In search of the last malaria cases: ethnographic methods for community and private-sector engagement in malaria elimination in Vietnam, Laos, and Cambodia

Background Despite significant strides made in reducing malaria morbidity and mortality in the Greater Mekong Subregion, malaria transmission continues amongst the most ‘hard-to-reach’, such as forest-goers and mobile and migrant populations, who face access obstacles to malaria diagnosis and treatment. As such, regional malaria elimination strategies endeavour to incorporate the private sector and local communities in improving surveillance and detection of the last malaria cases in remote forested areas. The question remains, however, whether such strategies can reach these hard-to-reach populations and effectively reduce their disproportionate burden of malaria. This paper evaluates the strategy of community and private sector engagement in a malaria elimination project in Vietnam, Laos, and Cambodia. Methods Ethnographic research, incorporating in-depth interviews, participant observations with informal discussions, and group discussions were conducted in Bu Gia Map commune, Binh Phuc province of Vietnam; in Phouvong district, Attapeu province of Laos; and, in nine newly established and informal communities in the provinces of Mondul Kiri, Steung Treng, Kratie, Kampong Thom, and Prah Vihear of Cambodia. Results Different types of factors limited or enhanced the effectiveness of the participatory approaches in the different settings. In Vietnam, inter-ethnic tensions and sensitivity around forest-work negatively affected local population’s health-seeking behaviour and consequent uptake of malaria testing and treatment. In Laos, the location of the project collaborative pharmacies in the district-centre were a mismatch for reaching hard-to-reach populations in remote villages. In Cambodia, the strategy of recruiting community malaria-workers, elected by the community members, did manage to reach the remote forested areas where people visited or stayed. Conclusions ‘Hard-to-reach’ populations remain hard to reach without proper research identifying the socio-economic-political environment and the key dynamics determining uptake in involved communities and populations. Solid implementation research with a strong ethnographic component is required to tailor malaria elimination strategies to local contexts.

Mobilizing private adaptation finance: lessons learned from the Green Climate Fund

The mobilization of effective private sector engagement is considered to be critical to address the adaptation challenge, but literature demonstrates that it has proven difficult. In the context of international climate finance, the focus has been on mobilizing private finance for adaptation and in addressing barriers that prevent investments from materializing. In contrast, this article identifies options to engage the private sector in adaptation beyond finance and focuses on market imperfections instead of barriers. This moves the focus away from simply mobilizing more private adaptation finance towards identifying market forces that innovate, engage, and direct investments towards adaptation. The Green Climate Fund (GCF) and its portfolio of 74 adaptation projects serve as a case study. Two of these projects are categorized as private sector projects and an additional nine mobilize private co-finance or non-financial private contributions. Beyond these two indicators, we demonstrate that an additional 60 projects engage the private sector in other ways, thus indicating the important broader role of the private sector in adaptation. Furthermore, our ordinal regression demonstrates that by addressing the market imperfections of positive externalities, imperfect financial markets, and incomplete and/or asymmetric information, all have a significant positive effect on private sector engagement in the GCF’s adaptation portfolio. Both findings indicate that there is a large potential for the GCF—and other climate finance providers—to increase private sector engagement in adaptation. It must be noted, however, that the mobilization of private sector engagement in adaptation is a means to an end, not an end in itself. The main aim should be to adapt society as a whole in an efficient manner, including the most vulnerable groups and people.

Forests and Sustainable Development in the Brazilian Amazon: History, Trends, and Future Prospects

Ongoing deforestation in the Brazilian Amazon is the outcome of an explicit federal project to occupy, integrate, and “modernize” the region. Although there have been isolated periods of deforestation control, most recently between 2004 and 2012, the overall trajectory of the region since the colonial period has been one of forest loss and degradation. Addressing this challenge is especially urgent in the context of adverse climate-ecology feedbacks and tipping points. Here we describe the trends and outcomes of deforestation and degradation in the Amazon. We then highlight how historical development paradigms and policies have helped to cement the land use activities and structural lock-ins that underpin deforestation and degradation. We emphasize how the grounds for establishing a more sustainable economy in the Amazon were never consolidated, leading to a situation where forest conservation and development remain dependent on external programs—punitive measures against deforestation and fire and public social programs. This situation makes progress toward a forest transition (arresting forest loss and degradation and restoring forest landscapes) highly vulnerable to changes in political leadership, private sector engagement, and global market signals. After summarizing these challenges, we present a suite of measures that collectively could be transformational to helping overcome destructive path dependencies in the region. These include innovations in agricultural management, improved forest governance through landscape approaches, developing a local forest economy, sustainable peri-urbanization, and the empowerment of women and youth. These initiatives must be inclusive and equitable, enabling the participation and empowerment of local communities, particularly indigenous groups who have faced numerous historical injustices and are increasingly under threat by current politics. Expected final online publication date for the Annual Review of Environment and Resources, Volume 46 is October 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

