Magister Philosophiae - MPhil / Zambia has, since independence in 1964, endeavoured to build an effective local government system anchored on decentralisation in an effort to attain the values and principles of democracy, autonomy and transparency. These values and principles are essential in enhancing service delivery and development. Within the South African context, De Visser and May argue, in keeping with the developmental imperatives for decentralisation, that local governments should be entrusted with fundamental powers and functions related to basic service delivery. A local government entrusted with fundamental powers is said to be the best foundation for building democracy, social and economic development. Therefore, the desire to build a strong foundation for an effective local government system is what motivates the design of local government administrations in many countries. One of the essential aspects in the design of a local government system is administrative autonomy. Administrative autonomy is important because it plays a complementary role to the realisation of political and fiscal autonomy. Administrative autonomy refers to the discretion to appoint, remunerate, discipline and dismiss staff as well as determining internal administrative procedures. It further ensures that the implementation of local policies is locally directed and driven by promoting accountability of local administrative officials to sub-national governments. In an effort to have a local government system that promotes accountability of local administrative officials to sub-national governments, Zambia has over the years employed three systems of local government administrations from 1964 to 2016 namely, the separate, unified and integrated systems.

A thesis submitted to the faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa; in fulfillment of the requirements for the award of PhD in Demography and Population Studies. September, 2016. / Background: While there has been a significant global reduction in maternal mortality rates from 546 000 in 1990 to 287 000 in 2010 (Zureick-Brown et al., 2013;Merdad, et al., 2013), maternal mortality in Zambia continues to be above at 483 per 100 000 live births, eluding the millennium development target of 162 (CSO, 2012). Data on maternal mortality are not disaggregated by provinces. Various studies on maternal mortality conducted in Zambia (Ahmed et al., 1999; Banda et al., 2007; Hazemba & Siziya, 2009; Kilpatrick, Crabtree & Kemp, 2002) have evaluated maternal deaths at national level using direct death inquiry and though it is useful for international comparisons, neither one of these approaches are appropriate for evaluating maternal mortality in small districts where safe motherhood initiatives are often carried out. These studies have rarely included neighbourhood influence on maternal mortality risks. Moreover, no known study has attempted to use the Zambia Demographic and Health Survey maternal health indicators to evaluate maternal mortality by regions in Zambia. Yet, analyses of differentials within small districts provide an improved awareness of the social situation in which the risks are high for regional priority interventions. In addition, other researchers (Achia & Mageto 2015; Stephenson & Elfstrom 2012) have all posted that inclusion of neighbourhood level variables is helpful to understand several maternal health outcomes. Objective: Guided by the conceptual framework developed by McCarthy & Maine (1992), this study contributes the new method of use of the mean Maternal Death Risk Factor Index model to estimate the levels and differentials in the risks of maternal mortality by regions and enhance the understanding of determinants of maternal mortality risks. This model is helpful in that it highlights regional and socioeconomic differentials in maternal mortality risks and ranks regions according to their potential maternal mortality burdens. Benchmarks are set by using this model and indicators are used to identify probable high-risk areas or regions. Methodology: The study utilised existing data sources from the 2007 Demographic and Health Surveys (DHS) and 2011-2013 Health Management Information System Routine Data (HMIS). Bivariate analysis was utilised to investigate the distribution and differentials in exposure to maternal mortality risks. Multilevel logistic regression was performed to investigate the independent and moderating functions of neighbourhood aspects on exposure to maternal mortality risks and the moderating functions of neighbourhood causes on the relationship between individual circumstances and exposure to maternal mortality risks. The mean Maternal Death Risk Factor Index (MDRFI) model that uses the history of individual women health indicators was used to predict maternal mortality and highlight regional and socioeconomic differentials of maternal mortality risks. The analysis was based on 5 410 women aged 15 to 49 who had a live birth in the five years prior to the 2007 Zambian Demographic and Health Surveys. The HMIS 2011-2013 data was also utilised for a comparative analysis and complementing DHS data on maternal health matters in Zambia. Results: The predicted maternal mortality ratios (MMRs) values by region showed larger regional disparities. All the seven rural regions had MMR above the national average (591/100 000 live births); the highest being in Northern Zambia (738 per 100 000 live births) and Central Zambia (679 per 100 000 live births). The predicted ratios in the two urban regions of Lusaka and Copper-belt were significantly below the national average. The findings of both bivariate and multivariate analyses showed that skilled birth attendance at delivery significantly lowered the risks of exposure to adverse pregnancy outcome. The likelihood of using skilled personnel at birth was advanced for women who resided in neighbourhoods, with advanced proportion of women who utilized skilled delivery at birth compared to women who lived in neighbourhoods that had a high