PHA-Exch> EQUINET Discussion Paper 69: How power relations affect the implementation of policy on equity in access to anti-retroviral therapy: The case of rural health centres in Malawi

[Rene Loewenson]

EQUINET Discussion Paper 69: How power relations affect the implementation
of policy on equity in access to anti-retroviral therapy: The case of rural
health centres in Malawi, 
LK Simwaka 

Cite as: Simwaka LK (2008) 'How power relations affect the implementation of
policy on equity in access to anti-retroviral therapy: The case of rural
health centres in Malawi,' EQUINET Discussion Paper 69. Malawi Interfaith
AIDS Association  EQUINET: Harare.

Available online at:
http://www.equinetafrica.org/bibl/docs/DIS69POLsimwaka.pdf

The national ART scale-up plan contains several measures to promote equity,
considering also that there are insufficient resources to cover everyone who
is eligible. Thus study  focused on four of these covering ART enrolment on
an open 'first-come, first-served' basis; targeted gender-sensitive health
promotion of ART, measures to overcome specific geographical barriers to
access for remote populations and prioritisation of  people already on ART,
pregnant women and young children.  Using a case study approach the study
analysed the power relations that influenced outcomes on these policy
measures on four health facilities in Malawi.  The findings indicate that
health workers commonly exercise power in relation to patients, and that
patient acquiesce with health worker behaviours. In poorly performing
facilities, implementation of policy measures is negatively affected by
managerial practices that discourage teamwork and de-motivate health
workers, while in the two better performing facilities, management practices
had a more positive role in supporting positive health worker practices. The
study findings highlight that  implementing equity policies needs to include
measures to orient and involve staff, and address power and resource
imbalances that can undermine access. 


December 2008

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