Anuj Kapilashrami

Transforming governance or reinforcing hierarchies and competition: Examining the public and hidden transcripts of the Global Fund and HIV in India

Global health initiatives (GHIs) have gained prominence as innovative and effective policy mechanisms to tackle global health priorities. More recent literature reveals governance-related challenges and their unintended health system effects. Much less attention is received by the relationship between these mechanisms, the ideas that underpin them and the country-level practices they generate. The Global Fund has leveraged significant funding and taken a lead in harmonizing disparate efforts to control HIV/AIDS. Its growing influence in recipient countries makes it a useful case to examine this relationship and evaluate the extent to which the dominant public discourse on Global Fund departs from the hidden resistances and conflicts in its operation. Drawing on insights from ethnographic fieldwork and 70 interviews with multiple stakeholders, this article aims to better understand and reveal the public and the hidden transcript of the Global Fund and its activities in India. We argue that while its public transcript abdicates its role in country-level operations, a critical ethnographic examination of the organization and governance of the Fund in India reveals a contrasting scenario. Its organizing principles prompt diverse actors with conflicting agendas to come together in response to the availability of funds. Multiple and discrete projects emerge, each leveraging control and resources and acting as conduits of power. We examine how management of HIV is punctuated with conflicts of power and interests in a competitive environment set off by the Fund protocol and discuss its system-wide effects. The findings also underscore the need for similar ethnographic research on the financing and policy-making architecture of GHIs.

The Global Fund and the re-configuration and re-emergence of 'civil society': widening or closing the democratic deficit?

Abstract The past decade has witnessed a tremendous growth in the scale and policy influence of civil society in global health governance. The AIDS ‘industry’ in particular opens up spaces for active mobilisation and participation of non-state actors, which further crystallise with an ever-increasing dominance of global health initiatives. While country evaluations of global initiatives call for a greater participation of ‘civil society’, the evidence base examining the organisation, nature and operation of ‘civil society’ and its claims to legitimacy is very thin. Drawing on the case of one of the most visible players in the global response to HIV epidemic, the Global Fund to Fight AIDS, Tuberculosis and Malaria, this article seeks to highlight the complex micropolitics of its interactions with civil society. It examines the nature of civil society actors involved in the Fund projects and the processes through which they gain credibility. We argue that the imposition of global structures and principles facilitates a reconfiguration of actors around newer forms of expertise and power centres. In this context, the notion of ‘civil society’ underplays differences and power dynamics between various institutions and conceals the agency of outsiders under the guise of autonomy of the state and people.

Gender blind? An analysis of global public-private partnerships for health

BackgroundThe Global Public Private Partnerships for Health (GPPPH) constitute an increasingly central part of the global health architecture and carry both financial and normative power. Gender is an important determinant of health status, influencing differences in exposure to health determinants, health behaviours, and the response of the health system.We identified 18 GPPPH - defined as global institutions with a formal governance mechanism which includes both public and private for-profit sector actors – and conducted a gender analysis of each.ResultsGender was poorly mainstreamed through the institutional functioning of the partnerships. Half of these partnerships had no mention of gender in their overall institutional strategy and only three partnerships had a specific gender strategy. Fifteen governing bodies had more men than women – up to a ratio of 5:1. Very few partnerships reported sex-disaggregated data in their annual reports or coverage/impact results. The majority of partnerships focused their work on maternal and child health and infectious and communicable diseases – none addressed non-communicable diseases (NCDs) directly, despite the strong role that gender plays in determining risk for the major NCD burdens.ConclusionsWe propose two areas of action in response to these findings. First, GPPPH need to become serious in how they “do” gender; it needs to be mainstreamed through the regular activities, deliverables and systems of accountability. Second, the entire global health community needs to pay greater attention to tackling the major burden of NCDs, including addressing the gendered nature of risk. Given the inherent conflicts of interest in tackling the determinants of many NCDs, it is debatable whether the emergent GPPPH model will be an appropriate one for addressing NCDs.

Meaningful change or more of the same? The Global Fund's new funding model and the politics of HIV scale-up

As we enter the fourth decade of HIV and AIDS, sustainability of treatment and prevention programmes is a growing concern in an environment of shrinking resources. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) will be critical to maintaining current trajectories of scale-up and ultimately, ensuring access to HIV treatment and prevention for people in low/middle-income countries. The authors’ prior research in India, Zambia and South Africa contributed evidence on the politics and impact of new institutional and funding arrangements, revealing a ‘rhetoric-reality gap’ in their impact on health systems, civil society participation, and achievement of population health. With its new funding strategy and disbursement model, the Fund proposes dramatic changes to its approach, emphasising value for money, greater fund predictability and flexibility and more proactive engagement in recipient countries, while foregrounding a human rights approach. This paper reviews the Funds new strategy and examines its potential to respond to key criticisms concerning health systems impact, particularly the elite nature of this funding mechanism that generates competition between public and private sectors and marginalises local voices. The authors analyse strategy documents against their own research and published literature and reflect on whether the changes are likely to address challenges faced in bringing HIV programmes to scale and their likely effect on AIDS politics.

