Local perspectives on policy implementation of free maternity health services in Kenya: Implications for universal health coverage.

Kenya introduced free maternity services (FMS) in 2013 to enable all pregnant women to give birth for free in all government public health facilities. Currently, Kenya is rolling out universal health coverage (UHC), which has been acknowledged as a priority goal for every health system and part of the 'Big Four Agenda' for sustainable national development in Kenya. FMS is one of the core services in Kenya, but since its launch, it is not clear whether the decentralized approach chosen to implement FMS is leading to UHC. This nine-month ethnographic study in Kilifi County, Kenya, was conducted between March-July 2016 and February-July 2017. A narrative approach to analysis was applied. In this article, we interrogate local perceptions of participation during the crafting and implementation of FMS. Findings show that FMS was detached from local realities, and this was a major inadequacy of the top to bottom approach. FMS did not consider local power relations and bargaining power which are requisites during policy formulation and implementation. The participants expressed desire for more localized control over resources from the national government. The findings suggest that as UHC is rolled out in Kenya, consultation of local stakeholders at the grassroots by the state departments would likely improve maternal healthcare outcomes. Such consultations must take into consideration differences in bargaining power and local power relations. Borrowing from the basic tenets of the recent anthropological theorization of constitutionality, this article proposes a bottom to top approach that leverages and integrates local views during policy-making process to create trust, a sense of ownership and accountability.

Measures adopted by indigent mothers in Kilifi County to tackle maternal health challenges during the COVID-19 pandemic: A qualitative study.

Many sub-Saharan African countries have experienced various challenges that threaten the quality of health services offered to the population. The COVID-19 pandemic disrupted access to healthcare services in many countries as they grappled with implementing measures to curb its spread. The consequences of COVID-19 have been catastrophic for maternal and newborn health. There is a dearth of information on expectant mothers' negotiation mechanisms to access maternal health services during COVID-19 in Kenya. This rapid qualitative study draws data from purposefully selected 15 mothers who were either pregnant or had newborn babies during the COVID-19 pandemic in Kilifi county in Kenya. Data were analyzed thematically and presented in a textual description. Women used the following alternatives to access maternal health: giving birth at the homes of traditional birth attendants (TBAs), substituting breastfeeding with locally available food supplements, relying on limited resources and neighbours for delivery and local savings and rotating credit associations. This study shows that urgent measures are needed to provide high quality maternal and child health services during and after the COVID-19 pandemic. These include but are not limited to developing special interventions for the pregnant women for any emergency and establishing trust between communities and individuals through the TBAs.

A new understanding and evaluation of food sustainability in six different food systems in Kenya and Bolivia.

Food systems must become more sustainable and equitable, a transformation which requires the transdisciplinary co-production of knowledge. We present a framework of food sustainability that was co-created by academic and non-academic actors and comprises five dimensions: food security, right to food, environmental performance, poverty and inequality, and social-ecological resilience. For each dimension, an interdisciplinary research team-together with actors from different food systems-defined key indicators and empirically applied them to six case studies in Kenya and Bolivia. Food sustainability scores were analysed for the food systems as a whole, for the five dimensions, and for food system activities. We then identified the indicators with the greatest influence on sustainability scores. While all food systems displayed strengths and weaknesses, local and agroecological food systems scored comparatively highly across all dimensions. Agro-industrial food systems scored lowest in environmental performance and food security, while their resilience scores were medium to high. The lowest-scoring dimensions were right to food, poverty and inequality, with particularly low scores obtained for the indicators women's access to land and credit, agrobiodiversity, local food traditions, social protection, and remedies for violations of the right to food. This qualifies them as key levers for policy interventions towards food sustainability.

Externalities in appropriation: responses to probabilistic losses.

Using an appropriation game setting, we examine individual responses to changes in a groups' vulnerability to a probabilistic loss (L) of a public good. The probabilistic loss parameter entails losing 10, 50 or 90% of the value of the public good that is maintained through cooperation, where the likelihood of the loss decreases in total group cooperation. By design, the expected marginal net benefits to an individual and the expected harm to others depends endogenously on the individuals' expectations of group cooperation and exogenously on the magnitude of the loss parameter. We find that individual cooperation is greater when forecasts of total group cooperation are greater and where the magnitude of the probabilistic loss is larger. There is, however, an interesting asymmetry in responses by two subgroups. Subjects who are pessimistic regarding total group cooperation decrease cooperation the higher the magnitude of the probabilistic loss and their decisions are tied systematically to changes in their expectations of other's cooperation. On the other hand, subjects who are optimistic regarding total group cooperation are found to be more cooperative, but their decisions are not systematically tied to changes in expectations of others' cooperation.

Culture, changing livelihoods, and HIV/AIDS discourse: reframing the institutionalization of fish-for-sex exchange in the Zambian Kafue Flats.

Discussions about the cultural dimensions of the spread of HIV/AIDS in Africa persist. Drawing on data on fish-for-sex deals between local Ila or Tonga women and immigrant fishermen in the Zambian Kafue Flats, we argue against the notion that traditional institutions governing extra-marital sexual relationships are responsible for the spread of HIV/AIDS. We argue that fish-for-sex exchanges are based not on tradition, but on the economic opportunities provided by the fish trade in conditions of poverty and changing livelihoods. Stigmatization of women involved in fish-for-sex deals is, however, on the increase, since they are accused of spreading the disease in their community. Women's inability to follow the sexual prescriptions conveyed by HIV prevention programmes produces shame and moral distress, associated with the fear of social exclusion. In this situation, lubambo, a former customary regulation of extramarital sexual relations among the Ila, may provide women with legitimacy for sexual transactions. Additionally, customary marriage arrangements institutionally secure their access to fish.