirths. This was reduced by 40%, to reach a point estimate of 83·2 (95% CI (C Mbuya MPH, G Upunda MPH); 70·1–96·3) deaths per 1000 livebirths in 2004. The change in absolute risk was 58·4 (95% CI 32·7–83·8; p<0·0001). World Health Organization, Between 1999 and 2004 we noted important improvements in Tanzania’s health system, including doubled public Geneva, Switzerland (T Boerma PhD); and University expenditure on health; decentralisation and sector-wide basket funding; and increased coverage of key child-survival of Pelotas, Pelotas, Brazil interventions, such as integrated management of childhood illness, insecticide-treated nets, vitamin A supplementation, (Prof C Victora PhD) immunisation, and exclusive breastfeeding. Other determinants of child survival that are not related to the health Correspondence to: system did not change between 1999 and 2004, except for a slow increase in the HIV/AIDS burden. Honorati Masanja, Ifakara Health Research and Development Centre, Kiko Avenue, Plot N 463, Interpretation Tanzania could attain MDG 4 if this trend of improved child survival were to be sustained. Investment Mikocheni, Dar es Salaam, in health systems and scaling up interventions can produce rapid gains in child survival. Tanzania [email protected] Funding Government of Norway.

Introduction birth-history surveys to obtain direct retrospective The Millennium Development Goal (MDG 4) to reduce estimates of child mortality.11 Such national surveys are mortality in children younger than 5 years by two-thirds done every 4–5 years and generally include measures of between 1990 and 2015 has come into focus in recent coverage for priority child-health interventions.12 The years as a galvanising force to align global and national surveys are standardised by national bureaux of statistics eff orts towards poverty reduction and better health.1–4 such as demographic and health surveys (DHS), which Much of the current burden of mortality in children are sponsored by USAID, and multiple indicator cluster younger than 5 years in low-income countries is surveys, which are sponsored by UNICEF. More than preventable if eff ective coverage of available cost-eff ective 40 national mortality surveys from the 60 priority interventions can be achieved.5 However, global countries will be available in 2005–07,12 one of the fi rst of assessments of the 60 priority countries where most which is from Tanzania. children younger than 5 years die show that very few are In 1990, mortality in children younger than 5 years in on track to reach MDG 4.1,6 Many of these countries are in Tanzania was 141 per 1000 livebirths; thus, Tanzania’s sub-Saharan Africa, where little or no reduction in MDG 4 is to reduce this to 47 per 1000 by 2015. In mortality in children younger than 5 years was evident Tanzania, demographic and health surveys were done throughout the 1990s. Since 2000, global health initiatives in 1992, 1996, 1999, and 2005.13–16 The fi rst three surveys and resources for health have increased sharply,7 which showed that the rate of child mortality throughout has increased coverage of life-saving child health the 1990s was high but static, oscillating between 141 and interventions in several countries.8–10 We would therefore 147 deaths per 1000 children (table 1). The most recent expect to see more evidence of progress towards MDG 4 survey, from late 2004 and early 2005, showed that the in such settings in the mid-decade assessments. probability that a child would die before they reached Since registration systems in sub-Saharan Africa have their fi fth birthday fell by 24%, from 146·6 (95% CI low coverage, most countries rely on periodic national 128·4–164·8) deaths per 1000 in 1999 to 112·0 (95% CI

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102·6–121·5) deaths per 1000 in 2004 (p<0·02).15 Similarly, Midpoint of period Sample size Mortality (deaths per 1000) the probability of dying before the fi rst birthday (data not (households) shown) fell by 31% from 99 to 68 deaths per 1000 over the 1987–9213 1990 8327 141·2 (95% CI 128·1–154·3) same period. Reductions in mortality were concentrated 1991–9614 1993 7969 136·5 (95% CI 124·8–148·2) in postneonatal infants (ie, those older than 28 days and 1994–99*16 1996 3615 146·6 (95% CI 128·4–164·8) younger than 12 months) and were greater in rural areas. 15 Neither neonatal nor maternal survival increased during 2000–05 2003 9735 112·0 (95% CI 102·6–121·5) this period. The 24% drop in mortality in children Data from four demographic and health surveys in Tanzania since 1990.13–16 *The 1999 survey was an interim survey of younger than 5 years, to 112 deaths per 1000, was reproductive and child health, that used a smaller sample size but identical methods for estimation of mortality. calculated from the average mortality across the 5 years Table *: Estimates of mortality in children younger than 5 years before the survey. Such a decline is unlikely to be due to one factor.17 But in 1991–92, and 22 000 in 2001–02. The sampling of the what can account for it? What are the prospects now for survey was designed to allow estimates of household Tanzania to reach MDG 4 over the ensuing 10 years? And variables for the 21 administrative regions of mainland what can we learn that would help other countries to Tanzania. Household and individual indicators included accelerate progress towards MDG 4? We aimed to measures of income poverty and performance of priority calculate the annual rates to examine the pattern of the sectors as defi ned in a paper on the government’s reduction in mortality and to see if the point estimate for poverty-reduction strategy.20,21 Data for trends in gross the year 2004 diff ered from historical values or from the domestic product (GDP) per person were obtained from period average. We also investigated Tanzania’s health- the Bank of Tanzania’s annual reports,22 the Penn World system investments, including coverage of child-survival Tables,23 and the Tanzania public expenditure review.24 interventions between the late 1990s and 2000–04, and examined other factors, not related to the health system, Statistical analysis such as national economic growth, poverty reduction, We analysed the raw data from all four Tanzania DHS food security, climate shock, fertility, maternal education, surveys (1992, 1996, 1999, and 2004)13–16 to generate several and HIV/AIDS, that could plausibly have exerted large, estimates of mortality in children younger than 5 years rapid eff ects on child survival. for every 1-year period before the respective survey back to 1990, by use of direct methods based on complete birth Methods histories. For every child recorded in these birth histories, Data sources we computed survival for every month from birth until To assess trends in mortality since 1990 we used all four either their fi fth birthday or the date of the survey. We Tanzanian demographic and health surveys, from 1992, grouped periods at risk and deaths for each calendar year, 1996, 1999, and 2004–05.13–16 These were nationally and constructed a separate life table for each year in the representative cluster sample surveys that covered 8327, birth histories for which suffi cient data were available to 7969, 3615, and 9735 households in 1992, 1996, 1999, and show, for a person at each age, the probability that they 2005, respectively. The surveys provided direct estimates would die before their next birthday. This generated of child mortality through complete fertility (birth) 35 estimates of mortality over the 15-year period from 1990 histories of 32 877 women aged between 15 and 49 years. to 2004. We estimated trends in mortality from 1990 The surveys also provided detailed information about to 2004 by fi tting Lowess regression25 of the natural log of household demographics; asset ownership; dwelling mortality in children younger than 5 years [ln(5q0)] to conditions; health and nutritional status of women and time with bandwidths ranging from 0·2 (representing children; coverage of health-care services such as high sensitivity to recent data) to 2·0 (low sensitivity) and immunisation, insecticide-treated nets, and maternal forecasted this trend for mortality from 2005 to 2015 with and child health; and current knowledge and practices the same range of bandwidths. We calculated confi dence related to health. Survey data were obtained by trained intervals for probabilities with Greenwood’s formula.26 personnel, with the verbal informed consent of We obtained fi scal-year data on total health spending, participants. To assess coverage of child-health both on-budget and off -budget, from the public-expenditure interventions, we also used a 2003 survey on service reviews of the Tanzanian Ministry of Finance and Ministry provision in Tanzania, which was a nationally of Health and Social Welfare.24 Spending data included all representative facility-based survey of maternal and child domestic government health spending (including the health and HIV/AIDS services.18 All the surveys provided government’s contribution to the national health insurance cross-sectional data on intervention coverage in their fund) and all aid spending on health from offi cial respective years. documents. We did not include private out-of-pocket We obtained data for poverty from Tanzanian household expenditure. We adjusted total government health budget surveys in 1992 and 2002,19 which tracked the expenditure for each year with consumer price-index progress of the government’s poverty-monitoring defl ators on the 1998/99 base year to provide the total strategy. These surveys sampled 4000 households government health expenditures per person per year. Thus,

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Factors not related to health systems included fertility, 200 GDP per person, and rates of poverty. We also examined 180 153·1 any major shocks, such as measles or meningitis 141·5 160 epidemics, famine, or increased food insecurity, that 128·2 140 might have aff ected mortality diff erently in the 1990s and 108·6 120 after 2000. 100 83·2 Role of the funding source 80 The corresponding author had full access to all the data 60 in the study and had fi nal responsibility for the decision (deaths per 1000 livebirths) 40 to submit for publication.