proportion of women giving birth at home. The outcome from the multilevel analysis showed that the consequence of individual and neighbourhood influences on the exposure to high risk pregnancy in Zambia operates at different levels. Women with no education were found to be more exposed to high risk pregnancy than women with post primary education. The rate of women in the neighbourhood who utilized skilled birth attendance had a strong positive impact on the reduction of exposure to high risk pregnancy. In the analysis of autonomy level – although results indicated that women with low autonomy had higher odds of exposure to high risk pregnancy compared to women with high autonomy – the results were not significant, and therefore autonomy level in terms of exposure to high risk pregnancy was not supported in this study. Conclusion: The MDRFI model is much easier to use at any level and quicker to forecast interventions as well as prevent probable risks compared to the use of the sisterhood method. The model proposed here could serve as the basis for a new and better system of mortality estimation for populations with incomplete data. The results reveal a number of challenges to confront with the purpose of reducing maternal mortality in Zambia. Women’s high risk reproductive behaviours and the use of imperative fertility healthcare utilities have yet to increase considerably to result in a decrease in maternal deaths in the nation. The continuous disparities in maternal death hardship by province, rural-urban dwelling and socioeconomic position of the society further heightened the issue, making attempts to enhance maternal health and thereby decrease maternal deaths more demanding. Advancements to lower maternal mortality should either lessen the probability that a woman will become pregnant or lower the possibility that a pregnant woman will experience adverse reactions during pregnancy or childbirth or better the outcomes for women with complex pregnancies. This research makes it evident that programs to combat maternal mortality risks in the country require several avenues that embrace diverse protective measures looking beyond the individual level as women’s health is essentially affected by their social environment. The amount of differential at neighbourhood and individual level found in our study indicates the need to contextualise efforts to increase resources towards mitigating exposure to high risk pregnancy. Hence, adopting neighbourhood-specific strategies along with identifying and addressing neighbourhood factors affecting the exposure to high risk pregnancy would give better results. The use of multilevel analysis in this research has shown that individual and neighbourhood aspects are crucial components associated with the exposure to high risk pregnancy. The multilevel framework demonstrated crucial neighbourhood differentials in the exposure to high risk pregnancy. Improving quality and access to health services is essential if the most deprived are to benefit. The Ministry of Health should align its plans of action to Zambia’s development strategy articulated in its own Vision 2030. Neighbourhood health workers need to be involved in sensitising pregnant women about the risks of maternal mortality, for instance short birth interval, risky maternal age and danger signs during pregnancy. To close the gap in exposure to high risk pregnancy between neighbourhoods, interventions should aim at poverty reduction, increasing neighbourhood maternal education and facility delivery in deprived neighbourhoods. The model used in this study could serve as the basis for a new and better system of mortality estimation for populations with incomplete data and will be much easier to use at any level, as well as vital for quick forecasting of priority interventions. / GR2017

ABSTRACT The purpose of the project research was to investigate the impact of the Zambian 2003 national cultural policy on the performing arts industry with specific reference to working conditions both in the public and private domains in Zambia. It is also an effort to assess the efficacy of the cultural policy within a broader policy environment. Generally, two categories of performing artists namely the publicly and privately sponsored exist in Zambia. Two sample groups representing the two categories of performing artists were consulted in the study. The publicly sponsored sample was drawn from the uniformed services and the national dance troupe while the privately sponsored performers were represented by a selection of performers who do not work in the civil service. The methodology included field and desk research in which social-scientific and humanistic methods involving structured and semi-structured interviews were used, coupled with the use of textual materials from employment and performance contracts, civil service terms of employment, the National Arts Council Act, national arts associations’ constitutions, cultural and labour policies among others. The results revealed mixed reactions from all the respondents with regard to the research question; however it became apparent that the policy had not positively impacted on the industry as the negative responses outweighed the positive feedback. Despite the policy theoretically addressing a number of issues in the arts industry, it was very difficult to practically implement the strategies therein successfully. A number of reasons can be advanced for the inefficiency such as lack of matching sectoral legislation to enforce the policy and the absence of a union to complement government’s efforts. It was further discovered that to some extent, the formulation of the policy was rushed and did not very well fit into the traditional perspectives of the people about the arts industry. This reinforces the question of whether is it necessary for all nations to have cultural policies when supporting institutional and legal frameworks are not in place. The Zambian case reveals the pitfalls in legislating culture. 1

No description available.

