health initiatives. Global initiatives are responsible for many nationally implemented health programmes. This happens under the system of policy transfer, which allows one state to emulate, learn from, or use in some way the lessons learnt through policy initiatives in some other country or at the international organisational level. In this essay, the World Health Organisation (WHO) initiative of Roll Back Malaria, is discussed in the context of its application in Cameroon.
The phenomenon of policy transfer has become quite important in the recent times. There is growing evidence of significant amounts of national policy in most countries in the world, to be a result of international or even national policy of some other country in the world. Therefore, it is seen that much of the policy in one nation may be based on the policy of some other country or an international policy initiative (Caroll & Common, 2013). Policy transfer analysis is a theory of policy development “that seeks to make sense of a process or a set of processes in which knowledge about institutions, policies and delivery systems in one nation or its sector of governance can be seen to influence the policy and delivery systems of another nation” (Evans, 2013, p. 7). At times, policy transfer may happen as between different sectors of government within the same nation. There are four criteria that have to be understood in order to understand and identify policy transfer. First, the agents of policy transfer must be identified. Not only that, their policy belief system must also be understood. Second, the resources that these agents bring to the policy-oriented learning must also be distinguished. Third, the role that these agents play in the transfer must also be identified. And fourth, there should be positive identification of the nature of the transfer that the agent is justifying (Evans, 2013, p. 7). There are at least eight categories of agents that can be identified, as being participant in the policy transfer process of a nation. These agents are: politicians, think tanks, bureaucrats, , academicians and experts, knowledge institutions, lobbyists and pressure groups, international organisations, and global financial institutions (Evans, 2013).
Policy transfer can be done in three primary ways. First, policy transfer can be voluntary and focussed on lesson-drawing from another nation’s policy or international policy. The second is policy transfer through negotiation. The third is a coercive transfer of policy. The second process is mostly and commonly seen in the developing world, where influential donor nations, transnational corporations, global financial institutions coerce these countries to apply some desired policy in exchange of grants, aid, or some other support. The third process is an extreme situation, where policy is coerced upon the state against the will of its people, or contrary to its constitutional law.
In the UK, one can see evidence of both the first and second type of processes discussed above. Most of the policy transfer in the UK is a result of a voluntary or lesson drawing type of transfer. However, due to its membership of the European Union (EU), the UK is also subject of negotiated transfer of policy and this is evident in many of the policies formed in the UK as a result of implementation of EU directives.
The study of policy transfer and its impact on national policy is often traced back to the seminal work of Dolowitz and Marsh (1996). The authors focussed on key concepts in policy transfer, such as, emulation, policy learning, diffusion and lesson-drawing (Ladi, 2005). Thus, there are different degrees of policy transfer. Since then, there is now a respectable amount of literature on the issue of policy transfer. However, it is noteworthy that policy transfer as an issue interests not only the academics, but it is also of special interest to government. In 1999, the Cabinet Office made a specific mention to policy transfer in its White Paper (Cabinet Office, 1999). The Paper said:
We are exchanging ideas with other countries on policy making, on delivering services, and on using information technology in new and innovative ways. We are learning from each other (Cabinet Office, 1999, p. 17).
The Paper itself defined policy making as the “translation of political vision into programmes and actions that are aimed to deliver outcomes, that is, the desired changes in the real world” (Cabinet Office, 1999). It is important to study policy transfer in the perspectives of globalisation, because ultimately policy transfer is a consequence of processes of globalisation (Ladi, 2005, p. 27). It is a fact that there has been a lot of change in the patterns of global communications and the structuring of political and economic institutions. It can be said that these are responsible for the fact that the world of public policy has now shrunk in size and it is not uncommon to see impact of international and national public policy on policy making processes of most countries in the world (Evans, 2013). An important point is made by one writer where she identifies the role played by non-state actors. These actors are termed ‘policy entrepreneurs’ interacting with governments and international organisations. These actors are influential and have networks within the government. Indeed, as the writer points out, policy transfer is a process that happens best when conducted within networks (Stone, 2001). She says:
Cross-national experience is having an increasingly powerful impact upon decision-makers within the private, public and third sectors of nation-states. In particular, 'policy transfer' and 'lesson-drawing' is a dynamic whereby knowledge about policies, administrative arrangements or institutions is used across time or space in the development of policies, administrative arrangements and institutions elsewhere (Stone, 2001, p. 1).
