ECAS 2013

Different studies have analyzed international health politics in Africa identifying questions related with effectiveness, ideology, sanitary targets or public governance. This paper wants to contribute to this healthcare debate in Africa stressing the potential of Governmentality Studies. This paper proposes that healthcare has been one of the basic competences to establish authority in postcolonial Africa. So, this paper researches aid to healthcare systems and the role of non-state agents as well as political processes related with authority and health as a political terrain.

The paper has four points: Firstly, the paper presents some of the main contributions to Governemantality Health Studies in Africa and their applications to one target of the panel; the study of the relationship between the different health actors in Africa. Secondly, the paper presents the possibilities to adopt Bayart´s extraversion concept to study the effect of aid on healthcare and particularly the role of themain international agents. I defend these possibilities through different contemporary historical examples. Thirdly, the paper studies the good governance agenda for the health sector in Africa as a political terrain where different actors seek global and local legitimization. Finally the paper presents some examples where the fight for authority is central to understanding the effect of aid on healthcare and welfare systems in Africa.

The project consider that women are the more sensible sector of the population to the international macro-economic decisions that lead to the development of the non-public health sector in countries dependent of external aid. The public health sector in Africa refers to a heterogeneous field of operation that comprises the action of non-profit organizations such as NGOs and associations, and profit institutions that stand from private clinics and medicine sellers to traditional therapists. This sector has been developing in West and Sub-Saharan Africa, both on the aftermath of the local governments progressive abandon of the public health programs following the directions of the Structural Adjustment Plans of the late eighties and nineties. A more detailed knowledge of health care options for women and their choices in this sector is essential for the implementation of an effective health strategy coordinating both public health planning and the heterogeneous non-public sector. The project is focused in three Lusophone countries (Guinea Bissau, Angola and Mozambique) and with a broader comparison track done in one francophone country (Niger).

The objective of this investigation, inserted in the project "Gender and therapeutic pluralism women's access to private health sector in Africa" funded by the Foundation for Science and Technology (FCT), is figure out what the framework reference of Gender and Health Strategies Development undertaken by national governments and multilateral actors in the context of African Countries of Portuguese Official Language (PALOP). In defining the main objective takes into account the following initial research questions: (1) find a common dynamic in Gender and Health Strategies Development defined by national governments and multilateral actors in the context of PALOP? And (2) What theoretical perspectives on gender and health (Wellness Approach, Women in Development Approach and Gender and Development Approach) that reflect the Gender and Health Strategies Development defined by national governments and multilateral actors in the context of PALOP? It also takes into account the theoretical basis of three key concepts for the development of research: (1) sexual rights (International Planned Parenthood Federation, 2008), (2) reproductive rights (UN, 1995) and (3) sexual and reproductive health (WHO, 2004).

Starting from my fieldwork experiences in Ghana (from 90s to 2006) and Ethiopia (from 2007 up to now) I would like to propose a reflection on some of the social actors who normally are not involved in the healthcare project. I refer mainly to the churches, especially the Pentecostal and the Spiritual ones, and to some kind of healers who cannot be immediately recognized as "traditional", and who do not belong to any association of traditional healers.

The International and national strategies for constructing a delivery health care system in many African countries, have reserved a certain space to different social actors: the Public facilities, the Private ones, the NGO and the Charity organizations. As stressed sometimes, those actors have not always facilitated a reduction in inequalities in access to healthcare services. Paradoxically, their intervention has created new inequalities and new forms of unequal citizenship.

Describing this framework for Ethiopia and Ghana, I would like to reflect on those actors who normally have no room in national and international projects. On one hand the churches, acting in the field of health through their peculiar healing activity and ven creating support networks for patients. On the other, taking into account those healers "on the border" using syncretic forms of care, that, since they are not properly "traditional", are not always taken into account by policy makers

This paper analyzes the targeting of development assistance for health across countries in a multivariate regression framework, based on data from 22 bilateral donors to 160 recipients between 1990 and 2007. The results show that health performance is considered when allocating health assistance. HIV prevalence significantly increases aid receipts, while under-five mortality and maternal mortality do not influence allocation decisions for health by the average donor. Yet, health performance is not the only aspect that matters. Bilateral relations influence the allocation process. In fact, economic links as trade relations, cultural proximity as the same dominant language or religion, or the common colonial past influence these decisions significantly. Yet, political ties or geographic proximity are insignificant factors for the decision-making process. In the discussion about aid effectiveness, a major issue is the sensitivity of donors as regards potential problems related to a weak institutional environment such as corruption. The results show that more corrupt countries do receive less health assistance. The level of effort put into national health by the recipient country is insignificant. Neither the level of public health expenditures nor the immunization coverage has any statistical effect. The available evidence suggests that the preference of the donor for health on the national political agenda increases the provision of health assistance. The average donor does not decide independently but acts strategically. Particularly the donor with a large budget is inclined to complement allocations made by the US and by multilateral donors. However, the effect is not substantial.