Philosophiae Doctor - PhD / English is the official language in Zambia and a compulsory subject from grade 1 to the final year of secondary education. Communicative competence in English is therefore critical to mobility in education and is also central to one’s job opportunities in the country. This implies that the teaching of English in schools is of paramount importance. Eclecticism is the recommended approach to teaching of English in Zambian secondary schools. However, no study had been done in Zambia on eclecticism in general, and on teachers’ understanding and application of the eclectic approach to English grammar teaching in particular. Hence, this study was a critical reflection on Eclecticism in the teaching of English language grammar to Grade 11 learners in selected secondary schools in Zambia. The aim of the study was to establish how Eclecticism in English language teaching was understood and applied by Zambian teachers of English. The study employed a mixed research study design employing both quantitative and qualitative approaches. In this regard, questionnaires, classroom observations, interviews (one-on-one and focus groups) and document analysis were the main data sources. Purposeful sampling was used to delineate the primary population and to come up with teachers and lecturers. In total, 90 teachers and 18 lecturers participated in this study. The documentary analysis involved documents such as the senior secondary school English language syllabus and Teacher training institutions’ English teaching methods course outlines. These documents were analysed to establish to what extent they supported or inhibited Eclecticism as an approach to English language teaching. Data was analysed using qualitative data analysis techniques looking for naturally occurring units and reducing them to natural meaning units to check for regular patterns of themes. Data from quantitative questionnaires were analysed using the statistical package for social sciences (SPSS) to generate frequencies and percentages. The documents provided information on the efficacy of using Eclecticism as an approach to English language teaching in the multilingual contexts of Zambia. Theoretically, the study drew on Bernstein’s Code Theory and Pedagogic Discourse with its notion of Recontextualisation. The Code theory was used to examine power relations in education while recontextualisation was used to explore the transfer of knowledge from one site to another. The study also used the constructivist theory which views teachers and learners as co-participants in the process of teaching and learning and treats learners’ backgrounds as crucial to effective teaching. Considering recent developments in technology, the study also explored the extent of the use of multimodal tools in the teaching of English grammar, and the contestations around the ‘grammars’ arising from the dialogicality between the so-called ‘British English Grammar’ and home grown Zambian English grammar. The idea here was to explore how English was taught in the context of other English varieties and Zambian languages present in Zambian secondary school classrooms. The findings showed that while course outlines from teacher training institutions and the senior secondary school English language syllabus showed that teacher training was aimed at producing an eclectic teacher, teacher training was facing a lot of challenges such as inadequate peer teaching, short teaching practice and poor quality of student teachers. These were found to negatively affect the effective training of teachers into eclecticism. Further, while some teachers demonstrated understanding of the eclectic approach and held positive attitudes, others did not leading to poor application and sometimes non application of the approach. In terms of classroom application, of the five teachers whose lessons have been presented in this thesis, four of them used the eclectic approach while one did not, implying that while the policy was accepted by some, others contested it. In addition, teachers stated that grammar meant language rules and they further stated that they taught formal ‘Standard’ English while holding negative attitudes towards Zambian languages and other varieties of English. The study observed that teachers held monolingual ideologies in which they used English exclusively during classroom interaction. Finally, teachers reported that they faced a number of challenges when using the eclectic approach such as limited time, lack of teaching materials and poor low English proficiency among some learners leading to limited to non use of communicative activities in the classroom. The study concludes that while the eclectic approach is practicable in Zambia, a lot has be to done especially in teacher training in order to equip teachers with necessary knowledge and skills to use the eclectic approach. Among other recommendations, the study recommends that there is need for teacher training institutions to improve the quality of teacher training and ensure that student teachers acquire skills of resemiotisation, semiotic remediation and translanguaging as a pedagogical practice. The study also recommends refresher courses to already serving teachers to acquaint them with how the eclectic approach can be recontextualised in different teaching contexts. The study contributes to the body of knowledge in the theoretical and practical understanding of the eclectic approach and how it is used in the Zambian context. The study also adds to literature on the eclectic approach. In addition, the findings act as a diagnostic tool among government education officials, teacher educators and teachers of English in Zambia in particular as they can now see where things are done right and where improvement is needed. Other countries where English is taught as a second language can also learn from the Zambian situation as they search for better ways of training eclectic teachers of English and how to teach English in their own respective contexts.