Global health initiatives are humanitarian in nature. These initiatives are generally focussed on providing important aid in combating disease, or helping a country or a specific community within that country to improve certain areas of concern in health. The Organisation for Economic Co-operation and Development (OECD), claims that there is increasing development assistance given to health sector. Many different countries and organisations in the world are involved in giving this assistance. There is an increase from US$ 6 billion in 1999 to US$ 13.4 billion in 2005 alone and since then the efforts have only increased tremendously (Banatia & Moattib, 2008).
The importance of these efforts are to be seen from the perspective of those who are the end beneficiaries of these efforts. It is noteworthy that unlike in the developed world, health expenditures for people in developing countries create a burden on the personal savings and household incomes of the affected people (Banatia & Moattib, 2008, p. 820). When global health initiatives are used to contribute towards the health care initiatives in such countries, the burden on the private household income is reduced considerably. Most of this is felt in the area of medicines, which are subsidised as a result of the aid. Another initiative benefit is that user-fees are done away with and cost recovery policies are provided. These help to create an ease of access for people who earn less salary (Banatia & Moattib, 2008).
The Ottawa Charter of 1986 stated that:
“The overall guiding principle for the world, nations, regions and communities alike is the need to encourage reciprocal maintenance - to take care of each other, our communities and our natural environment” (World Health Organisation, 1986).
Another important point made here with significance to the global health policy is: “Health promotion policy combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change. It is coordinated action that leads to health, income and social policies that foster greater equity. Joint action contributes to ensuring safer and healthier goods and services, healthier public services, and cleaner, more enjoyable environments” (World Health Organisation, 1986).
Finally, the Ottawa Conference also advocated that the WHO along with other international organizations would be the good facilitator of health initiatives around the world. It should therefore support countries to strategise and create programmes that would improve general health of the beneficiaries of such programmes (World Health Organisation, 1986).
The Ottawa charter is important because it was instrumental in leading to the creation and implementation of global health policies for specific problems or countries. Global health partnerships (GHPs) have therefore become important in this endeavor and are being implemented on the basis of the specific problems in within the contexts of the country or countries for whom the policy is devised (Ngoasong, 2011). GHPs are important measures for combating complex and large scale health problems, that a country may be unable to combat on its own. It may be said that GHPs are “relatively institutionalised initiatives, established to address global health problems, in which public and for-profit private sector organisations have a voice in collective decision making” (Buse & Harmer, 2007, p. 259). This covers the Roll Back Malaria programme as it manages to encapsulate the involvement of all actors are involved in the programme. The Roll Back Malaria programme, true to the definition given above involves national governments, multilateral and bilateral agencies, and even non-state actors and private industry, in the process of formulating and implementing of policies.
Cameroon became independent in1961. Since that time, Cameroon focused on providing health reforms that would lead to general improvement in public health. The objective of Cameroon, in how it has devised its health policy, has been to providing increasingly high-quality public health services to its population so that the general and public health can be improved. Cameroon’s measures to achieve its health policy aims and goals has generally been in the nature of policy transfer from international health policy directives, thus, there is a lot of evidence of policy transfer in the case of Cameroon (Ngoasong, 2011). At first, these policy transfers were of a voluntary nature, with Cameroon adopting health models from the WHO and implementing the variants of these models within its national health policy initiatives. However, the problems within governance, economic crisis and Cameroon’s inability to implement the policy transfers in their true spirit led to a situation in which the health policies collapsed, there were rising numbers of Malaria and AIDS/HIV deaths, and the government’s inability to deal with the situation became more and more evident. Cameroon’s direction in the context of policy transfer from voluntary to negotiated policy transfer changed at this time, aided greatly by its civil society and non-government agencies that demanded change. At this point the GHP programmes were implemented in Cameroon, especially in regard to combating HIV/AIDS and malaria. Once these programmes were implemented, Cameroon’s policy shifted to negotiated policy transfer. This happened because western development agencies, such as the IMF, began to reformulate their patterns of international or bilateral relations with Cameroon. Now, the relations and interactions merged the debt programmes and the GHP approach, in order to make the government implement the policy transfer as per the GHP policy (Ngoasong, 2011).
