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Abstract
Healthcare strikes have been a remarkably common and varied phenomenon. Strikes have taken a number of forms, lasting from days to months, involving a range of different staff and impacting a range of healthcare systems, structured and resourced vastly differently. While there has been much debate about strike action, this appears to have done little to resolve the often polarising debate that surrounds such action. Building on the existing normative literature and a recent synthesis of the empirical literature, this paper will present a deliberative framework to assess the justifiability of strike action. I will first review the empirical literature that explores the impact of strike action, on patient outcomes and healthcare delivery. I will then discuss the debates that have occurred in this area, including an existing deliberative framework proposed by Selemogo (2014). I will argue that this framework is overly restrictive in that it could lead us to find otherwise justified strike action, unjust. I will then propose a framework that remedies these shortcomings. The framework outlines two broad conditions that should be met if strike action is to be justified. It then goes on to outline two deliberative, interrelated questions that should be used to assess whether strike action meets these conditions. For the purposes of this framework, healthcare strike action is justified when 1) it makes demands or raises grievances about some form of injustice, unfairness or threat to health and when 2) the risks in striking are proportionate to its demands or grievances. These two conditions should be considered in light of two further questions, namely, the 3) social and political context of the strike and 4) the characteristics of the strike. I will offer some further reflections on the application of this framework and its shortcomings.
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Affiliation(s)
- Ryan Essex
- Institute for Lifecourse Development, The University of Greenwich, London, UK
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McGivern G, Wafula F, Seruwagi G, Kiefer T, Musiega A, Nakidde C, Ogira D, Gill M, English M. Deconcentrating regulation in low- and middle-income country health systems: a proposed ambidextrous solution to problems with professional regulation for doctors and nurses in Kenya and Uganda. HUMAN RESOURCES FOR HEALTH 2024; 22:13. [PMID: 38308369 PMCID: PMC10835984 DOI: 10.1186/s12960-024-00891-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 01/08/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Regulation can improve professional practice and patient care, but is often weakly implemented and enforced in health systems in low- and middle-income countries (LMICs). Taking a de-centred and frontline perspective, we examine national regulatory actors' and health professionals' views and experiences of health professional regulation in Kenya and Uganda and discuss how it might be improved in LMICs more generally. METHODS We conducted large-scale research on professional regulation for doctors and nurses (including midwives) in Uganda and Kenya during 2019-2021. We interviewed 29 national regulatory stakeholders and 47 subnational regulatory actors, doctors, and nurses. We then ran a national survey of Kenyan and Ugandan doctors and nurses, which received 3466 responses. We thematically analysed qualitative data, conducted an exploratory factor analysis of survey data, and validated findings in four focus group discussions. RESULTS Kenyan and Ugandan regulators were generally perceived as resource-constrained, remote, and out of touch with health professionals. This resulted in weak regulation that did little to prevent malpractice and inadequate professional education and training. However, interviewees were positive about online licencing and regulation where they had relationships with accessible regulators. Building on these positive findings, we propose an ambidextrous approach to improving regulation in LMIC health systems, which we term deconcentrating regulation. This involves developing online licencing and streamlining regulatory administration to make efficiency savings, freeing regulatory resources. These resources should then be used to develop connected subnational regulatory offices, enhance relations between regulators and health professionals, and address problems at local level. CONCLUSION Professional regulation for doctors and nurses in Kenya and Uganda is generally perceived as weak. Yet these professionals are more positive about online licencing and regulation where they have relationships with regulators. Building on these positive findings, we propose deconcentrating regulation as a solution to regulatory problems in LMICs. However, we note resource, cultural and political barriers to its effective implementation.