Understanding women's experience of violence and the political economy of gender in conflict: the case of Syria

Abstract Political conflicts create significant risks for women, as new forms and pathways of violence emerge, and existing patterns of violence may get amplified and intensified. The systematic use of sexual violence as a tactic of war is well-documented. Emergent narratives from the Middle East also highlight increasing risk and incidence of violence among displaced populations in refugee camps in countries bordering states affected by conflict. However, much less is known about the changing nature of violence and associated risks and lived experiences of women across a continuum of violence faced within the country and across national borders. Discussion on violence against women (VAW) in conflict settings is often stripped of an understanding of the changing political economy of the state and how it structures gender relations, before, during and after a conflict, creating particular risks of violence and shaping women’s experiences. Drawing on a review of grey and published literature and authors’ experiences, this paper examines this underexplored dimension of VAW in political conflicts, by identifying risk environments and lived realities of violence experienced by women in the Syrian conflict, a context that is itself poorly understood. We argue for multi-level analysis of women’s experiences of violence, taking into account the impact of the political economy of the wider region as shaping the lived realities of violence and women’s response, as well as their access to resources for resistance and recovery.

Confronting ‘scale-down’: Assessing Namibia's human resource strategies in the context of decreased HIV/AIDS funding

In Namibia, support through the Global Fund and Presidents Emergency Plan for AIDS Relief has facilitated an increase in access to HIV and AIDS services over the past 10 years. In collaboration with the Namibian government, these institutions have enabled the rapid scale-up of prevention, treatment and care services. Inadequate human resources capacity in the public sector was cited as a key challenge to initial scale-up; and a substantial portion of donor funding has gone towards the recruitment of new health workers. However, a recent scale-down of donor funding to the Namibian health sector has taken place, despite the countrys high HIV and AIDS burden. With a specific focus on human resources, this paper examines the extent to which management processes that were adopted at scale-up have proven sustainable in the context of scale-down. Drawing on data from 43 semi-structured interviews, we argue that human resources planning and management decisions made at the onset of the countrys relationship with the two institutions appear to be primarily driven by the demands of rapid scale-up and counter-productive to the sustainability of interventions.

Examining intersectional inequalities in access to health (enabling) resources in disadvantaged communities in Scotland: advancing the participatory paradigm

BackgroundMultiple structural, contextual and individual factors determine social disadvantage and affect health experience. There is limited understanding, however, of how this complex system works to shape access to health enabling resources (HER), especially for most marginalised or hard-to-reach populations. As a result, planning continues to be bereft of voices and lived realities of those in the margins. This paper reports on key findings and experience of a participatory action research (PAR) that aimed to deepen understanding of how multiple disadvantages (and structures of oppression) interact to produce difference in access to resources affecting well-being in disadvantaged communities in Edinburgh.MethodsAn innovative approach combining intersectionality and PAR was adopted and operationalised in three overlapping phases. A preparatory phase helped establish relationships with participant groups and policy stakeholders, and challenge assumptions underlying the study design. Field-work and analysis was conducted iteratively in two phases: with a range of participants working in policy and community roles (or ‘bridge’ populations), followed by residents of one Edinburgh locality with relatively high levels of deprivation (As measured by the Scottish Index of Multiple Deprivation, a geographically-based indicator. See http://www.gov.scot/Topics/Statistics/SIMD/DataAnalysis/SPconstituencyprofile/EdinburghNorthern-Leith). Traditional qualitative methods (interviews, focus groups) alongside participatory methods (health resource mapping, spider-grams, photovoice) were employed to facilitate action-oriented knowledge production among multiply disadvantaged groups.ResultsThere was considerable agreement across groups and communities as to what healthful living (in general) means. This entailed a combination of material, environmental, socio-cultural and affective resources including: a sense of belonging and of purpose, feeling valued, self-esteem, safe/secure housing, reliable income, and access to responsive and sensitive health care when needed. Differences emerge in the value placed by people at different social locations on these resources. The conditions/aspects of their living environment that affected their access to and ability to translate these resources into improved health also appeared to vary with social location.ConclusionIntegrating intersectionality with PAR enables the generation of a fuller understanding of disparities in the distribution of, and access to, HER, notably from the standpoint of those excluded from mainstream policy and planning processes. Employing an intersectionality lens helped illuminate links between individual subjectivities and wider social structures and power relations. PAR on the other hand offered the potential to engage multiply disadvantaged groups in a process to collectively build local knowledge for action to develop healthier communities and towards positive community-led social change.

