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Julie Kiguli1, Elizabeth Ekirapa-Kiracho1, Olico Okui1, Aloysius Mutebi1, Hayley MacGregor2, George William Pariyo11Makerere University School of Public Health, Kampala, Uganda; 2Institute of Development Studies, Sussex, UKAbstract: This paper examines the community’s perspectives and perceptions on quality of health care delivery in two Uganda districts. The paper addresses community concerns on service quality. It focuses on the poor because they are a vulnerable group and often bear a huge burden of disease. Community views were solicited and obtained using eight focus group discussions, six in-depth and 12 key informant interviews. User perceptions and definitions of the quality of health services depended on a number of variables related to technical competence, accessibility to services, interpersonal relations and presence of adequate drugs, supplies, staff, and facility amenities. Results indicate that service delivery to the poor in the general population is perceived to be of low quality. The factors that were mentioned as affecting the quality of services delivered were inadequate trained health workers, shortage of essential drugs, poor attitude of the health workers, and long distances to health facilities. This paper argues that there should be an improvement in the quality of health services with particular attention being paid to the poor. Despite wide focus on improvement of the existing infrastructure and donor funding, there is still low satisfaction with health services and poor perceived accessibility.Keywords: quality, health care, poor, community, perceptions, utilization

Summary This paper explores gaps and limitations in the conceptualisation, methodology and policy implications of debates about informal health care providers by examining a cross section of empirical studies. Drawing on a tradition of critical medical anthropology, we argue that existing debates hinge on a particular understanding of what constitutes appropriate knowledge and on particular expectations of how economic actors in the medical marketplace will behave.

This article offers an analysis of the body-mapping dimension of the 'treatment literacy' initiatives of the Treatment Action Campaign (TAC), an HIV/AIDS-focused social movement in South Africa. It situates body mapping within the politics of HIV/AIDS activism in South Africa. The alliance between activists and biomedical practitioners is explored and the emphasis on the 'science of HIV' in TAC treatment literacy considered alongside the foregrounding of social realities, such as poverty and inequality. The article argues that the education activities of the TAC illustrate 'context-sensitive' science, rather than following a linear model of 'public understanding of science'. The personal accounts published alongside the first body maps are explored to illustrate an evident re-socialisation of biological organs and an emphasis on the relationality of bodies. The bounded bodies and the activist emphasis on body politics become ways to counteract fears of the virulence of the illness.

In keeping with international trends, South African health policy is moving towards comprehensive primary health care, with mental health care offered as integral to this service. This move is consonant with other moves towards integration in a formerly divided country. We consider some ideological bases for the move towards integration, and the consequences for psychiatric patients. We show how the specialist terrain of the mental health nurse has been recast as focusing primarily on violence, substance abuse and HIV/AIDS rather than on psychiatric care. Using case material to illustrate our argument we suggest that integrating mental health care into the primary health care system may have unintended negative consequences for patients. The argument has implications for services in other poorly resourced and postconflict societies.

Interdisciplinary research on zoonotic disease has tended to focus on ‘risk’ of disease transmission as a conceptual common denominator. With reference to endemic zoonoses at the livestock–human interface, we argue for considering a broader sweep of disciplinary insights from anthropology and other social sciences in interdisciplinary dialogue, in particular cross-cultural perspectives on human–animal engagement. We consider diverse worldviews where human–animal encounters are perceived of in terms of the kinds of social relations they generate, and the notion of culture is extended to the ‘natural’ world. This has implications for how animals are valued, treated and prioritized. Thinking differently with and about animals and about species' boundaries could enable ways of addressing zoonotic diseases which have closer integration with people's own cultural norms. If we can bring this kind of knowledge into One Health debates, we find ourselves with a multiplicity of worldviews, where bounded categories such as human:animal and nature:culture cannot be assumed. This might in turn influence our scientific ways of seeing our own disciplinary cultures, and generate novel ways of understanding zoonoses and constructing solutions.This article is part of the themed issue ‘One Health for a changing world: zoonoses, ecosystems and human well-being’.

Background: The government of Malawi is committed to the broad rollout of antiretroviral treatment in Malawi in the public health sector; however one of the primary challenges has been the shortage of trained health care workers. The Practical Approach to Lung Health Plus HIV/AIDS in Malawi (PALM PLUS) package is an innovative guideline and training intervention that supports primary care middle-cadre health care workers to provide front-line integrated primary care. The purpose of this paper is to describe the lessons learned in implementing the PALM PLUS package. Methods: A clinical tool, based on algorithm- and symptom-based guidelines was adapted to the Malawian context. An accompanying training program based on educational outreach principles was developed and a cascade training approach was used for implementation of the PALM PLUS package in 30 health centres, targeting clinical officers, medical assistants, and nurses. Lessons learned were identified during program implementation through engagement with collaborating partners and program participants and review of program evaluation findings. Results: Key lessons learned for successful program implementation of the PALM PLUS package include the importance of building networks for peer-based support, ensuring adequate training capacity, making linkages with continuing professional development accreditation and providing modest in-service training budgets. The main limiting factors to implementation were turnover of staff and desire for financial training allowances. Conclusions: The PALM PLUS approach is a potential model for supporting mid-level health care workers to provide front-line integrated primary care in low and middle income countries, and may be useful for future task-shifting initiatives.