Mortality in children younger than 5 years than 5 younger Mortality in children 20 0 Results 1990 1991 1992 19931994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Our results for disaggregated annual mortality (ﬁ gure 1) Year show that the rate of reduction accelerated between 2000 Figure *: Annual mortality in children younger than 5 years from 1990 to 2005 and 2004. In 2004–05, the reduction in mortality Data are from an analysis of the 2004–05 national demographic and health surveys in Tanzania.15 Dotted line between 1990 and 1999 was 1·4% per year whereas shows Tanzania’s MDG-4 target of 47 deaths per 1000 livebirths by 2015. Vertical lines show 95% CIs for survival probabilities. for 2000 to 2005, this trend accelerated to 10·8% per year (from regression trend analysis). The point estimate of mortality in children younger than 5 years in 2004 200 was 83·2 (95% CI 70·1–96·3) per 1000, which was 180 40% lower than typical values seen in the 1990s corresponding to a change of 58·3 per 1000 in absolute 160 risk (95% CI 32·7–83·9). This raises the question: is 140 MDG 4 more achievable than was previously appreciated? Figure 2 shows the family of smoothed regressions of the 120 combined disaggregated mortality data from all four 100 demographic and health surveys with extrapolation to 2015 under diﬀ erent weightings for the recent past. All 80 these weighting projections suggest that MDG 4 is within reach in Tanzania by 2015. (deaths per 1000 livebirths) 60 We compared the status of selected health-system

Mortality in children younger than 5 years than 5 younger Mortality in children 40 factors across the major functions of governance, fi nancing, resource allocation, and service delivery 20 for 1999 and 2005. Health systems improved substantially 0 on the basis of most of the indicators that we investigated. 1990 1995 2000 2005 2010 2015 With respect to governance, fi nancing, and resources, Year Tanzania adopted a sector-wide approach (SWAp) for Figure 1: Estimates of annual mortality in children younger than 5 years medium-term and long-term planning, in which a Data are from reanalysis of four national demographic and health surveys in Tanzania, which included the birth coherent policy and expenditure programme, under histories of 32 877 women aged 15–49 years in 1992, 1996, 1999, and 2004–05.13–16 The MDG-4 target in 2015 is government leadership, was jointly funded by pooled shown by the horizontal line. The dotted line shows the rate of reduction needed to reach this target. Lowess regression forecasts of possible future trends are shown by coloured lines, with red giving most weight and yellow government and donor partners. A so-called basket giving least weight to recent data trends. fund, jointly funded by partners, was created to provide an additional US$0·50 per person to districts as monetary amounts are represented in the international recurrent fi nancing support. This approach was dollar, a hypothetical unit of currency with the purchasing implemented in 2000–01 and constituted a major change power that the US dollar had in the USA at a specifi c time. in the health system that decentralised substantial We obtained total health expenditure including private fi nancial resources for the fi rst time. Moreover, out-of-pocket spending from WHO statistics.27 between 1999 and 2004, we noted a 2·3-fold increase in We searched for information on all contextual factors total government health expenditure, from US$4·70 to that might have aff ected trends in child survival, $11·70 per person. Total health expenditure, including diff erentiating factors related to health systems from private expenditure, increased from US$23 to $29 per those that were not.28 Factors related to health systems person,27 indicating that most of the growth in health included the comparative provision, use, or coverage of spending was due to increases in government key child-survival interventions in 1999 and 2004; relevant expenditure. policy changes regarding management, decentralisation, On the policy front, many health reforms planned and services; and trends in public expenditure on health. during the 1990s started to be implemented during

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the 2000s, including the sector-wide approach basket 1999 funding; new guidelines, methods, and informatics for 2005 district planning and management; and new policies (eg, substitution of more eﬀ ective ﬁ rst-line anti-malarial Antenatal care drugs). Under its poverty-reduction strategy, Tanzania’s Measles immunisation Ministry of Health and Social Welfare increased the

priority of cost-eﬀ ective interventions which supported Fully immunised child at 12 months national decisions and commitments to scale up and strengthen several key child-survival interventions such Exclusive breastfeeding 0–2 months as Integrated Management of Childhood Illness (IMCI), vitamin A supplementation, immunisation, and Child given oral rehydration treatment insecticide-treated nets. We did not record major gains in numbers of health professionals or physical Iron supplementation infrastructure for health during this period. Malaria intermittent preventive treatment

For service delivery, the coverage of interventions Intervention relevant to child survival improved between the 1999 Exclusive breastfeeding 0–6 months and 2004–05 surveys (ﬁ gure 3). The most noticeable changes were vitamin A supplementation (up from 14% Households with at least one mosquito net in 1999 to 85% in 2005), IMCI (up from 19% to 73% of districts), households with mosquito nets (up from 21% Districts with integrated management of childhood illnesses to 46%), children sleeping under insecticide-treated nets (up from 10% to 29%), iron supplementation in Vitamin A supplementation pregnancy (up from 44% to 61%), oral rehydration Child sleeping under ever-treated therapy for children (up from 57% to 70%), and exclusive insecticide-treated net

breastfeeding for those younger than 2 months of age 0 10 20 30 40 50 60 70 80 90 100 (up from 58% to 70%) and younger than 6 months (up Coverage (%) from 32% to 41%). Coverage of other interventions did not change signifi cantly, since it was already high Figure 2: Comparison of access to key child survival interventions between 1999 and 2005 in 1999 (fi gure 3). Coverage of prevention of Data are from national demographic and health surveys in Tanzania. mother-to-child transmission of HIV (PMTCT) and antiretroviral therapy as of 2005 remained very low, and water was a protected source.29 The total fertility rate therefore unlikely to have contributed to a reduction in did not change over this period, but the average age at mortality in children younger than 5 years. As a risk fi rst birth was 19·0 years in 2000, and 19·4 years in factor for child mortality, rates of underweight and 2002; the rate of adolescent childbearing diminished stunted children improved from 29% and 44% in 1999, (from 26·1% to 24·6%); and median birth intervals did to 22% and 38% in 2005, respectively. not change (33·3 and 33·4 months, respectively). Of all the factors not related to Tanzania’s health Tanzania had a low rate of food-energy defi ciency (43·9%) system that could possibly have aff ected child survival in 2000.30 (table 2), the only change was a worsening of the The estimated prevalence of HIV in adults aged manifestations of the HIV epidemic. Over the 5 years 15–49 years was 8%, according to the demographic and of our study, Tanzania’s national wealth (in GDP per health survey in 1999,16 whereas the fi rst national person) increased by 93 international dollars: from $819 community-based survey of HIV prevalence in 2003–04 to $912 per person between 1999 and 200423 (or US$256 established the rate to be 7% in adults aged 15–49 years.18 to $303). The proportion of households living below the Urban areas had higher rates of HIV than did rural areas. poverty line was 36% in 2001–02 and 39% in 1991–92 In 2004, only 3–9% of health facilities ran programmes (p=0·29). Poverty in urban areas, excluding Dar es for prevention of mother-to-child-transmission of HIV; Salaam, decreased from 29% to 26% during this period most of these were district and faith-based hospitals and (p=0·60), whereas that in rural areas dropped from 41% a few health centres. By 2006, only 13% of health facilities to 39% (p=0·52).29 The educational attainment of adults off ered at least one of the four components of the PMTCT improved only marginally between 1999 and 2004, with programme.31 greater gains for women than for men (table 3).14,15 When we analysed the diff erentials between coverage Similarly, literacy rates did not change; about two-thirds of health interventions between 1999 and 2004 using a of the women were reported to be literate throughout modelling system,32 we extrapolated a 33% reduction of this period. Population-based statistics on access to safe mortality in children younger than 5 years, from 129 to water in Tanzania were sparse; those that were available 86 deaths per 1000 livebirths. These eff ects would mainly indicated no change between 2000 and 2002 in the be attributable to reduction of postneonatal mortality in proportion of households for which the main supply of children younger than 5 years.