Philosophiae Doctor - PhD / The current study framed as Social Structuring of Language and the Mobility of Semiotic Resources across the Linguistic Landscapesof Zambia: A Multimodal Analysis, is situated in Lusaka and Livingstone and their selected surrounding peri-urban and rural spaces (of Kabanana, Bauleni and Chipata; Kafue, Chongwe, Chief Mukuni’s area and stretches between Livingstoneand Zimba and Livingstone and Kazungula). The study aims to explore the linguistic landscapes (LL) of these urban, peri-urban and rural spaces in order to gain insight into the social structuring of language and the mobility of semiotic resources across the LL. This entails an understanding of how languages are distributed and realized across the research sites. In particular, the study aims at understanding how the regionalization of languages is (re-)produced, contested and maintained in (and beyond) the territories for which they are promulgated for use. Thus, the study foregrounds the mobility of the semiotic resources across the LL. In essence, artefactual material, symbols including languages are, in a multimodal fashion, investigated to see their pliability and mobility from context to context. In the light of the mobility of the semiotic resources, the study privileges both translocal and transnational mobility as the force behind the movement and the dispersal of the semiotic material across ethnolinguistic, formal, informal, urban and rural boundaries. This meant understanding the kind of signs in both urban and rural areas and why they are emplaced in the broader context of sign/place-and meaning making. In order to achieve the aim and objectives, the study has been foregrounded in ethnographic research paradigm in which walk, gaze, talk (interview) and photography were of irreplaceable importance. The conflation of walk, gaze (observation), talk and photography in one investigation avails much. Firstly, the walk brought the researcher within the allowable observation range in order to gain an insider impression while, at the same time, maintaining the objectivity required for an unbiased analysis. Participant observation coupled with gaze offered the required positioning for carrying out a multimodal analysis especially in the rural areas which turned out to have the paucity of signage. Thus, by being a participant observer, I keenly observed how sign-and meaning making were accomplished in oral-dominant communities. This meant positioning oneself as a new comer needing direction. It was in such moments when practices of sign-and meaning making were observed and recorded. For example, I would ask: how do I get to the next village/school/headman? The reference to ecological features such as trees, hills and streams extended the taxonomy of signs available for use in rural areas. Interviews with business owners about the emplaced signs brought to the fore the hidden narratives often gushing out from individualized orientation and personal experiences, as well as the shared sociocultural knowledge and histories of both the producer and consumers of the multimodal LL. Photography yielded digital images forming not only the quantitative data but also the qualitative one upon which a multimodal analysis was done. The aim was to capture over 1500 of images which were to be processed by the Software Package of the Social Sciences (SPSS). Over 1500 images were collected but only 1157 were coded based on the languages present, materiality, inscription, and emplacement. The quantitative data arising from this exercise provided insight into the social structuring of language and mobility of the semiotic resources across the urban, peri-urban and rural spaces. These results were later compared with the national census reports. The analysis of images as qualitative data availed much about the multimodal nature of the signage in place. The analysis of the qualitative data was accomplished by multimodality in its evolve form. Kress and Van Leeuwen’s(2006) Grammar of Visual Design, Scollon and Sollon’s (2003) Geosemiotics, and theoretical concepts such as resemiotization, remediation, recontextualization, decontextualization, multivocality and metamorphosis provided a sound theoretical toolkit to analyse the multimodal/multisemiotic signage emplaced across the public spaces of the research sites. As a result of a robust methodology and theoretical base, the study was able to underpin the social structuring of language and the mobility of semiotic resources across the linguistic landscapes in a manner too apparent. First, apart from showing the linguistic heterogeneity of the research sites, the study shows that social structuring of languages being experienced is one that is predicated on predictability, flexibility, flux and indeterminacy. The results showing the social structuring of English, for example, demonstrate the uneven spread of English across the urban, peri-urban and rural spaces. In particular, the results go against the normative expectation that the urbanized centres of Lusaka and Livingstone would have more signs in English. Peri-urban (Kabanana) and rural (Chongwe/Kafue) spaces showed more signs in English. This suggests a disembodiment of language and locality as well as social actors. Moreover, the results showed the co-occupancy of English and local languages in one micro-space/time. This entails the blurring of boundaries between languages of different socio-political statuses. The bilingualsigns on which English and non-regional languages occur demonstrate the persistent percolation of minor languages onto the LL. The presence of regional languages, albeit differentially, in and beyond their regions for which they were promulgated reminds us that there is a counter hegemonic narrative going on in the LL of the research sites –in defiance of regionalization (zoning). Thus, the results show that languages in the research sites do