Background: Rapid Ethical Assessment (REA) is a form of rapid ethnographic assessment conducted at the beginning of research project to guide the consent process with the objective of reconciling universal ethical guidance with specific research contexts. The current study is conducted to assess the perceived relevance of introducing REA as a mainstream tool in Ethiopia.\ud \ud Methods: Mixed methods research using a sequential explanatory approach was conducted from July to September 2012, including 241 cross-sectional, self-administered and 19 qualitative, in-depth interviews among health researchers and regulators including ethics committee members in Ethiopian health research institutions and universities.\ud \ud Results: In their evaluation of the consent process, only 40.2% thought that the consent process and information given were adequately understood by study participants; 84.6% claimed they were not satisfied with the current consent process and 85.5% thought the best interests of study participants were not adequately considered. Commonly mentioned consent-related problems included lack of clarity (48.1%), inadequate information (34%), language barriers (28.2%), cultural differences (27.4%), undue expectations (26.6%) and power imbalances (20.7%). About 95.4% believed that consent should be contextualized to the study setting and 39.4% thought REA would be an appropriate approach to improve the perceived problems. Qualitative findings helped to further explore the gaps identified in the quantitative findings and to map-out concerns related to the current research consent process in Ethiopia. Suggestions included, conducting REA during the pre-test (pilot) phase of studies when applicable. The need for clear guidance for researchers on issues such as when and how to apply the REA tools was stressed.\ud \ud Conclusion: The study findings clearly indicated that there are perceived to be correctable gaps in the consent process of medical research in Ethiopia. REA is considered relevant by researchers and stakeholders to address these gaps. Exploring further the feasibility and applicability of REA is recommended.

Background In South Africa, policy with respect to HIV/AIDS has had a strong rights-based framing in line with international trends and in keeping with the constitutional overhaul in the post-Apartheid era. There have also been considerable advances since 1994 towards legal enshrinement of sexual and reproductive health rights and in the provision of related services. Since HIV in this setting has heavily affected women of reproductive age, there has been discussion about the particular needs of this subgroup, especially in the context of service integration. This paper is concerned with the way in which HIV positive women conceptualise these rights and whether they wish and are able to actualise them in their daily lives. Methods In 2003 a group of women involved with the Treatment Action Campaign and Medicines Sans Frontières participated in an initiative to ‘map’ their bodies as affected by the virus. A book containing the maps and narratives was published and used as a political tool to pressure the government of the day to roll out antiretroviral therapy (ART) to the population. In 2008, the authors coordinated an initiative that involved conducting follow-up in-depth interviews in which five of these women reflected on those body maps and on how their lives had changed in the intervening five years since gaining the right to treatment through the public sector. Results Drawing upon this qualitative data and published sources, these new accounts are analysed in order to reflect the perspectives of these women living with chronic HIV with respect to their sexual relations and fertility desires. The paper reveals difficulties faced by these women in negotiating sexual relationships and disclosure of their HIV positive status. It focuses on how they perceive relative responsibilities in terms of taking preventative measures in sexual encounters. Women adopt tactics within a context characterised by various inequalities in order to ‘make do’, such as by remaining silent about their status. Concerns about childbearing can be addressed by information and support from a health care worker. Conclusions Women’s experience of HIV as a chronic illness and the need to adhere to ART, is linked to the way in which the language of responsibility can come to counter-balance a language of rights in treatment programmes.

Current debates and market based interventions in international public health seek to bring about explicit improvements in the quality of care offered by informal providers. In this paper we examine how informal providers are framed as problematic and question assumptions about what constitutes appropriate knowledge and expectations of how economic actors in the medical marketplace will behave. We argue that existing portraits of informal providers tend to establish clear cut distinctions between different kinds of practitioner; 'dis-embed' biomedical transactions from the broader relationships within which they take place; freeze or anatomise what are dynamic economic relationships between stakeholders, and obscure or ignore the position of informal providers in a global pharmaceutical supply chain.

Despite the severity of the HIV epidemic worldwide, and particularly in southern Africa, persons with disabilities have until recently been generally excluded from consideration in HIV prevention campaigns. This chapter outlines the situation with regard to HIV/AIDS as it affects persons with disabilities. The chapter will begin by first providing an outline of the experience and prevalence of disability in South Africa, highlighting how little is known about how HIV affects persons with disabilities in South Africa. An outline of some of the international literature, including a recent global survey on HIV/AIDS and disability, will be presented. With the background of findings from international studies, we shall then look at the issue of HIV/AIDS as it affects persons with disabilities in South Africa, with reference to recent research in this area. The chapter will also discuss and highlight some of the current contested issues involved with regard to HIV/AIDS as a disability and the disability grant.

In South Africa, disability grant allocation has been under review and tensions are evident in government rhetoric stressing welfare provision on the one hand, and encouraging ‘rationalization’ on the other. This ambiguity is traced down to the level of grant negotiations between doctors and ‘clients’ in a psychiatry clinic in Khayelitsha. Here ‘having nerves’ embodies the distress associated with harsh circumstances and is deemed by supplicants as sufficient to secure a grant. The paper illustrates how national discourses influence the presentation and experience of suffering and the way in which doctors mediate diagnoses. The implications of local understandings of ‘health citizenship’ for expectations of the post-apartheid state are explored.

The emergence and spread of antibiotic resistant pathogens poses a big challenge to policy-makers, who need to oversee the transformation of health systems that evolved to provide easy access to these drugs into ones that encourage appropriate use of antimicrobials, whilst reducing the risk of resistance. This is a particular challenge for low and middle-income countries with pluralistic health systems where antibiotics are available in a number of different markets. This review paper considers access and use of antibiotics in these countries from a complex adaptive system perspective. It highlights the main areas of intervention that could provide the key to addressing the sustainable long term use and availability of antibiotics.A focus on the synergies between interventions addressing access strategies, antibiotic quality, diagnostics for low-resource settings, measures to encourage just and sustainable decision making and help seeking optimal therapeutic and dosing strategies are key levers for the sustainable future of antibiotic use. Successful integration of such strategies will be dependent on effective governance mechanisms, effective partnerships and coalition building and accurate evaluation systems at national, regional and global levels.