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suggest that Tanzania is on the trajectory necessary to 1999 2004–05 achieve MDG 4 by 2015, for a range of diff erent weightings Gross domestic product per person US$256 US$303 of past performance in the distant or near past, back Number living in poverty (food) 21·6% 18·7% to 1990. Our results diff er from those of an analysis of all Number living in poverty (basic 38·6% 35·7% available data from direct and indirect estimates of needs) mortality disaggregated into 2-year intervals, including Food security No change data before 1990, which concluded that Tanzania would Climate shock No change not be able to achieve this goal.6 However, the data from Total fertility rate (children for 5·6 (5·0–6·1) 5·7 (5·4–5·9) before 1990 can have little bearing on the ability to achieve every mother) a goal for which the starting point is 1990, especially Low birthweight 133/3206 (3·8%) 344/8551 (3·7%) since the purpose of the MDG was to elicit changes in Age at fi rst birth (years) 19·2 (17·4–21·6) 19·4 (17·7–21·8) trends. To assume that the trend before 1990 continued Birth spacing (months) 33·3 (28·0–41·0) 33·4 (28·0–42·4) would imply that setting the goal was futile. In this Meningitis epidemics None None specifi c instance, performance was poor before 1990, and Measles epidemics None None inclusion of earlier data biases the conclusion towards a HIV/AIDS epidemics Increasing mortality slower improvement. Furthermore, all extrapolations must, of necessity, assume a degree of continuity in the Data are number (%), rate (95% CI), or median (IQR), unless otherwise specifi ed. underlying processes, and so tend to over-smooth if a Table 1: Comparison of non-health system changes between 1999 trend accelerates, as it seems to have done in Tanzania in and 2005 that might be expected to aff ect child survival about 2000. Since aggregation of the data into longer time-units tends to increase the degree of this smoothing, we disaggregated the data into shorter time units. Completed primary education Completed secondary Years of schooling The large reduction in mortality evident since 2000 education immediately raises questions about the quality of surveys 1999 2004–05 1999 2004–05 1999 2004–05 and data and about comparability over time. Additional Women 46% 49% 5% 9% 6·1 6·2 quality control was provided for the 2004–05 demographic Men 51% 52% 7% 11% 6·2 6·3 and health survey and its data precisely because fewer child deaths were recorded than were expected.15 Data are from demographic and health surveys in Tanzania in 1999 and 2005.15,16 Under-reporting bias could also have occurred, for Table 2: Educational attainment of men and women aged 15–49 years example if maternal mortality increased because of HIV/AIDS or other factors. The cross-sectional Discussion demographic and health surveys did not gather In Tanzania, the most recent demographic and health information about children whose mothers died. survey in 2005 showed a 24% improvement in child However, the demographic surveillance systems in survival, with mortality rates in children younger than Tanzania, which track entire populations longitudinally, 5 years down from 147 deaths per 1000 for 1994–99 to also reported reductions in mortality in children younger 112 deaths per 1000 for 2000–04 (p<0·02).15,33 In national than 5 years, which substantiates the data from the birth-history surveys, these 5-year averages conceal the demographic and health surveys.35 Furthermore, pattern and degree of change in yearly rates. Since this demographic and health surveys in 1999 and 2005 did 5-year change substantially exceeded 15%, the minimum not detect any major increases in maternal mortality regarded by Korenromp and colleagues34 as indicative of between these two periods, although such changes would a true reduction, we decided to calculate the yearly rates be diffi cult to detect in sample sizes used in the to examine the pattern of the reduction and to see if the demographic and health surveys. With respect to deaths point estimate for the year 2004 diff ered from historical of mothers due to HIV/AIDS, reduced mortality in values or from period average. children younger than 5 years is probably not an artifact Our analysis of the annual rates shows a pattern of caused by the under-reported deaths, since the estimated continuous reduction in mortality reaching 83·2 (95% CI magnitude of this eff ect in a rural Tanzanian population 70·1–96·3) deaths per 1000 in 2004. Within the with an HIV prevalence of 4·3% would underestimate 2004–05 survey data, fi ve of the six lowest values over the deaths in children younger than 5 years by only 2·3%.36 15 years were recorded in the last 5 years,15 indicating that If we assume that our fi nding of a reduction in mortality mortality in this group fell by 40% between 1990 and 2004. for children younger than 5 years is real, what can explain Based on Tanzania’s 2002 population of 34·4 million, this apparent acceleration of survival in Tanzania after a this fi nding suggests that 280 000 children’s lives were decade of high but static mortality rates in the 1990s? saved between 1999 and 2005 that would otherwise have And can this improvement be sustained? We examined been lost had the prevailing rate of the 1990s continued. diff erences in the health system in Tanzania between 1999 Our analyses of data from all four demographic and and 2004 and in external factors that could reasonably be health surveys, analysed by year of reference, thus expected to have contributed to large survival gains over

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this short period. Between 1999 and 2004, Tanzania more interventions, such as antenatal care an immunisation, than doubled its public expenditure on health; such coverage was already high, and did not change. increased expenditure has been strongly correlated with Modelling showed that a 33% reduction of mortality in increased survival in children younger than 5 years in children younger than 5 years could be expected developing countries, especially in poor people.37 between 1999 and 2004, from 129 to 86 deaths per Increased public expenditure on health could also be 1000 livebirths. These eff ects would mainly be in especially powerful in decentralised health systems when reduction of postneonatal mortality in children younger such resources are targeted towards essential cost-eff ective than 5 years. The predicted failure to aff ect neonatal (and interventions.38 Tanzania implemented such governance maternal) mortality draws attention to problems with the shifts towards greater decentralisation in 2000, by continuum of care necessary to achieve MDGs. The introducing sector-wide capitation grants that gave general scarcity of data and analyses continues to limit districts substantial fi nancial resources. This was perhaps programme eff orts and monitoring of progress. one of the most important distinctions in Tanzania’s Among factors not related to the health system, gains health system between the 1990s and the 2000s, since it in wealth would be expected to exert a major eff ect on opened opportunities for local problem solving and survival in children younger than 5 years. Tanzania has provided resources for districts to selectively increase enjoyed many decades of political stability and, in recent resources for key interventions, as has been shown in years, steady economic growth. Nevertheless, GDP per pilot studies since 1996.38 person has increased by only 93 international dollars Decentralisation allowed the introduction and scale-up (US$47) over the 5 years between 1999 and 2004. An of new interventions such as the integrated management increase of this size corresponds to an expected decrease of childhood illness, which facilitated adoption of new in mortality in children younger than 5 years of 2·2%, on treatment policies for malaria that replaced failing the basis of a regression of GDP (in international dollars) fi rst-line treatments with more eff ective case management per person and mortality in children younger than 5 years for the largest single cause of death for children. The for 45 sub-Saharan countries (data reanalysed from WHO IMCI programme also assisted promotion of the use of statistics).27 Although important, this growth in national insecticide-treated nets for malaria prevention. Sentinel wealth would be unlikely to account for much of our districts had piloted the introduction of IMCI from 1997, fi nding of a 40% reduction in mortality, especially since with full provision, increased use, and eff ective coverage the proportion of the population living below the absolute by 1999–2000.39 Impact studies showed that, after a 2-year poverty line and food poverty line in the 1990s had follow-up, IMCI was associated with 13% lower child improved only slightly in 2002. Although gains have been mortality in pilot districts that had health-system made in the education of Tanzania’s current cohort of strengthening than in other districts.40 Other pilot studies schoolchildren, child-health outcomes are aff ected by the in Tanzania showed the high local eff ectiveness of educational status of parents, which had improved only insecticide-treated nets for reduction of mortality in marginally by 2004. Early child-bearing and short children of this age.41 birth-spacing both raise the risk of child mortality, and Tanzania started nationwide scale-up of the total fertility rate, average age at fi rst birth, adolescent insecticide-treated nets in 1999 and of IMCI in 2000, and childbearing, and median birth intervals remained changed its drug policy for malaria in 2001. Since malaria similar in the two periods. Hence changes in fertility mortality in Tanzania is concentrated in postneonatal probably did not contribute to our fi ndings of a large infants younger than 5 years,42 the survival gains recorded improvement in child survival. in the 2004–05 demographic and health survey were We did not fi nd evidence of any major epidemics (for highest for postneonatal infants, suggesting that example, of measles or meningitis) that might have malaria-specifi c mortality reduction has made progress. occurred in the late 1990s but not in the early 2000s. Moreover, several sentinel sites in Tanzania, which Conversely, adult and child mortality due to HIV/AIDS monitor cause-specifi c mortality by use of continuous continued to increase slowly,43 and therefore diff erentials longitudinal demographic surveillance systems, also in HIV/AIDS interventions might have aff ected overall reported reductions in mortality in children younger mortality, since 25% of children who are born to than 5 years before the fi ndings of the 2004–05 HIV-positive mothers are infected. The PMTCT demographic and health surveys, and detected declines programme is a proven cost-eff ective combination of in malaria and acute febrile illness deaths in children strategies and interventions that can be tailored to specifi c younger than 5 years.34,43 These fi ndings add plausibility local conditions. These interventions and strategies, to the hypothesis that the collective eff ect of a multifaceted including voluntary and confi dential counselling and approach to malaria contributed to child-survival gains testing, provision of antiretroviral drugs to HIV-positive during this period.44 Coverage of other child-survival pregnant women, planning of safe delivery procedures, interventions, such as vitamin A supplementation,45 and counselling about appropriate infant-feeding options, exclusive breastfeeding, oral rehydration therapy and can reduce mother-to-child transmission by 50%. iron supplementation for children, increased. For other However, in Tanzania access to HIV/AIDS interventions