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Affiliation(s)
| | | | | | - Tina Kiefer
- University of Warwick, Coventry, United Kingdom
| | | | | | | | - Mike Gill
- University of Oxford, Oxford, United Kingdom
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Koon AD, Marten R. Framing health taxes: a scoping review. BMJ Glob Health 2023; 8:e012055. [PMID: 37813439 PMCID: PMC10565303 DOI: 10.1136/bmjgh-2023-012055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/06/2023] [Indexed: 10/13/2023] Open
Abstract
Health taxes are increasingly positioned as effective policy instruments for curbing non-communicable disease, improving health and raising government revenues. Their allure has caused many health advocates to look beyond tobacco and alcohol to other harmful products such as sugar-sweetened beverages (SSBs), salty foods, fatty foods and fossil fuels. These efforts, however, directly conflict with commercial actors' interests. Both pro-tax health advocates and anti-tax industry representatives seek to frame health tax policy in favourable ways. Yet, little is known about which types of frames resonate in which settings, or how they deploy morals and values in their attempts to persuade. To fill this gap, we conducted a scoping review on framing health taxes using six databases in 2022. A total of 40 peer-reviewed empirical research articles, from 2006 to 2022, were identified from 20 different countries. Most research was conducted in high-income countries, published in the last 4 years and increasingly focused on excise taxes for SSBs. Studies captured multiple actors constructing context-specific frames, often tied to broader economic, health and administrative considerations. Actors also engaged in a range of political activities in addition to framing. We found some evidence that anti-tax framing strategies potentially incorporated a broader array of morals and social values. More in-country comparative research, particularly from low/middle-income countries, is needed to understand the politics of framing health taxes. We argue that these insights can improve efforts to advance health taxes by constraining corporate power, improving population level health and promoting greater social harmony.
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Affiliation(s)
- Adam D Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert Marten
- Secretariat, WHO Alliance for Health Policy and Systems Research, Geneva, Switzerland
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Sriram V, Brophy SA, Sharma K, Elias MA, Mishra A. Associations, unions and everything in between: contextualising the role of representative health worker organisations in policy. BMJ Glob Health 2023; 8:e012661. [PMID: 37758667 PMCID: PMC10537963 DOI: 10.1136/bmjgh-2023-012661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023] Open
Abstract
Associations, unions and other organised groups representing health workers play a significant role in the development, adoption and implementation of health policy. These representative health worker organisations (RHWOs) are a key interface between employers, governments and their members (both actual and claimed), with varying degrees of influence and authority within and across countries. Existing research in global health often assumes-rather than investigates-the roles played by RHWOs in policy processes and lacks analytical specificity regarding the definitional characteristics of RHWOs. In this article, we seek to expand and complicate conceptualisations of RHWOs as key actors in global health by unpacking the heterogeneity of RHWOs and their roles in policy processes and by situating RHWOs in context. First, we define RHWOs, present a typology of RHWO dimensions and discuss perceived legitimacy of RHWOs as policy actors. Next, we unpack the roles of RHWOs in policy processes and distinguish RHWO roles in regulation from those of regulatory agencies. The final sections situate RHWOs in political and labour relations contexts, and in sociohistorical contexts, with attention to institutional frameworks, professional hierarchies and intersectional factors such as race, gender, sexuality, class, caste and religion. We conclude by outlining research gaps in the study of RHWOs and policy, and by encouraging global health researchers and practitioners to incorporate an expanded focus on these actors. Taking this approach will generate a wider range of strategies to better engage these organisations in policy processes and will ensure stronger health workforce policies globally.
