Between orchestrated and organic: Accountability for loss and the moral landscape of childbearing in Malawi

Kok, Bregje Christina de

doi:10.1016/j.socscimed.2018.09.036

Cited by 13 publications

(16 citation statements)

References 23 publications

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“…This article contributes to literature, marginal in public health, that places globally designed "traveling models", such as user-fee exemption policies and skilled birth attendance, in the broader context of the day-to-day functioning of health systems and public health policy. 11,35,36 Our analysis shows how dynamic responses and accountability relationships 24 can help explain problems with the implementation of policy 36,37 and their inequitable effects when confronted with broader malfunctions of health systems. 12,13,35 This article contributes to understanding processes leading to inequity, which is a central challenge to achieving the Global Strategy for Women's, Children's and Adolescents' health and the SDGs.…”

Section: Resultsmentioning

confidence: 97%

“…HP and BdK analysed actors' perceptions and dynamic responses to the unfolding events and each other's actions. Discussions between the authors, BdK's knowledge on Safe Motherhood policies in Malawi and her work on power and accountability, 24 as well as data triangulation across multiple sources and perspectives, facilitated a nuanced analysis that considers multiple perspectives. Study limitations are the absence of data on the number of women who gave birth at the district hospital and at home, and the limited geographical scope as actors in other villages might have responded differently.…”

Section: Methodsmentioning

confidence: 99%

“…Actors are involved in multiple accountability relationships or "webs of accountability", which are uneven. The moral landscape that forms, enacted in a context of risk and under-resourced systems, affects behaviours, interactions, health systems functioning and the quality of maternity care, 24 as discussed below.…”

Section: Power and Accountabilitymentioning

confidence: 99%

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When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi

Pot

Kok

Finyiza³

2018

Reproductive Health Matters

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Despite the strong global focus on improving maternal health during past decades, there is still a long way to go to ensure equitable access to services and quality of care for women and girls around the world. To understand widely acknowledged inequities and policy-to-practice gaps in maternal health, we must critically analyse the workings of power in policy and health systems. This paper analyses power dynamics at play in the implementation of maternal health policies in rural Malawi, a country with one of the world's highest burdens of maternal mortality. Specifically, we analyse Malawi's recent experience with the temporary reintroduction of user-fees for maternity services as a response to the suspension of donor funding, a shift in political leadership and priorities, and unstable service contracts between the government and its implementing partner, the Christian Health Association of Malawi. Based on ethnographic research conducted in 2015/16, the article describes the perceptions and experiences of policy implementation among various local actors (health workers, village heads and women). The way in which maternity services "fall apart" and are "fixed" is the result of dynamic interactions between policy and webs of accountability. Policies meet with a cascade of dynamic responses, which ultimately result in the exclusion of the most vulnerable rural women from maternity care services, against the aims of global and national safe motherhood policies.

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Section: Resultsmentioning

confidence: 97%

Section: Methodsmentioning

confidence: 99%

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When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi

Pot

Kok

Finyiza³

2018

Reproductive Health Matters

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“…The temporary reintroduction of user-fees contradicted SLAs between the government of Malawi and CHAM, which provides 75% of health services in rural areas. 25 In Mangochi, four out of fifteen CHAM facilities had a SLA, 26 where CHAM provides maternal and newborn health services free of charge and the government reimburses the costs. The government pays staff salaries and essential medication.…”

Section: Service Level Agreementsmentioning

confidence: 99%

Public Servants as Development Brokers: The Shaping of INGOs’ Reducing Teenage Pregnancy Projects in Malawi’s Primary Education Sector