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such as voluntary counselling and testing, PMTCT, and We were unable to estimate the relative contributions antiretrovirals was not yet suffi cient as of 2004 to have of diff erent factors in the health system to reduction of aff ected child survival on a national scale. Epidemic child mortality since 2000. However, the collective weight patterns, including HIV/AIDS and its response, can of so many positive changes in the health system, in the therefore be excluded as an explanation for the reduction absence of other explanations, is compelling. Rather, we in child mortality, and could even have worked against could ask why we would not expect to see gains in this trend. survival.5 Broad, multifaceted progress in stewardship, Nutrition can be determined by health systems (eg, public expenditure on health, decentralised fi nancing, micronutrient supplementation and other health sector resource allocation, and better coverage of essential interventions) and by other factors (eg, food insecurity, child-survival services can work synergistically to eff ect poverty, climate shocks, and natural disasters). We did important progress towards MDG 4 in low-income not identify evidence of major events outside the health countries such as Tanzania. Increased health resources system that could have contributed to changes in combined with strengthening of decentralised health nutritional status in Tanzania during the study period. systems to ensure that life-saving interventions reach However, the nutritional status of children did improve those in need is a key child-survival strategy. slightly, possibly because of better access to various Contributors general health interventions (eg, IMCI, insecticide-treated HM and DDS led the conceptualisation of the paper with contributions nets, and vitamin A supplementation), and slight gains from all authors and wrote the fi rst draft. PS compiled statistical data, and HM, TS, and DDS did statistical analyses. JS, TJ, CM, GU, TB, and in wealth. Improved nutritional status is likely to have CV contributed to the interpretation and writing of this manuscript. All contributed to the reduced risk of mortality in children authors have seen and approved the fi nal version. younger than 5 years. Confl ict of interest statement If we assume that the trend is real, and is due to a We declare that we have no confl ict of interest. strengthening health system and increased access to key Acknowledgments child-survival interventions, can this trend be continued? We thank the Government of Norway for encouragement and fi nancial It should be noted that the most recent demographic and assistance. health survey, in 2004–05, preceded the potential eff ect of References increased funding to Tanzania from the Global Fund to 1 Horton R. A new global commitment to child survival. Lancet 2006; 368: 1041–42. Fight HIV/AIDS, Tuberculosis and Malaria. Although 2 Martines J, Paul VK, Bhutta ZA, et al. Neonatal survival: a call for the fi rst grants were announced in late 2002, the actual action. Lancet 2005; 365: 1189–97. programmes that they supported did not begin until 3 Lawn JE, Cousens S, Bhutta ZA, et al. 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Social Science & Medicine

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The emergence of community health worker programmes in the late apartheid era in South Africa: An historical analysis

Nadja van Ginneken a,*, Simon Lewin a,b,c, Virginia Berridge d a Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK b Health Systems Research Unit, Medical Research Council of South Africa c Norwegian Knowledge Centre for the Health Services d Centre for History in Public Health, London School of Hygiene and Tropical Medicine, United Kingdom article info a b s t r a c t

Article history: There is re-emerging interest in community health workers (CHWs) as part of wider policies regarding Available online 23 June 2010 task-shifting within human resources for health. This paper examines the history of CHW programmes established in South Africa in the later apartheid years (1970se1994) e a time of innovative initiatives. Keywords: After 1994, the new democratic government embraced primary healthcare (PHC), however CHW Community health workers initiatives were not included in their health plan and most of these programmes subsequently collapsed. Community health worker (CHW) policy Since then a wide array of disease-focused CHW projects have emerged, particularly within HIV care. South Africa Thirteen oral history interviews and eight witness seminars were conducted in South Africa in April Oral history Apartheid 2008 with founders and CHWs from these earlier programmes. These data were triangulated with Task-shifting written primary sources and analysed using thematic content analysis. The study suggests that Community participation 1970se1990s CHW programmes were seen as innovative, responsive, comprehensive and empowering for staff and communities, a focus which respondents felt was lost within current programmes. The growth of these earlier projects was underpinned by the struggle against apartheid. Respondents felt that the more technical focus of current CHW programmes under-utilise a valuable human resource which previously had a much wider social and health impact. These prior experiences and lessons learned could usefully inform policy-making frameworks for CHWs in South Africa today. Ó 2010 Elsevier Ltd. All rights reserved.

Introduction interest waned in the late 1980s and 1990s for several reasons: structural adjustment programmes; government failure in coun- Community health workers (CHWs) are increasingly advocated tries where large programmes were operational; and changes in as a potential solution to overcoming current shortfalls in human ideology (Frankel, 1992; Walt & Gilson, 1990; WHO, 1986). resources for health in different settings (Chopra, Munro, Lavis, South Africa has a rich history of CHW projects that burgeoned Vist, & Bennett, 2008; Lewin et al., 2010; WHO, 2008). CHW is an during the repressive regime of apartheid (Table 1 juxtaposes key umbrella term used for a heterogenous group of lay health workers. historical and project events). Under this racially and politically Their remit can range from implementing biomedical interventions divided regime, healthcare was intentionally inequitably distrib- to acting as community agents of social change (Lewin et al., 2010; uted (WHO, 1983). Among the first CHWs were malaria assistants Werner & Bower, 1982). This paper defines CHWs as people chosen trained in the late 1920s by G.A. Park Ross, a senior health officer in within a community to perform functions related to healthcare Natal and Zululand (MacKinnon, 2001). In the 1940s, despite an delivery, who have no formal professional training or degree. CHWs early Smuts government advocating racial segregation, supporters initially gained global support at the 1978 Alma Ata conference on of social medicine initiated the ‘health centre’ movement. Chief primary healthcare. They were seen as a key element of the strategy among the politicians involved was Henry Gluckman, the then to achieve WHO’s goal, set in 1975, of ‘Health for All by the year Minister of Health, who had been influenced by the United King- 2000’. Many CHW programmes were established in the 1970s in dom’s Beveridge Report (1942). The ambitious 1942 National low- and middle-income countries (Walt & Gilson, 1990). However, Health Service Commission and 1945 Gluckman Report set out to provide “unified healthcare to all sections of the people of South Africa”. They addressed both the social and biomedical causes of * Corresponding author. disease, responding in part to concerns regarding the effects of poor E-mail addresses: [email protected], [email protected] ’ ’ (N. van Ginneken). health on black migrant labourers and miners productivity