not stay put where they are officially put by legislation. The conflation of multiple semiotic resources has further (re-)produced linguistic coinages resulting in what I refer to as a sociolinguistics of amalgamation predicated on hybridity, fusion and tr ans languaging. This evidence is framed within the trans local and transnational mobility where both the social actors and the semiotic resources are constantly in circulation. The study observes that mobility is not only restricted to local circulation of cultural materialities from urban to rural and rural to urban,but also a more transnational circulation of semiotic resources. For example, the ubiquitous spread of Chinese signage across the urban, peri-urban and rural LL accentuates the permeating effect of translocal and transnational mobility, leading to the de-territorialization of spaces. The study further shows the sociocultural narratives in place-and meaning making. Place and meaning making as an agentive act is premised on shared sociocultural knowledge and histories (Kress 2010), but is further exploited and extended by creatively drawing on individualized orientation, experiences and subjective sensibilities. In this regard, the study agrees with Hult (2009) that in order to glean the subjective narrations and re-imagining of space embedded in the emplaced signs, interviews with the owners of the emplaced signs is in dispensible. Thus, like Blommaert (2012) aptly suggests, spaces are semiotized as themed spaces. The study has shown how spaces are Christianized, moralized, gendered and anonymized, thus, gaining insight into the forces and meanings behind both the emplacement of and emplaced signs. Further, the reading of artefacts in Livingstone Museum shows how the juxtaposition of the material culture of multilingualism and multiculturalism is a semiotic strategy to double-articulate multiple localities simultaneously: local and global; familiar and unfamiliar; modern and tradition. The transaction of multi vocality in a single moment of emplacement and gaze transforms space dramatically and extends the meaning potential of the emplaced signage in micro-space/time. Further, the observable paucity of signs in rural areas forces us to defer to an ecological approach in which oral language mediation, recycling and repurposing of material affordances provide a comprehensive account of the signage and sign-making/consumption in place. form. Kress and Van Leeuwen’s(2006) Grammar of Visual Design, Scollon and Sollon’s (2003) Geosemiotics, and theoretical concepts such as resemiotization, remediation, recontextualization, decontextualization, multivocality and metamorphosis provided a sound theoretical toolkit to analyse the multimodal/multisemiotic signage emplaced across the public spaces of the research sites. As a result of a robust methodology and theoretical base, the study was able to underpin the social structuring of language and the mobility of semiotic resources across the linguistic landscapes in a manner too apparent. First, apart from showing the linguistic heterogeneity of the research sites, the study shows that social structuring of languages being experienced isone that is predicated on unpredictability, flexibility, flux and indeterminacy. The results showing the social structuring of English, for example, demonstrate the uneven spread of English across the urban, peri-urban and rural spaces. In particular, theresults go against the normative expectation that the urbanized centres of Lusaka and Livingstone would have more signs in English. Peri-urban (Kabanana) and rural (Chongwe/Kafue) spaces showed more signs in English. This suggests a disembodiment of language and locality as well as social actors. Moreover, the results showed the co-occupancy of English and local languages in one micro-space/time. This entails the blurring of boundaries between languages of different socio-political statuses. The bilingualsigns on which English and non-regional languages occur demonstrate the persistent percolation of minor languages onto the LL. The presence of regional languages, albeit differentially, in and beyond their regions for which they were promulgated reminds us that there is a counter hegemonic narrative going on in the LL of the research sites –in defiance of regionalization (zoning). Thus, the results show that languages in the research sites do not stay put where they are officially put by legislation. The conflation of multiple semiotic resources has further (re-)produced linguistic coinages resulting in what I refer to as a sociolinguistics of amalgamation predicated on hybridity, fusion and translanguaging. This evidence is framed within the translocal and transnational mobility where both the social actors and the semiotic resources are constantly in circulation. The study observes that mobility is not only restricted to local circulation of cultural materialities from urban to rural and rural to urban,but also a more transnational circulation of semiotic resources. For example, the ubiquitous spread of Chinese signage across the urban, peri-urban and rural LL accentuates the permeating effect of translocal and transnational mobility, leading to the de-territorialization of spaces. The study further shows the sociocultural narratives in place-and meaning making. Place and meaning making as an agentive act is premised on shared sociocultural knowledge and histories (Kress 2010), but is further exploited and extended by creatively drawing on individualized orientation, experiences and subjective sensibilities. In this regard, the study agrees with Hult (2009) that in order to glean the subjective narrations and re-imagining of space embedded in the emplaced signs, interviews with the owners of the emplaced signs is indispensible. Thus, like Blommaert (2012) aptly suggests, spaces are semiotized as themed spaces. The study has shown how spaces are