In Search of the Last Malaria Cases: Ethnographic Methods for Community and Private-sector Engagement in Malaria Elimination in Vietnam, Laos, and Cambodia

Background Despite significant strides made in reducing malaria morbidity and mortality in the Greater Mekong Subregion, malaria transmission continues amongst the most ‘hard-to-reach’ such as forest-goers and mobile and migrant populations, who face access obstacles to malaria diagnosis and treatment. As such, regional malaria elimination strategies endeavour to incorporate the private sector and local communities in improving surveillance and detection of the last malaria cases in remote forested areas. The question remains, however, whether such strategies can reach these hard-to-reach populations and effectively reduce their disproportionate burden of malaria. This paper evaluates the strategy of community and private sector engagement in a malaria elimination project in Vietnam, Laos, and Cambodia.Methods Ethnographic research, incorporating in-depth interviews, participant observation with informal discussions, and group discussions were conducted in Bu Gia Map commune, Binh Phuc province of Vietnam; in Phouvong district, Attapeu province of Laos; and, in nine newly established and informal communities in the provinces of Mondul Kiri, Steung Treng, Kratie, Kampong Thom, and Prah Vihear of Cambodia. Results Different types of factors limited or enhanced the effectiveness of the participatory approaches in the different settings. In Vietnam, inter-ethnic tensions and sensitivity around forest-work negatively affected local population’s health seeking behaviour and consequent uptake of malaria testing and treatment. In Laos, the location of the project collaborative pharmacies in the district-centre were a mismatch for reaching hard-to-reach populations in remote villages. In Cambodia, the strategy of recruiting community malaria-workers, elected by the community members, did manage to reach the remote forested areas where people visited or stayed. Conclusions ‘Hard-to-reach’ populations remain hard to reach without proper research identifying the socio-economic-political environment and the key dynamics determining uptake in involved communities and populations. We emphasise the need for solid implementation research with a strong ethnographic component in order to tailor malaria elimination strategies to local contexts.

Mobilising Private Adaptation Finance: Lessons Learned From the Green Climate Fund

The mobilisation of private sector engagement is considered to be critical to address the adaptation challenge, but literature demonstrates that it has proven difficult. In the context of international climate finance, the focus has been on mobilising private finance for adaptation, and in addressing barriers that prevent investments from materialising. In contrast, this article identifies options to engage the private sector in adaptation beyond finance and focuses on market imperfections instead of barriers. This moves the focus away from simply mobilising more private adaptation finance towards identifying market forces that innovate, engage and direct investments towards adaptation. The Green Climate Fund (GCF) and its portfolio of 67 adaptation projects serve as a case study. We demonstrate that 79 per cent of the GCF projects engage the private sector in ways that go beyond co-finance or project development, thus indicating the important broader role of the private sector in adaptation. Furthermore, our ordinal regression demonstrates that addressing the market imperfections of positive externalities, imperfect capital markets, and incomplete and/or asymmetric information all have a significant positive effect on private sector engagement in the GCF’s adaptation portfolio. Both findings indicate that there is a big potential for the GCF - and other climate finance providers - to increase private sector engagement in adaptation. However, the mobilisation of private sector engagement in adaptation is a means to this end, not an end in itself. The main aim should be to adapt society as a whole in an efficient manner, including the most vulnerable people.

Exploring Private Sector Engagement for Faecal Sludge Emptying and Transport Business in Khulna, Bangladesh

In Khulna, Bangladesh, mechanical faecal sludge (FS) emptying and transport (E&T) service is provided by community development committees (CDCs) and the Khulna City Corporation (KCC). Without considering capital expenditure and depreciation, financial analysis for one year revealed that a CDC-1 m3 vacutug made a profit of Bangladeshi taka (BDT) 145,780 (USD $1746) whereas a KCC-2 m3 vacutug was in the loss of BDT 218,179 (USD $2613). There is a need to engage the private sector for sustainable service provision. Some of the key elements of enabling the environment for private sector engagement are policy/strategy, institutional and regulatory framework, implementation capacity, and financial viability. Existing policy/strategy/frameworks acknowledged the need and suggested plans for private sector engagement, and decentralised authority to city corporations. With increasing private-public partnership projects and collaboration in the sanitation sector, capacity of the KCC and the private sector are increasing. Financial viability of the FS E&T business is primarily dependent on the number of trips and the emptying fee. For the E&T business to be financially viable, a 2 m3 vacutug should make six trips/day (internal rate of return (IRR)—13%, discount rate—6.5%) with an emptying fee of BDT 750 (USD $9)/m3. Despite the lack of operative guidelines for faecal sludge management (FSM), enabling the environment for private sector engagement in FS E&T business in Khulna seems favourable.