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Table 1 to the ‘homeland’ governments (van Rensburg & Harrison, 1995). Timeline of CHW projects and historical landmarks in South Africa. Most of these governments were under-resourced and corrupt and Date Event thus neglected health service funding. 1913 Natives Land Act (7.3% of South African land Another phase of CHW projects began in the 1970s and dedicated for Africans’ habitation) continued into the 1990s, established mostly by individuals or 1930s Park Ross: Malaria assistants small civic or religious organisations (Tollman & Pick, 2002). There 1940s Revival of African nationalism. African National was a growing conviction from the late 1980s that apartheid would Congress (ANC) rebuilt 1940 Pholela Health Unit founded by the Karks soon end, particularly after African nationalist organisations were (Kwazulu) unbanned and their leaders released (Baldwin-Ragavan, Gruchy, & 1942e1944 National Health Services Commission London, 1999). This encouraged progressive thinkers and 1945 Gluckman Report: intersectoral academics to develop community initiatives and formulate advice recommendations for comprehensive health which they hoped would inform a new government’s health poli- service. Only health centres and IFCH established. cies (Price, 1993). 1948 Nationalist Party comes to power In 1994, South Africa welcomed its first democratic government. 1951 Bantu Authorities Act: forcible relocation of Though the government adopted the district health system (DHS) ‘ ’ blacks to homelands as the cornerstone of their national health plan, CHWs were not 1951 Valley Trust established 1958 Karks’ exodus included. Subsequently, many CHW projects collapsed as interna- 1960 Sharpville massacre; ANC and Pan African tional donors withdrew their earlier support, or redirected their Congress (PAC) banned. funds through government departments. In recent years, an 1970 Chalumna/Newlands project started uncoordinated array of CHW programmes has re-emerged, mainly 1976 Soweto uprising: sparks nationwide uprisings within healthcare for people living with HIV/AIDS (Friedman, 1976 Elim Care Groups started 1977 Steve Biko (leader of Black Consciousness 2005). Movement) tortured/dies in detention The early history of the 1930s and 1940s CHW projects has been 1977 Public Health Act: dual/segregated healthcare analysed elsewhere (Jeeves, 2000, 2005; Marks, 1997; Tollman, e 1979 Health Care Trust VHW project started 1994). However the late apartheid period (post-1970s) lacks 1980 Valley Trust establishes CHW programme; SACLA clinic historical analysis. This study aims to explore the factors affecting 1982 National Medical and Dental Association these late apartheid projects’ evolution. This historical analysis founded to address human rights intends to contribute to current debates on the appropriateness, 1985e1986 3 states of emergency: detentions/repression/ effectiveness and sustainability of CHW initiatives within South assassinations Africa and to similar global debates. 1986 SACLA clinic taken over by army 1986 Mamre Community Health Project and Rural Foundation Health Project started 1987 National Progressive Primary Health Care Methods Network founded 1989 Relaxing of emergency laws 1990 ANC/PAC unbanned; progressive release of Our approach used oral history interviews (in-depth, open- imprisoned leaders (including Mandela) ended interviews seeking people’s reconstruction and interpreta- 1991 Mamre/Zibonele projects start CHW tion of events) with founders, coordinators and health workers of programmes CHW initiatives active during the study period. This approach was 1992e1994 Preliminary ANC health plan; national CHW chosen as people working within CHW projects at this time were workshops/conferences ‘ ’ ‘ ’ 1992 HCTe Brown’s Farm and Agincourt started busy doing rather than documenting . This technique recognises (CHWs until mid-1990s) individual experience, often missing from standard social histories, 1994 First democratic elections (Mandela elected); and gathers unrecorded information (Perks, 1992). fi nal health plan To select interviewees, four contacts known to one of the 1994e2003 Social/health policies promoting development and intersectoral collaboration (e.g. 1994: authors (SL) helped identify further participants through snow- Reconstruction and Development Programme); balling. Participants were chosen from urban and rural projects Many late-apartheid CHW programmes close where documentation was available. Of 54 potential interviewees, 2004 Community Health Policy Framework 39 were selected on the basis of representativeness of professional background, involvement in CHW programmes, and availability. Tragically, one key participant, Ivan Toms, died unexpectedly before (Phillips, 1993). However, the government only adopted the his interview. A total of 38 participants were therefore interviewed recommendation to establish health centres (Jeeves, 2000, 2005; from 10 projects (Table 2). One author (NvG) visited five provinces Marks, 1997). Modelled on the rural health centre in Pholela (Western Cape, Eastern Cape, Kwazulu-Natal, Mpumalanga and (near Durban) initiated by Sidney and Emily Kark e a progressive Limpopo) in South Africa in April 2008 to conduct 10 oral history and politically well connected medical couple e these centres were interviews. An additional two interviews were conducted by staffed by community nurses and assistants who treated and phone, and one in London. Eight witness seminars (focus groups surveyed health problems (Kark, 1951; Tollman, 1994). Only 40 of with two to seven participants from the same project) were also the suggested 400 centres were eventually built to serve black conducted, partly out of convenience but also because groups may communities. This service became racialised and gained a reputa- encourage recollection of events. This research’s principal limita- tion for being a “second class service” (Marks, 1997). tions are that snowballing may not have reached saturation and the As the Afrikaner National Party strengthened from 1948, the chosen CHW initiatives may not have included the full range of government withdrew its support from these centres. Many centres contemporaneous programmes. closed and a number of their founders, including the Karks, went Most interviews were conducted in English; four required an into exile (Marks, 1997). From the 1960s to 1980s, when the interpreter (Zulu and Shangaan) and professional translation. bantustans (‘homelands’) became ‘independent’, the responsibility Interviews explored how respondents became involved in CHW for the forcibly relocated black population’s health care was given programmes, their experiences and their views on CHW

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Table 2 Details of projects.

Project Comments CHW characteristics Current Status Interviewees CHW C D/N F

(PERI-)URBAN INITIATIVES 1110 (2010) 71 Medicine & Science Social / al. et Ginneken van N. South African Christian Leadership CHW programme in several peri-urban Paid; generic and specialist (rehabilitation) Running 1 3 2 1 Assembly Health Project townships in Cape Town Mamre Community Health Project Coloured community. 3 components: Paid; specialist (youth, chronic illnesses, Closed 1 1 1 research, CHW project, student teaching hypertension) (academic) Health Care Trust e Brown’s Farm Peri-urban township in Cape Town Paid; generic Closed 1 Project Zibonele Peri-urban township in Cape Town Paid; specialist (women, children) Closed 1 1 (academic)

RURAL INITIATIVES The Elim Care Group Project Originally focussed on trachoma, Most volunteers; generic: (care-group volunteers, Running 8 1 1 then expanded to general health motivators, CHWs) (Northern-Province) Chalumna and NewlandsVillage In the former Ciskei (Eastern Cape) Stipend; generic Closed 1 Health Worker Project Focus on nutrition, immunisation, TB Health Care Trust e Village Health Xalanga district in the former Transkei Volunteers; generic Closed 1 Worker Project (Eastern Cape) The Valley Trust Community Care CHW project: part of Valley Trust e a large Volunteers then paid; generic Running 1 Project inﬂuential organisation, Kwazulu-Natal. Focus on health and ecology. e The Rural Foundation Health Nationwide CHW programme for farm Paid by farmers; generic CHW programme 2 4 1 1118 Programme workers (started in Transvaal) closed National Progressive Primary Umbrella organisation for progressive Closed 1 1 Health Care Network community health projects. Set up a CHW National Training Centre. Agincourt Community health project with a focus on Paid research assistants Running 1 surveillance in Gazankulu (academic) C, coordinator; CHW, community health worker; D, doctor; N, nurse; F, founder. 353 N. van Ginneken et al. / Social Science & Medicine 71 (2010) 1110e1118 1113