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Affiliation(s)
- Veena Sriram
- School of Public Policy and Global Affairs, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sorcha A Brophy
- Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Kartik Sharma
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Maya Annie Elias
- School of Development, Azim Premji University, Bengaluru, Karnataka, India
- Sociology, University of Antwerp, Antwerpen, Belgium
| | - Arima Mishra
- School of Development, Azim Premji University, Bengaluru, Karnataka, India
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Sriram V, Keshri VR. Interest Groups and Health Facility Regulation - Future Directions for Health Policy and Systems Research Comment on "What Lies Behind Successful Regulation? A Qualitative Evaluation of Pilot Implementation of Kenya's Health Facility Inspection Reforms". Int J Health Policy Manag 2023; 12:7826. [PMID: 37579407 PMCID: PMC10461866 DOI: 10.34172/ijhpm.2023.7826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/18/2023] [Indexed: 08/16/2023] Open
Abstract
In their paper, Tama and colleagues observe that one key challenge in a pilot, multi-component intervention to strengthen health facility regulation was the reaction from health facility owners and providers to regulatory processes. In this commentary, we propose that future research and action on health facility regulation in low- and middle-income countries (LMICs) contexts adopt an explicit focus on addressing the role of interests and interest groups in health systems 'hardware' and 'software.' Research on policy processes in LMICs consist of fewer investigations into the political economy of national or sub-national interest groups, such as physician associations or associations of health facility owners. A growing body of literature explores supply-side and demand-side interest groups, power relations within and between these stakeholders, and their advocacy approaches within LMIC health sector policy processes. We posit that such analyses will also help identify facilitators and challenges to implementation and scale-up of similar reforms to health facility regulation.
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Affiliation(s)
- Veena Sriram
- School of Population and Public Health, School of Public Policy and Global Affairs, University of British Columbia, Vancouver, BC, Canada
| | - Vikash R. Keshri
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health India, New Delhi, India
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Tsofa B, Waweru E, Munywoki J, Soe K, Rodriguez DC, Koon AD. Political economy analysis of sub-national health sector planning and budgeting: A case study of three counties in Kenya. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001401. [PMID: 36962920 PMCID: PMC10022076 DOI: 10.1371/journal.pgph.0001401] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 11/27/2022] [Indexed: 05/06/2023]
Abstract
Devolution represented a concerted attempt to bring decision making closer to service delivery in Kenya, including within the health sector. This transformation created county governments with independent executive (responsible for implementing) and legislative (responsible for agenda-setting) arms. These new arrangements have undergone several growing pains that complicate management practices, such as planning and budgeting. Relatively little is known, however, about how these functions have evolved and varied sub-nationally. We conducted a problem-driven political economy analysis to better understand how these planning and budgeting processes are structured, enacted, and subject to change, in three counties. Key informant interviews (n = 32) were conducted with purposively selected participants in Garissa, Kisumu, and Turkana Counties; and national level in 2021, with participants drawn from a wide range of stakeholders involved in health sector planning and budgeting. We found that while devolution has greatly expanded participation in sub-national health management, it has also complicated and politicized decision-making. In this way, county governments now have the authority to allocate resources based on the preferences of their constituents, but at the expense of efficiency. Moreover, budgets are often not aligned with priority-setting processes and are frequently undermined by disbursements delays from national treasury, inconsistent supply chains, and administrative capacity constraints. In conclusion, while devolution has greatly transformed sub-national health management in Kenya with longer-term potential for greater accountability and health equity, short-to-medium term challenges persist in developing efficient systems for engaging a diverse array of stakeholders in planning and budgeting processes. Redressing management capacity challenges between and within counties is essential to ensure that the Kenya health system is responsive to local communities and aligned with the progressive aspirations of its universal health coverage movement.
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Affiliation(s)
- Benjamin Tsofa
- KEMRI-Wellcome Trust Research Programme–KEMRI Centre for Geographic Medicine Research -Coast, Kilifi, Kenya
- Department of Public Health–Pwani University School of Health Sciences, Kilifi, Kenya
- * E-mail:
| | - Evelyn Waweru
- KEMRI-Wellcome Trust Research Programme–KEMRI Centre for Geographic Medicine Research -Coast, Kilifi, Kenya
| | - Joshua Munywoki
- KEMRI-Wellcome Trust Research Programme–KEMRI Centre for Geographic Medicine Research -Coast, Kilifi, Kenya
| | - Khaing Soe
- United Nations Children’s Fund (UNICEF) Kenya, Country Office, Kisumu, Kenya
| | - Daniela C. Rodriguez
- Johns Hopkins Bloomberg School of Public Health, Dept. of International Health, Baltimore, Maryland, United States of America
| | - Adam D. Koon
- Johns Hopkins Bloomberg School of Public Health, Dept. of International Health, Baltimore, Maryland, United States of America
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