A Key Ingredient in Deforestation Slowdowns? A Strong Brazilian Economy

For much of the past two decades, the scientific and policy community has sought to reduce forest loss through well-targeted public policy and enforcement measures and private sector engagement. Unfortunately, recent increases in forest loss in the Amazon have raised new concerns over the drivers of deforestation in the region, and the durability of the policies designed to mitigate it. Here we argue that recent deforestation trends are a partial reflection of Brazil's economic trajectories. In this article we show that poor economic conditions, nationally, will increase micro-level incentives for forest clearing. Conversely, economic growth, nationally, will suppress prices and land clearing incentives. Ultimately, we argue that, at the national-scale, economic growth may be closely aligned with, and possibly a pre-condition to, the attainment of international or national-level environmental goals.

Integrating Xpert MTB/RIF for TB diagnosis in the private sector: evidence from large-scale pilots in Patna and Mumbai, India

Background Xpert MTB/RIF (Xpert) has been recommended by WHO as the initial diagnostic test for TB and rifampicin-resistance detection. Existing evidence regarding its uptake is limited to public health systems and corresponding resource and infrastructure challenges. It cannot be readily extended to private providers, who treat more than half of India’s TB cases and demonstrate complex diagnostic behavior. Methods We used routine program data collected from November 2014 to April 2017 from large-scale private sector engagement pilots in Mumbai and Patna. It included diagnostic vouchers issued to approximately 150,000 patients by about 1400 providers, aggregated to 18,890 provider-month observations. We constructed three metrics to capture provider behavior with regards to adoption of Xpert and studied their longitudinal variation: (i) Uptake (ordering of test), (ii) Utilization for TB diagnosis, and (iii) Non-adherence to negative results. We estimated multivariate linear regression models to assess heterogeneity in provider behavior based on providers’ prior experience and Xpert testing volumes. Results Uptake of Xpert increased considerably in both Mumbai (from 36 to 60.4%) and Patna (from 12.2 to 45.1%). However, utilization of Xpert for TB diagnosis and non-adherence to negative Xpert results did not show systematic trends over time. In regression models, cumulative number of Xpert tests ordered was significantly associated with Xpert uptake in Patna and utilization for diagnosis in Mumbai (p-value< 0.01). Uptake of Xpert and its utilization for diagnosis was predicted to be higher in high-volume providers compared to low-volume providers and this gap was predicted to widen over time. Conclusions Private sector engagement led to substantial increase in uptake of Xpert, especially among high-volume providers, but did not show strong evidence of Xpert results being integrated with TB diagnosis. Increasing availability and affordability of a technically superior diagnostic tool may not be sufficient to fundamentally change diagnosis and treatment of TB in the private sector. Behavioral interventions, specifically aimed at, integrating Xpert results into clinical decision making of private providers may be required to impact patient-level outcomes.

Understanding Pathways Between Agriculture, Food Systems, and Nutrition: An Evidence and Gap Map of Research Tools, Metrics, and Methods in the Last 10 Years

ABSTRACT New tools, metrics, and methods in agriculture, food systems, and nutrition (A&N) research proliferated in the decade following the 2007–2008 food price crisis. We map these developments across themes derived from conceptual A&N pathways and expert consultations. We created an interactive Evidence and Gap Map (EGM) from a systematic search of published and gray literature since 2008, following Campbell Collaboration guidelines. We retrieved over 30,000 reports from published literature databases, and individually searched 20 online repositories. We systematically screened 24,359 reports by title and/or abstract, 1577 by full report, and included 904 eligible reports. The EGM consists of rows of thematic domains and columns of types of tools, metrics, and methods, as well as extensive coding applied as filters. Each cell of the map represents research surrounding a type of tool, metric, or method within a given theme. Reports in each cell are grouped by stage of development, which expand to a corresponding bibliography. Users can filter EGM reports by various characteristics. The 4 most populated domains were: diets, nutrition, and health; primary food production; water, sanitation, and hygiene; and environment and sustainability. The 4 most common types of metrics, methods, and tools were: diet metrics; footprint analysis (especially water); technology applications; and network or Bayesian analysis. Gaps represent areas of few or no reports of innovation between 2008 and 2018. There were gaps in reports and innovations related to: power or conflicts of interest; food environments; markets; private sector engagement; food loss and waste; conflict; study design and system-level tools, metrics, and methods. The EGM is a comprehensive tool to navigate advances in measurement in A&N research: to highlight trends and gaps, conduct further synthesis and development, and prioritize the agenda for future work. This narrative synthesis accompanies the EGM, which can be found at https://www.anh-academy.org/evidence-and-gap-map.