programmes’ development. The interview guide was adapted to The motive for helping the black population was not always incorporate emerging themes. altruistic. There was also fear of a spill-over of ‘black diseases’ to the Primary and secondary historical sources were obtained from white community. This provided an incentive for a study on health libraries (UK and South Africa), government databases, the South and urbanisation to assess the impact of black urban migration on African National Archives in Cape Town and from bibliographies. white city dwellers. Prevention strategies to ‘sanitise’ the most Grey literature held by interviewees (conference papers, reports, disadvantaged are globally recognised in history across public minutes, theses, photographs) was reviewed. The interviews were health reform (Pelling, Berridge, Harrison, & Weindling, 2001). This manually transcribed, coded and analysed by one author (NvG) study ultimately led to the creation of the Centre for Epidemio- using thematic content analysis. The other authors read selected logical Research in Southern Africa (CERSA), which included transcripts and commented on emerging themes. progressive thinkers concerned with documenting and addressing The analysis involved an inductive process to identify emerging the ill health of the underprivileged (F5). themes. Constant comparison ensured that the themes reflected The Karks’ Community Oriented Primary Care (COPC) model, the original data. Oral sources were cross-examined with written developed in South Africa, contributed to shaping the 1977 Alma- material. This methodological triangulation allowed the identifi- Ata declaration and subsequent global community health move- cation of critical perspectives and emerging themes (Green & ments. It also influenced later projects in South Africa. The Karks’ Thorogood, 2004). visits to Johannesburg and Durban in the 1980s and 1990s Because some respondents requested anonymity, participants contributed to academics reviving surveillance/research-based have been kept anonymous. Their quotes are coded according to projects based on the COPC approach. Mamre (in the Western Cape) participants’ professional background (C: coordinator; CHW: and the Agincourt site (in Gazankulu, now Limpopo Province) of community health worker; D: doctor; N: nurse; F: founder). This the University of Witwatersrand Health Systems Development research was approved by the ethics committees of the London Unit, developed and utilised participatory research approaches to School of Hygiene and Tropical Medicine and the University of create an important body of evidence on community health needs Cape Town. (Katzenellenbogen, Hoffman, & Miller, 1990; Tollman, 1999). Leaders of non-academic civic projects drew less influence from the Karks’ model. Though South Africa did not attend the Alma Ata Results conference due to international sanctions, project founders embraced these principles as they reflected and justified their How CHW programmes started efforts. One founder explained why: The driving force for non-governmental organisations’ (NGO) or “Immediately.I was taken up with the idea. In fact Alma-Ata was rural health initiatives was often the desire of individuals to address in 1978, so ideas about primary healthcare were floating around at the health of the under-served black majority. Most leaders of these that time and were starting to get formalised. What was clear to me initiatives were white doctors or nurses as oppression and poverty was that [our project] had been practising PHC for nearly two made it difficult for blacks to establish such infrastructures. Ithuseng decades before that. Because if you looked at what the principles of health centre project set up by Mamphela Ramphele was one excep- Alma-Ata were, things like community involvement, community tion to this (Ramalepe, 1992). Involvement was sometimes fuelled by development, appropriate health technologies, using a basic religious conviction (CHW12, C3) or by guilt about their privileged approach, even. basic equity. I mean there were things of course position compared to racially-oppressed black counterparts (C9). that weren’t being done, but some of those principles were being Founders of many programmes explained that these projects implemented and I felt very much at home. And for the next decade arose during a time of growing discontent with apartheid, we really tried to make it a living example of primary healthcare in expressed through uprisings and demonstrations. The promise that action.” (F2) the 1977 Public Health Act would expand healthcare for the black Some respondents, particularly from repressive regime areas population remained unfulfilled (De Beer, 1984; Digby, 2006). The like the Ciskei, felt that their projects started in isolation and had health and social problems experienced by the black majority few external influences as political sanctions hindered communi- worsened, as documented in the Second Carnegie Inquiry into cation and access to information from outside of South Africa: Poverty and Development in South Africa (1984), to which some project founders contributed (Wilson & Ramphele, 1989). “I was the only one. Mine was the only community health During this period, CHW projects often started as single inter- department. There weren’t any others in this province. There was ventions to address what was seen as the greatest need (Table 2). no such thing as community health work.you know. I was just the The Elim Care Groups, spear-headed by the Swiss ophthalmologist clinic doctor and then the sense of a community health service Erika Sutter, responded to trachoma (an eye infection causing grew.” (F8) blindness). The Newlands and Chalumna projects, led by Trudy In the late 1980s, conditions became more favourable to infor- Thomas, a paediatrician, set up a nutrition scheme to respond to mation exchange. Health activism grew alongside anti-apartheid kwashiorkor (protein-energy malnutrition). The success of these activism. A network of local community health organisations single interventions led them later to address wider health issues in formed the Progressive Primary Health Care Network (PPHCN). their communities. Supported by the National Medical and Dental Association and the Health projects, such as the Empilisweni SACLA (South African (Kaiser-Foundation, 1988), it strengthened project cross-fertilisa- Christian Leadership Association) in an informal settlement outside tion and collaboration to formulate a future primary healthcare Cape Town, and Health Care Trust’s (HCT) rural health initiative in strategy (NPPHCN, 1986). Cala in the Transkei (now Eastern Cape) were motivated partly by community requests: The political nature of CHW projects “We weren’t looking for long term projects. We were approached to do these so I think it was something that we had as part of our Most respondents felt that healthcare provision was inseparable values. We weren’t just ‘go and plonk ourselves’ in communities. It from democracy, reflecting De Beer’s (1984) description of apart- had to be something that we were approached by.” (F7) heid as the most important ‘disease’ affecting South Africa. Some