Pot

2018

Forum for Development Studies

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International non-governmental organisations (INGOs) play an increasingly prominent and multifaceted role in the field of global healthas policy advocates, recipients of donor funds, and implementers of donor-funded programmes. Many such NGOs and their local affiliates have become highly professionalized and oriented towards the priorities of global-level actors, with potential negative consequences for their ability to represent the grassroots and to challenge structures of power and inequality. In this thesis, I examine the dynamics around INGO project implementation in Malawi, within the broader context of overlapping development initiatives, shifting priorities, conditions of scarcity and donor dependence, and poor health outcomes. I draw on ethnographic research conducted in rural Malawi between May 2015 and August 2016, which focused on the implementation of a Save the Children project that aimed to improve maternal health by reducing teenage pregnancies, primarily by keeping girls in school and increasing their use of reproductive health services, notably contraceptives. My ethnographic gaze is on the individuals who serve as intermediaries between donors, northern (I)NGOs and local recipients, who I conceptualise as brokers. They include INGO district staff, primary school teachers, health workers, village heads, and community representatives. Through a focus on their practices, I examine how they translate global norms and aims into programmatic practice. The thesis brings together three peerreviewed articles. The first (in Forum for Development Studies) discusses how primary school teachers deal with, and implement, various overlapping NGO initiatives targeting girls, and the implications for public sector institutions. The second article (in Medical Anthropology) examines how INGOs' programmatic focus on behaviour change interventions inadvertently results in staff blaming culture for teenage pregnancies and school dropout, reinforcing ethnic stereotypes originating in historical inequalities and previous health development initiatives which targeted harmful cultural practices. The third article (in Reproductive Health Matters) analyses the responses of village heads, midwives and women to the reintroduction of userfees for maternal health services resulting from donors' suspension of budget support, shifting national priorities, and unstable service delivery contracts. Overall, I argue that examining the practices of the brokers who implement and reshape health development initiatives can shed light on policy-to-practice gaps and how unintended consequences occur. My ethnographic research thus helps to explain why initiatives might not be sustainable despite the intention of donors and INGOs to strengthen existing public and community structures. 1 This research is led by Professor Sidsel Roalkvam, Co-Investigator Katerini Storeng, and senior researchers at the University of Malawi-Professor Blessings Chinsinga, Peter Mvula and Joseph Chunga. Fieldwork in Malawi has been carried out by three Universit...

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“…By extension, certain behaviors may be considered as rights violation and abuse by some (e.g., women, advocates from high-income settings), but not others (e.g., providers). Ethnographic studies (Brown, 2010; de Kok, 2019) have problematized the application of generic labels (e.g., “verbal abuse”) and universal rights principles (e.g., “freedom from harm”) to judge health professionals’ behaviors (e.g., shouting). This may obscure important contextual and situational details which may reframe acts as (intended) care rather than abuse (de Kok, 2019).…”

Section: Introductionmentioning

confidence: 99%

From Global Rights to Local Relationships: Exploring Disconnects in Respectful Maternity Care in Malawi

et al. 2019

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Widespread reports of “disrespect and abuse” in maternity wards in low- and middle-income countries have triggered the development of rights-based respectful maternity care (RMC) standards and initiatives. To explore how international standards translate into local realities, we conducted a team ethnography, involving observations in labor wards in government facilities in central Malawi, and interviews and focus groups with midwives, women, and guardians. We identified a dual disconnect between, first, universal RMC principles and local notions of good care and, second, between midwives and women and guardians. The latter disconnect pertains to fraught relationships, reproduced by and manifested in mechanistic care, mutual responsibilization for trouble, and misunderstandings and distrust. RMC initiatives should be tailored to local contexts and midwife-client relationships. In a hierarchical, resource-strapped context like Malawi, promoting mutual love, understanding, and collaboration may be a more productive way to stimulate “respectful” care than the current emphasis on formal rights and respect.

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Between orchestrated and organic: Accountability for loss and the moral landscape of childbearing in Malawi

Cited by 13 publications

References 23 publications

When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi

When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi

Public Servants as Development Brokers: The Shaping of INGOs’ Reducing Teenage Pregnancy Projects in Malawi’s Primary Education Sector

From Global Rights to Local Relationships: Exploring Disconnects in Respectful Maternity Care in Malawi

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