Interrogating resilience in health systems development.

Abstract The Fourth Global Symposium on Health Systems Research was themed around ‘Resilient and responsive health systems for a changing world.’ This commentary is the outcome of a panel discussion at the symposium in which the resilience discourse and its use in health systems development was critically interrogated. The 2014‐15 Ebola outbreak in West‐Africa added momentum for the wider adoption of resilient health systems as a crucial element to prepare for and effectively respond to crisis. The growing salience of resilience in development and health systems debates can be attributed in part to development actors and philanthropies such as the Rockefeller Foundation. Three concerns regarding the application of resilience to health systems development are discussed: (1) the resilience narrative overrules certain democratic procedures and priority setting in public health agendas by ‘claiming’ an exceptional policy space; (2) resilience compels accepting and maintaining the status quo and excludes alternative imaginations of just and equitable health systems including the socio‐political struggles required to attain those; and (3) an empirical case study from Gaza makes the case that resilience and vulnerability are symbiotic with each other rather than providing a solution for developing a strong health system. In conclusion, if the normative aim of health policies is to build sustainable, universally accessible, health systems then resilience is not the answer. The current threats that health systems face demand us to imagine beyond and explore possibilities for global solidarity and justice in health.

Intersectionality and why it matters to global health

www.thelancet.com Vol 391 June 30, 2018 2589 Intersectionality and why it matters to global health 20 Gracia E, Merlo J. Intimate partner violence against women and the Nordic paradox. Soc Sci Med 2016; 157: 27–30. 21 Bonsang E, Skirbekk V, Staudinger UM. As you sow, so shall you reap: gender-role attitudes and late-life cognition. Psychol Sci 2017; 28: 1201–13. 22 Chen YY, Subramanian SV, Acevedo-Garcia D, Kawachi I. Women’s status and depressive symptoms: a multilevel analysis. Soc Sci Med 2005; 60: 49–60. 23 Van de Velde S, Huijts T, Bracke P, Bambra C. Macro-level gender equality and depression in men and women in Europe. Sociol Health Illness 2013; 35: 682–98. 24 McLaughlin KA, Xuan Z, Subramanian SV, Koenen KC. State-level women’s status and psychiatric disorders among US women. Soc Psychiatry Psychiatri Epidemiol 2011; 46 1161–71. 25 Kawachi I, Kennedy BP, Gupta V, Prothrow-Stith D. Women’s status and the health of women and men: a view from the States. Soc Sci Med 1999; 48: 21–32. 26 Flood M, Dragiewicz M, Pease B. Resistance and backlash to gender equality: an evidence review. Brisbane: Crime and Justice Research Centre, Queensland University of Technology, 2018.

Transformative or Functional Justice? Examining the Role of Health Care Institutions in Responding to Violence Against Women in India

With the growing salience of ideas and reforms concerning womens human rights and gender equality, violence against women (VAW) has received heightened policy attention. Recent global calls for ending VAW identify health care systems as having a crucial role in a multisector response to tackle this social injustice. Scholars emphasize the transformative potential of such response in its ability to not only address the varied health consequences but also prevent future recurrence by enabling wider access to support and justice. This wider consensus on the role of health systems, however, demands stronger empirical basis. This article reports findings from an exploratory research developed around the core question: What are the perceived strengths and challenges confronting health systems in offering a comprehensive response to VAW in India? Drawing on site visits, observations, and interviews with front-line staff and program managers of an integrated intervention to tackle violence in Kerala and nongovernment organisation staff in Delhi and Mumbai, the article presents its historical context and key barriers to effective implementation. While promising in terms of outreach and incremental changes in attitudes, barriers include deficits in infrastructure and institutional practices that reinforce inequities in gender-power relations, hostile attitudes, and limited capacities of health workforce to tackle the complex and diverse needs of women experiencing abuse. Locating these experiences in relation to other models rooted in feminist approach, I argue how conventional intervention models of provisioning fail to challenge institutional contexts and structural inequalities that underpin violence and compound vulnerabilities experienced by women, thereby serving a functional response. Health systems are social institutions embedded in prevailing gender norms and power relations that must be tackled alongside addressing imminent needs of women victims of abuse. To this end, feminist approaches to counselling and relational perspectives to social justice can strengthen responsiveness (and transformative potential) of integrated sector-wide interventions.