354 1114 N. van Ginneken et al. / Social Science & Medicine 71 (2010) 1110e1118 respondents’ conviction that politics and health are connected overload and demotivation of staff. Some projects, however, explained their involvement in political activism. This put them at successfully involved communities. Brown’s Farm health-clinic lay significant risk of detention without trial (D1, F3, F6), receiving managerial committees, and Elim and Rural Foundation coordina- threats (C11) or being harassed (CHW1), but did not hinder their tors were good mediators for enhancing community participation commitment to work. and dissipating personal and political disputes. However, commu- Other respondents were not politically active or found it too nity participation was never comprehensive e rather, it was dangerous. They masked their desire for political change under the restricted to certain tasks within projects. With the exceptions of banner of healthcare provision while simultaneously challenging SACLA and Elim, projects were established and run exclusively by the status quo by empowering CHWs to become agents of social people from outside the communities served. change. The Valley Trust, HCT and SACLA, for example, successfully Experienced programme clinicians and leaders developed and introduced democratic community structures and elections within undertook hands-on supervision and ongoing training of CHWs their projects. As one of the founders said: and coordinators. Most CHWs described their supervision as informative and non-threatening: “I felt we needed to bring in the social aspects, where we needed to bring in elements of community involvement. Dangerous stuff at “On the farm [the supervisor] walk with me and the house-visit. that time, because working with black communities was on the And she look at us. And when something not right she don’t say: ‘He fringe of social revolution, but luckily primary healthcare permitted he he, no’. She go with us in the clinic. In the container, we sit down, that ideology.” (F2) and she say: ‘Do you remember, what did you learn?’” (CHW3) Most of the respondents who were active politically worked in areas where major political and social injustices had been carried Appropriateness and adaptability out. The government’s systematic attempt in the 1980s to crack down on ‘illegal’ squatter areas through encouraging community Adapting the project’s goals to community needs was impor- riots led to a local SACLA clinic closing in 1986. Individuals working tant. Selina Maphorogo, the first CHW motivator (and later within projects that had some approval from their ‘homeland’ director) of the Elim Care Groups, re-shaped the project by governments, such as Agincourt/Manguzi in Gazankulu and Valley adopting culturally-sensitive methods for delivering community Trust in former Kwazulu, were less likely to be heavily involved in health messages. These methods were reported as effective and political activism. A project coordinator felt that their work was sustained through the project’s history (Maphorogo, Sutter, & part of the struggle for democracy. Jenkins, 2003). Projects in their early stages, or which were geographically “During apartheid our main struggle was for freedom. Once that and ideologically isolated, were innovative in their use of was achieved our remit was over.” (C10) appropriate technology and training approaches. Many suc- This statement, which was reflected by many respondents, rai- ceeded despite sanctions in accessing international literature and ses the question whether the same level of commitment of health low technology resources. They adapted key CHW training guides workers to communities can be reproduced in a more democratic including the Chinese Barefoot doctors manual (Hunan-Zhong, political climate in which human rights are less threatened. 1977), Werner’s books Where there is no doctor (1977) and Helping health workers learn (1982) as well as WHO guidelines Innovative and experimental leadership, supervision and training (1992). The Rural Foundation and Elim also used UNICEF tools such as Road-to-Health charts. In the late 1980s, networks Respondents saw the presence of a charismatic idealistic leader, wanted to create a feasible training model for the post-apartheid who had a firm development approach, as key to six projects’ era. Emerging training centres (such as the PPHCN learning success (Valley Trust, SACLA, HCT, Elim, Chalumna/Newlands and centre) were modelled, in part, on the Institute of Family and Rural Foundation). Ivan Toms, who helped establish the Empi- Community Health (IFCH) (1945e1961) which trained the 1940s’ lisweni SACLA clinic, was seen as an example of such a leader and as health centres. crucial to the project’s success. In addition to actively defending the In the late 1980s, these projects also adapted to a changing clinic and community during the mid 1980s’ riots, respondents disease burden in South Africa, moving away from child survival described how he enlisted and trained lay people to work as CHWs towards chronic diseases and HIV (Bradshaw et al., 1999). SACLA, or management staff, and empowered community members and Mamre and HSDU trained CHWs who specialised in rehabilitation, staff to later adopt full managerial and clinical responsibility (C2, chronic disease and HIV. This also coincided with the move to CHW1). a more selective PHC approach, influenced by international criti- Respondents from all projects admitted to being experimental. cisms that the comprehensive PHC approach provided few concrete Supervision, training and management of staff and CHWs were recommendations (Cueto, 2004). often done on an ad-hoc basis, as outlined by a SACLA doctor: There was an interesting paradox, which several key informants recognised. These CHW projects, they suggested, experi- “Those first CHWs were a huge experiment. We were just flying by enced a ‘golden’ era under the constraints of apartheid and lack of the seat of our pants, we didn’t know what we were doing. We political freedoms. Projects were free to respond innovatively to equipped them with basic medications and dressings and so on. needs. Funders e whether international donors (for most projects) And they were fantastic, so they were with the project for many, or ‘homeland’ governments (as for Valley Trust) e had minimal many years.” (C3) requirements. Project leaders felt their impact was greatest on Project leaders were health professionals or academics with community health and development during apartheid. In contrast, little experience in management e they were “trying things and they criticised current funding for being constrictive and condi- seeing if they worked” (C10). Management difficulties sometimes tional, and thus hindering creativity and local adaptation. developed, such as when SACLA and Rural Foundation became However these divergent views may result from a tendency to larger and more complex (C3, F10). One Elim report (Annual report, romanticise the achievements possible in times of struggle and to 1980) outlined difficulties of project expansion such as staff resist, as many did globally, the emerging funding bureaucracy of shortages and inadequate delegation. These caused management the 1990s.

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Links with communities Many dedicated nurses (including five coordinators and three founders interviewed) played a significant role in supporting and In the late apartheid era, some local authorities felt threatened by training CHWs within NGO projects (Clarke, 1991; Mamre, 1992). the growing influence of projects (Toms, 1987). Also communities Some CHW literature advocates nurses as ideally placed to support sometimes found it difficult to accept CHW programmes. With CHWs (Buch, Evian, Maswanganyi, Maluleke, & Waugh, 1984; individuals expressing jealousy regarding CHWs’ status (C6, F10, Roscher, 1990). However some CHW respondents were dispar- CHW-workshop, 1982). In addition, local expectations were hard to aging of clinical supervision by hospital nurses, one commenting meet. For example, within the HCT-Cala project, villagers “did not that it was only by “the will of God” that nothing disastrous get involved unless remuneration for services or products was happened during childbirth (CHW7). One founder suggested why guaranteed” (Alperstein & Bunyonyo,1998). Participation fluctuated nurses’ supervision was poor: and depended on social and power relationships, and satisfactory “[The nurse facilitators] wouldn’t have that kind of vision or incentivising, as described in the wider literature (Frankel, 1992). experience of working with communities in a democratic way, so Despite these challenges, rural and peri-urban projects reported they would tend to be bureaucratic and play things by the book. some success in retaining CHWs in voluntary or partially paid work They could supervise but it was much more mechanical. And that I and in community ownership of projects: found that was not helpful in developing the analytic skills of the “So we started January 1987. and we had patients that followed CHWs.”(F2) us from Old Crossroads. Because we moved to New Crossroads, that CHWs were not necessarily welcomed by formal health system community welcomed us. So we had patients who followed us, the staff. Although the South African Nursing Council e the main chronic patients saying that ‘we can’t do without you.’” (C2) regulatory body for the profession e supported CHWs in principle With the shift to employment within the public health system (Marks, 1994), in practice nurses on the ground were reportedly following the democratic elections, many CHWs felt that their intimidating and rude to them (C8). One doctor interviewed accountability to the community had changed. They were no longer explains: flexible community-based workers, but located in health clinics “The attitude of the nurses is very, very problematic, they’re also so full-time. A few missed community work intensely (CHW3, CHW6). hierarchical now. My thesis is that nurses are fighting a feminist However many CHWs now resented unpaid requests from fellow battle in their work place, black nurses in particular, because they villagers: have been so oppressed and the present health system oppresses “They used to come to my house asking for help after even after them too, but there’s a bit of a perverse feminism acting there.” (F8) working hours. I used to help them but now I am unable, I tell that I This quote illustrates that nurses have, in both the late apartheid am tired as I have started working at 06h00 in the morning until and post-apartheid eras, enforced hierarchies within healthcare 16h00 in the afternoon.” (CHW7) with CHWs in health centres often becoming nursing subordinates Coordinators (C11, C6) and founders (F2, F8) also commented on (Schneider et al., 2008). These limitations of nursing care in South changes in CHWs’ attitudes since 1994: Africa have been discussed extensively elsewhere (Marks, 1994; Stein, Lewin, & Fairall, 2007; Wood & Jewkes, 2006), with Marks “There’s a very serious materialist dependency. I hate it but I have (1994) noting that nurses may feel their role is threatened within to face up that it has happened. It’s not that I am saying it was primary healthcare, particularly in light of potentially pro- idealistic, the community health workers were at least as enthu- fessionalising CHWs. siastic as I. .I can’t talk about the CHWs now in those glowing terms. The government now has this huge thing, they’ve got this small business programme e the pay roll. And the village health The end of an era: the closure of CHW programmes in the 1990s worker., if the pay doesn’t come out, they ‘toyetoy’, they don’t go to work” (F8) Respondents noted that the early 1990s were a time of transition out of the bleak system of apartheid (F9) towards a more There is likely to be an element of romanticising the past in idealistic vision of the future (F8). Progressive community health describing volunteers as only committed during the apartheid era. leaders were active in formulating health policy which informed However, introducing a stipend would expectedly reduce a volun- the ANC’s forthcoming national health plan (NPPHCN, 1992a, teer’s willingness to work unpaid. The CHWs interviewed, who had 1992b). Sidney Kark also held many meetings with health officials worked in both the old and new systems, rejected volunteering. and academics to promote the Community Oriented Primary Care This is supported by contemporaneous literature (Binedell, 1990; decentralised approach with strong community involvement (Kark, HCT, 1982, pp. 45e50) and by recent findings in the Free State 1981). province (Schneider, Hlophe, & van Rensburg, 2008). Respondents were surprised that the new 1994 government had dropped support for CHW projects (A national health plan for South CHWs within the health system Africa, 1994), as the 1992 draft of the ANC health plan had favoured CHW coverage (Slabber, 1992). Despite decentralisation being a key Whether CHWs can adequately bridge the gap between the element of the new health plan (van Rensburg, 2004) the incoming formal health service and the community has long been debated minister of health, Nkosasana Zuma, believed that CHWs would internationally (Walt & Gilson, 1990). CHWs in Mamre and Elim provide second rate care (F2). Rather, a professionalised team of reported that knowledge of their communities allowed them to doctors and nurses was visualised. In addition, health service successfully bridge the gap between researchers and communi- leadership was preoccupied with structural transformation of the ties. For example, they explained the purpose of community health sector (Tollman & Pick, 2002). Respondents felt the 1994 surveys in culturally-sensitive ways. But because some CHWs, for health plan was poorly informed with regards to CHWs: example in Elim, officially reported to the nurse-in-charge at the hospital, they did not bridge the gap with health services but “[It was] highly ambitious, had little connection to and had not were instead viewed as the lowest level of the health service consulted contemporary projects on what they were actually doing hierarchy. and achieving.” (F9)