In July 2010, two of Senegal's largest health worker unions (SUSTAS and SAS) launched a countrywide health data retention strike. As part of this strike, health workers on every level of the national program have withheld from the Senegalese Ministry of Health routine patient data, in order to move the government to meet their demands for better working conditions. As the workers have continued to provide health services, the government has managed to remain at a stalemate with the SUSTAS/SAS alliance for almost three years. This data strike illustrates the ways in which government health workers in Senegal engage in politics that are on a simultaneously national and global scale. The withheld health data has been thought to be critical for the advancement of the Senegalese health system on the part of international and private health partners, whether for evaluating existing programs or for implementing new ones, and may eventually impact the level of funding Senegal's health programs receive. Like many other countries in Sub-Saharan Africa, Senegal receives a large amount of external aid to support its health system; for example, the National Malaria Control Program receives 95% of its funds from external aid. I argue that, by participating in a data retention strike, government health workers are performing simultaneously their national citizenship and their citizenship to a distinctly global network of funders and non-governmental organizations in order to materially impact their daily lives.

While private clinics are generally recognized as important care givers in current African cities, the sector remains under-studied in the social sciences. The research for my master thesis focused on the creation of a hospital anchored to a public-private partnership including the World Bank, the Beninese Health Ministry and a private non-governmental association. The main purpose of my enquiry is to understand how the status of this hospital influences (or not) its organization and its use by clients. Therefore, I firstly analyze the emergence and the diversity of the Beninese private health sector as well as the connotations of the notion of public-private partnership. These two points help to understand the particular context of creation of the studied public-private partnership and how it was imposed to the Ministry by the World Bank. Secondly, my research shows how the creation is nowadays read in different ways by the various actors in order to claim their rights on the management of the hospital. Thirdly, focusing on collaboration between the different categories of workers and their relationships with clients, I describe formal and informal organization of this private hospital. This part underlines the particularities of private direction in comparison with well-known studies of public centers. Using these data, I also try to understand why clients come to this specific hospital. I argue that status is not as important in their choice.

Parts of the northwestern equatorial forest are experiencing epochal transformations in demographic composition, in resource management and biodiversity, and in new forms of integration with both national and globalized economies. In the Republic of Congo, the northern Sangha province and its capital, Ouesso, are now poles of migration and development as the country moves onward in reconstruction and reconciliation after two civil wars. New road, air, and ferry links expand contact and exchange both with Brazzaville, far downriver, and with adjacent southeast Cameroon.

This paper considers some of the corresponding changes in health services and modalities in Ouesso and in nearby logging towns along the Sangha river. It contrasts postsocialist and pre-ARV circumstances of the 1990s with recent developments spurred by new national government, greater church and NGO investment, rapid population growth, intensified logging and road-building, and forest clearing and settlement.

In these growing towns, cross-sector collaborations bring new diagnostic, treatment, and counselling services to challenge local interpretations and existing arrangements that cope with HIV and AIDS. Recently-founded non-profits coordinate with expanded state health services, making referrals to church-aided clinics run by logging companies and funded by international donors. Resulting struggles over knowledge, healing power, and access to care reveal disparate understandings of truth, illness, and responsibility. They help us see how these social technologies are changing imaginations and conditions of health in relation to the long-term histories and diverse lifeways of this region.

In recent years there has been increased interest in revitalizing the Alma Ata Declaration to achieve the Millennium Development Goals. This interest is evident in Guinea-Bissau where the health policy has been under the influence of Alma Ata since the beginning. In Oio region the first community health units (CHUs) were opened in 1982 offering villagers primary health care (PHC) with a focus on mothers and children. The implementation of PHC was organized by government institutions and in the regions the regional health boards were responsible for implementation together with NGOs. In Oio the last NGO left the region in 1998 and after that government institutions had no resources to sustain PHC on their own. Consequently, only a few CHUs were functional a decade later. Today, with the revitalization process donors show an increased interest in allocating resources to NGOs instead of government institutions because of political instability. These NGOs are then expected to collaborate with government institutions.

This paper explores the importance of NGOs in the implementation of PHC in Guinea-Bissau and it discusses whether their assistance can be sustainable. The data is based on 20 months of anthropological fieldwork in Guinea-Bissau between 2009 and 2012. Interviews were taken with representatives of international organizations and NGOs, responsible people at the Ministry of Health, health staff and villagers. The paper argues that a fragile state like Guinea-Bissau is dependent on receiving assistance from NGOs to revitalize PHC. However, it is important to consider sustainability and to learn from past experiences.