Christianized, moralized, gendered and anonymized, thus, gaining insight into the forces and meanings behind both the emplacement of and emplaced signs. Further, the reading of artefacts in Livingstone Museum shows how the juxtaposition of the material culture of multilingualism and multiculturalism is a semiotic strategy to double-articulate multiple localities simultaneously: local and global; familiar and unfamiliar; modern and tradition. The transaction of multivocality in a single moment of emplacement and gaze transforms space dramatically and extends the meaning potential of the emplaced signage in micro-space/time. Further, the observable paucity of signs in rural areas forces us to defer to an ecological approach in which oral language mediation, recycling and repurposing of material affordances provide a comprehensive account of the signage and sign-making/consumption in place.

This thesis explores the relationship between social networks and economic life in rural Zambia. The motivation for the study lies in the crucial role played by social context and social networks in exchange behaviour in rural sub-Saharan Africa, and inherent difficulties in formalising market transactions in this context within a standard neoclassical economics framework. The study examines the role of social networks in rural production systems, focusing on crop market participation. It is based on analysis of findings from social network research conducted by the author in three predominantly Bemba villages in Northern Province, Zambia. Data collected using quantitative and qualitative methods are used to map social networks of individuals and households. Variables are constructed capturing network characteristics, and incorporated into transactions cost models of ommercialisation. The overarching question is: do social networks play a role in determining farming success in settings with little variability between households on assets and endowments – land, labour, inputs – and where markets are incomplete or missing? Do social networks mediate market and resource access, helping to explain socio-economic differences between households? The research finds rural life is characterised by diverse networks with multiple, overlapping functions. Much economic exchange takes place on reciprocal or kinship bases, rooted in social norms and reflecting community structures. How social networks are measured matters. Different network attributes are important for different people, and relationships between networks and outcomes depend on the measure used. Controlling for endogeneity, estimation results suggest larger networks have a negative effect on crop incomes whereas having a greater proportion of kin in the network has a positive effect, implying that in this context strong ties are key. Qualitative research suggests the nature of people's networks and their positions within them play an important role in the command over labour: “the famous always get their work done".

Magister Public Health - MPH / Background: The Zambian anti-retroviral therapy (ART) program has successfully enrolled over 770, 000 people living with HIV (PLWH), out of a population of 1.2 million PLWH. This tremendous success has overburdened the clinic system resulting in many challenges for both patients and healthcare staff. To promote ART initiation, adherence, and retention and at the same time relieve pressure on the health system, a home-based ART delivery model (HBM) was piloted in two urban communities of Lusaka. This study explored levels of acceptability of the model and factors influencing this among PLWH living in the two communities. Acceptability was defined as degree of fit between the patient’s expectations and circumstances and the home-based delivery model of ART, taking into consideration all the contextual elements surrounding the patient. Methodology: A qualitative study of HBM acceptability was nested within a clusterrandomized trial comparing outcomes in patients receiving HBM intervention compared to the standard of care in two communities in Lusaka, Zambia. Using an exploratory qualitative study design and a purposive sampling technique, qualitative data were collected using observations of HBM delivery (n=12), in-depth interviews with PLWH (n=15) and Focus Group Discussions with a cadre of community health workers called community HIV care providers (CHiPs) administering the HBM (n=2). Data were managed and coded using Atlas.ti 7 and analysed thematically. Results: Overall, the HBM was found to be a good fit with the lives and expectations of PLWH and therefore highly acceptable to them. This acceptability was influenced by a combination of cross cutting clinic based, program design and socio-economic factors that have been categorized into push and pull factors. Push factors were those related to the challenges that PLWH faced when accessing ART from the clinic and included congestion, long waiting times, confidentiality breaches and stigma arising from attending a dedicated clinic. These factors resulted in considerable direct and indirect livelihood opportunity costs. The HBM as an alternative had a number of ‘pull factors’. PLHW described services offered through the model as convenient, confidential, trusted, personalized, less stigmatizing, comprehensive, client centred, responsive, and respectful. Disclosure of client’s HIV status to people they lived with was found to be critical for the acceptability of the model. Conclusions and recommendations: The HBM is highly acceptable and this acceptability is influenced by a combination of crosscutting push and pull factors. Key to the HBM’s acceptability was its delivery design that was responsive to individual patient needs and the steps CHiPs took to minimize the ever-present threat of disclosure and stigma. Future adoption and scaling up of HBM should recognize the importance of these design features.