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Interviewees understood why international funders had redir- This statement equates to what Lund (1993) called a policy ected their support to the new democratic government. However paradox in describing the 1992 national CHW policy draft. The they were frustrated that established community-based initiatives policy, she argues, attempts “to give the category of CHW a place, folded because of the government’s idealistic vision of a profes- but whilst so doing, has failed to recognise diversity, needs and sional-driven DHS which, in their view, failed to incorporate flexibility, thus invalidating its initial aim.” adequately existing South African experiences. Some projects Others suggested that implementation of the CHW Framework survived with meagre charitable contributions (Elim, SACLA). remains rigid and gives insufficient focus to rural areas (Friedman, A few, such as the Valley Trust, continued to receive government 2005). The Framework has also been criticised for its vague and support and helped to develop a provincial health plan. conflicting statements about remuneration and responsibility for The government’s decision in the mid-1990s to provide free CHWs (Schneider et al., 2008). Respondents felt that community primary healthcare was a further blow to organisations such as the health leaders’ recommendations for appropriate incentives (C10) Rural Foundation which had relied partly on community contri- were distorted into meagre stipends. Keeping CHWs as volunteers butions. This decision changed community expectations of projects. may have serious implications for their motivation, retention and The HIV epidemic also negatively impacted several small the quality of care they provide (F2). vertical projects. Respondents suggested providing care to people The 2004 CHW framework suggests that the “government living with AIDS in the pre-antiretroviral drugs era had diverted would provide grants to NGOs who would employ CHWs” (DoH, funds away from CHW projects. In the late 1990s, when PPHCN 2004). Three respondents identified partnership with civic orga- struggled for funds, a budget ten times its global budget was nisations as positive but that the framework abdicates government allocated to it to run the national AIDS programme (F2). The AIDS financial responsibility and diminishes NGOs to stipend distribu- epidemic also shifted CHWs towards being single-purpose tors (Schneider et al., 2008). In addition, the policy was seen to put workers e a phenomenon also noted in Britain (Berridge, 1996). insufficient emphasis on supervision, with directors deploring the A comparison of past and present CHW programmes is shown in fact that so few current budgets included adequate funds for Table 3. Respondents saw these changes as having shattered the supervision (F2). Quality of supervision, they suggested, is poor and ideal of community-oriented and comprehensive primary care is performed by inexperienced and overburdened staff. (Oppenheimer & Bayer, 2007). Discussion Has more recent community health policy been informed by the This research contributes to filling a gap in the history of South past? African CHW programmes in the late apartheid period. These projects had similarities to the earlier community health initiatives The Community Oriented Primary Care approach informed the of the 1940s. For example, as a consequence of the socio-political development of the DHS in the late 1990s. However, it has been context, primarily outsiders, many of whom were white, middle- noted that its community focus and epidemiological surveillance class professionals, started these projects. However, early and late have not been implemented widely, mainly because of a poor apartheid projects evolved in different contexts. Due to a more management capacity and accountability to communities (Moosa, liberal political leadership, the 1940s projects received government 2006; Tollman & Pick, 2002). support as potential models for universal health care. In contrast, More recently, South Africa established a CHW Framework the late-apartheid projects studied were initiated within an era of (2004) to guide the development of a national CHW programme. heightened repression and segregation; were intertwined with the This aimed to establish cohesion between old and new CHW contemporaneous wider social aims of democracy and social community-based organisations and to address the growing crisis justice, and did not generally receive backing from the state. of health worker shortage. Interviewees felt “this policy [had] come Unfortunately, many late-apartheid programmes were poor at too late” (C10, F3) as this Framework had only drawn upon the documenting the process and impact of their work, in part because newer single-purpose fragmented projects not upon apartheid era of the repressive conditions. Projects of both apartheid periods, comprehensive community health initiatives. One interviewee, one which were influenced by Community Oriented Primary Care, were of the few to be consulted prior to the finalisation of this policy, was much better at this, given the epidemiological focus of this model. disappointed: Our respondents argued that the strong socio-political motiva- “The policy had ignored the recommendations we had made based tions of the late apartheid period projects were mostly not carried on the spirit and the experience of the CHW projects [in the through into the post-apartheid period. The current struggle to 1970e1990s]” (C10) redress the economic, health and racial inequalities is not, it could

Table 3 Comparison of past and current CHW programmes in South Africa.

Characteristics 1970e1990s programmesb Current programmes Supervision and training Experimental but applied; done by experienced and Supervisors are of lower grades and less motivated/committed. inspiring people Variable training qualitya Funding International donors. More ﬂexibility of allocation given Government-channelled funding, or charitable fundsa to project by funders Rigid spending allowance, often determined by fundersb Remuneration Variable, some CHWs well paid, many volunteers Discontent with voluntary contributionsb, low government stipenda Scope Started with a vertical issue, then extended to integrate larger Most are single-disease focused (e.g. HIV, TB) community-based health issues. PPHCN network established to coordinate projects. organisationsa Relationship with community Project more dependent on community and linked to activism. Different expectations since democracy (less dependence, Community more participatory. more individualistic attitude)b Relationship with health sector Filling a large gap that health service was not providing. Poor coordination among projects/health sector, leading to Mixed acceptance by health sector. competition and duplication of worka

a Based on (Friedman, 2005). b Based on interviewees responses/contemporaneous literature.

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be argued, fuelled by the same fervour for action, partly because the Acknowledgements country is now a stable democracy (Friedman, 2002). In addition, the changing burden of disease (HIV, TB, chronic diseases) means This research was funded as part of a studentship awarded by that a national CHW programme would now have to incorporate the Wellcome Trust to the Centre for History in Public Health as significantly different needs (Oppenheimer & Bayer, 2007). part of its Enhancement Award. We wish to thank the academic However, a number of contemporary social movements, such as staff at the University of Cape Town who helped facilitate this that to improve access to treatment for people living with HIV/ research, in particular Leslie London and Margaret Hoffman. Our AIDS, may have benefited from the leadership and experience of deepest gratitude goes to all participants whom we interviewed activists from the earlier projects (Ballard, Habib, Valodia, & Zuern, and consulted for this study. 2005). Though these small-scale programmes were a product of their References times, they have important lessons for current CHW programmes and policy within South Africa and potentially globally. It is sug- Alperstein, M., & Bunyonyo, B. (1998). Collective healthcare. A review of the Health gested that the now predominant, single-purpose CHWs’ focus on Care Trust’s village health worker project, Cala. In C. Barberton, M. Blake, & clinical conditions fails to address the social determinants of health H. Kotze (Eds.), Creating action space: The challenge of poverty and democracy in South Africa (pp. 229e243). Cape Town: Idasa and David Philip Publishers. (Friedman, 2005). Reinvigorating the political nature of community Annual report. (1980). Elim: Elim careeGroup project. healthcare by addressing social, economic and environmental Baldwin-Ragavan, L., Gruchy, J.d, & London, L. (1999). An ambulance of the wrong issues, may have a greater impact in tackling ill health of the most colour: Health professionals, human rights and ethics in South Africa. Cape Town: University of Cape Town Press. disadvantaged. Ballard, R., Habib, A., Valodia, I., & Zuern, E. (2005). Globalization, marginalization Although interviewees claimed that dissatisfaction among and contemporary social movements in South Africa. African Affairs, 107(417), CHWs with volunteering was minimal during apartheid, this may, 614e634. Berridge, V. (1996). AIDS in the UK: The making of policy, 1981e1994. Oxford: Oxford in part, be a romanticisation of the past. In reality, many late University Press. apartheid programmes had very limited funding and repressive Beveridge, W. (1942). Social insurance and allied services. 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