This article analyzes the HIV-positive women's perception of HIV treatment program, in the context of co-existence of physicians, traditional healers and Zion pastors. Based on the ethnographic data gathered in Maluana, this research reveals that in their search for health care, the HIV-positive women combine treatments from various health care providers, in three different ways. While some combine Hospitals and traditional Healers, others combine Hospitals and Zion pastors, and others combine Hospitals, traditional Healers and Zion pastors. These combinations are motivated by the perception that in each provider women receive specific treatment for their afflictions. However, such therapeutic combinations are not random; they follow a logic conditioned by beliefs integrated in the HIV-positive women's values. And once these values are not statics, HIV-positive women make adjustments, generating changes in the therapeutic combinations they had made before.

Therefore, within efficacy models designed by international actors, emerges an alternative practice in which therapeutic efficacy is perceived holistically. This misunderstanding may be one of the causes of failure of health and development programs in multiple actors context.

Key words: health and development, HIV-positive women, therapeutic pathways and Health Care Providers.

In Ivory Coast, a country where HIV/AIDS is generalised (prevalence of 3,7%), only 29% of people in need of treatment have an effective access. To reach universal access, two of the main challenges are to provide effective coordination between the plurality of actors involved in the public action and to reduce the strong dependency on international aid (87% of the budget)

In this context, some of the large private companies appear as strategic actor, insofar as they are able to initiate self-sufficient and innovative actions. The purpose of this paper is to analyze the participation of a financially self-sufficient actor, the private sector, within a public action characterized by its strong aid dependency.

At first, we will see that since the private sector programmes concerning HIV/AIDS are primarily self-funded, they operate outside the national and international framework of coordination and control. As a consequence, risks are present regarding the gap between their public declarations and the real impact of their action and the increased vulnerability of the employees.

Then, we will show that international funding for the private sector provided through « projects », such as the support to its mobilization or the development of private/public partnerships, are inappropriate with private business functioning and contribute to governmental disengagement.

This paper is based on an analysis of qualitative research involving actors of 30 large private companies (doctors, HRD, trade union, employees) and of active organizations in the fight against HIV/AIDS in the private sector in Ivory Coast.

In the development strategies undertaken by the Ethiopian federal government, the practices inspired by the Marxist-Leninist doctrine and developed in Tigray during the armed struggle merge with neoliberal discourses proper of the good governance agenda and with the centralized tradition of the Ethiopian imperial state, enacting the creative production of governmental techniques. In the rural areas, the health system decentralization is directed towards the extensive diffusion of the Primary Health Care and the achievement of the Millennium Development Goals on maternal and child health. Government policies, implemented either with foreign donors direct support to local budgets (PBS) or with funds specifically allocated to the health sector, seem to be heavily influenced by the international discourse on participatory development. The paper will reflect on EPRDF's (the power coalition) governance strategies, through the analysis of the "Women Development Army". The WDA is a health and development strategy recently introduced, which combines top-down and bottom-up approaches and is officially addressed to the empowerment and (self-) organization of women in order to implement the central government's programs in the rural districts. The preliminary results of a comparative research conducted in two Ethiopian Regions - Tigray and Oromia - will be presented with the aim to reflect on the ways in which the EPRDF's developmental-state policy intervenes in the production of processes of subjectivation. The exploration of the power relations shaping the "health arena" will show the indistinctness of the boundaries and the overlapping roles between state, NGOs and local communities.

Patient safety perspectives in Africa have become a key focus of the international health community. Many of the initiatives, however, embrace a vertical 'top down' approach focused on the hospital sector that engages operational and bureaucratic interventions. This paper argues for a new paradigm in patient safety that operates on an inclusive, horizontal level embracing concepts of upstream interventions and harnessing community and civil society organisations.

Authors from the Global South are vocal in the need to develop radical development approaches and criticise mainstream approaches of 'conceptual conservatism'. A new paradigm of community health and participation is emerging, not least in creative responses to these issues within Africa itself. The People's Health Movement (PHM) is one such group: a global South network bringing together grassroots health activists, civil society organizations and academic institutions from around the world, particularly from low and middle income countries (L&MIC).

This paper considers the experience of PHM Uganda of the challenges and opportunities for civil society networks and groups that represent the most vulnerable in society. Government intervention is often ineffective because of gaps between provision and access of services. These gaps, such as a knowledge deficit on the part of the consumers and communication deficit on the part of service providers at all levels, is the centre of the problem. It is argued that community involvement, education, mobilization and participation in health development is crucial in these communities. Their role is analysed using a rights to health based model.