acase@tulane.edu / The Zambian Ministry of Health (MOH) National Malaria Control center (NMCC) adopted artemisinin combination therapy (ACT) as a first-line antimalarial drug for uncomplicated malaria in 2003, and included rapid diagnostic testing (RDT) in its case management guidelines to reduce over-diagnosis of malaria and over-prescription of antimalarials. Prior research has highlighted gaps in the malaria case management process in Zambia, especially in diagnosis and treatment. The first paper of this study aimed to build quality indices or indicators for the four components of malaria case management: assessment, diagnosis, treatment and counseling. The Zambia MOH/NMCC conducted a nationally representative health facility survey in 2011 with the Malaria Control and Evaluation Partnership in Africa. The mean assessment quality (percentage of assessment items correctly completed) rate was 49.9%. The diagnostic quality (concordance with gold standard diagnosis) rate was 82.4%, with 86.9% sensitivity and 79.4% specificity. The treatment quality rate (correct treatment for those needing antimalarials and no treatment for patients not needing it) was 89.6%, and the mean counseling quality (percentage of counseling items correctly completed) rate was 48.6%. The second paper investigated factors association with each of the four components of malaria case management. Supervision was significantly associated with assessment and counseling but not diagnosis and treatment. Health facility managing authority was associated with assessment and diagnosis. Availability of blood tests was associated with correct diagnosis, and diagnosis was strongly associated with treatment. Malaria endemicity and availability of IMCI guidelines were associated with counseling quality. The third paper investigated the associated between counseling and patient recall of treatment regimen, and found that they were associated as hypothesized. The Zambia NMCC has improved the quality of malaria case management over previous years, although it is recommended that more health facility surveys are conducted in order to study the change in health worker performance over time. / 1 / Louie Rosencrans

Philosophiae Doctor - PhD / This study traces the political economy of the social protection policy processes in the two country case studies of Zambia and Zimbabwe. It focuses on the role of global actors/external agencies (bilaterals, multilaterals and IFIs), national actors (government, parliament) and local actors (beneficiary communities, INGOs, CSOs) in social protection policy evolution. It looks at the power dynamics within the policy space: who is more powerful and who is less powerful, who voices and whose voice matters, who makes decisions and who follows decisions, who drives the policy and who follows, who has the money and who follows the money, who consults and who is consulted, and whether the rural communities (perceived beneficiaries) are active participants or ‘passive’ recipients. Therefore, the study is based on key informant interviews with officials from government, external agencies, INGOs and CSOs as well as focus group discussions with the communities. What emerges is that social protection is a policy contestation between the external agencies themselves; between external agencies and the government; between personnel of the same external agency; and within the government itself. Despite being driven by a common goal to fight poverty, external agencies have different global social protection policy positions and each would ‘push’ for the adoption of that policy position over the rest. Contestation between external agencies and the government reflect that government priorities differ from those of the external agencies. While external agencies pushed for social protection, the government would prefer agricultural subsidies to support the productive capacity of the people. Intra-government ‘struggles’ relate to the contest over which ministry is best placed to coordinate social protection and Ministry of Finance’s ambivalence over budgetary commitment to social protection. The study therefore underscores the primacy of politics in social protection.