One very important global initiative is the Roll Back Malaria partnership (RBM) and this was implemented in Cameroon under the policy transfer initiatives mentioned above. Cameroon is one of the countries in the world, which at a point in time, was one of the worst malaria affected nations of the world. Malaria was one of the leading causes of infant mortality in Cameroon. It also affected pregnant women and was a leading cause of mortality for such women as well. The WHO pragrammes implemented in Cameroon in the 1960s and 1970s failed miserably to control the problem. Similarly, the anti-malarial campaigns in the early 1990s were also ineffective in controlling the rising cases of malaria and increasing malaria caused mortality rates. To add to the problem, Cameroon was also one of the countries where drug resistance was reported, leading to the failure of drugs in combating the problem. December 1998 saw the establishment of a Working Group on Malaria specific to Cameroon’s case. The group included the WHO and UNICEF, local organisations and a National Coordinator for Cameroon. This Working Group became responsible for the development of a National Strategic Plan for Malaria (Ngoasong, 2011). As a part of this plan, Cameroon ratified the Abuja Declaration to Roll Back Malaria in Africa (Ngoasong, 2011).
The Roll Back Malaria programme was launched by the WHO because malaria had come to be a major disease, especially in the underdeveloped and developing countries in the world. The World Health Report in the year 1999 documented the extent of the problem of Malaria in the world (World Health Organisation, Rolling Back Malaria, 1999). The Report documented the problems that countries and families faced in combating malaria. The Report made a particular point of the fact that the countries that are the most impacted by malaria are also the world’s most impoverished nations. In 1999, when the Report was published, it was reported that Malaria was the cause of nearly 250 times mortality rate of people in poor countries as compared to the rich countries (World Health Organisation, Rolling Back Malaria, 1999). The problem that these poor countries faced in combating malaria was due to the economic burden that was put on the countries. Consequently, it was left to the individuals to bear the economic costs of prevention and treatment of malaria. It was found that in sub-Saharan Africa, households spent between $2 to $25 on malaria treatment, whereas the cost of prevention was between $0.20 to $15 per month (World Health Organisation, Rolling Back Malaria, 1999). This was a big chunk of the families’ incomes for most part and the economic burden of malaria was therefore difficult to bear for these nations by themselves. The governments of these nations found themselves unable to bear the costs. This is where the global initiatives of Roll Back Malaria programme came to be of a great advantage to these countries (World Health Organisation, Rolling Back Malaria, 1999). Finally one point is of extreme significance here. The Report recognised the fact that to a great extent, the resurgence of malaria epidemics in different parts of the world, was due in part to certain global conditions. The Report mentioned in particular, the problems of “civil conflict and large-scale human migrations, climatic and environmental change, inadequate and deteriorating health systems, and growing insecticide and drug resistance” (World Health Organisation, Rolling Back Malaria, 1999, p. 61). Some of these problems were noted in Cameroon’s case as well.
Essentially the Roll Back Malaria initiative is a partnership. This global partnership is involving: international organizations; governments in both developed and developing or underdeveloped nations; academic institutions; nongovernmental organizations and even the private sector (World Health Organisation, Rolling Back Malaria, 1999). The committed international organisations in the initiative were the WHO, the World Bank, UNDP and UNICEF. Private sector entities involved in the initiative include research-based pharmaceutical companies and also the media. Endemic countries were required to commit themselves to the initiative. Once the country had committed itself, it was required to undertake a situational analysis (World Health Organisation, Rolling Back Malaria, 1999, p. 62). This would enable the country to devise a strategy for the combating of malaria, along with the other partners such as the committed partners and members of the civil society. The initiative was complex in terms of a number of parallel networks that were established under it. These networks targeted specific problems or issues, such as, use of antimalarial medication or insecticides. Ngoasong uses the term “transcalar network” to describe the global-national-local linkage that is involved in the Roll Back Malaria programme in Cameroon (Ngoasong, 2011). He says that the use of the term “transcalar” character “reveals the existence of social spaces through which global, national and local actors interact” (Ngoasong, 2011). In Cameroon’s case the success of the Roll Back Malaria initiative can be seen in the fact of decreasing mortality rates due to malaria over the years. The WHO reported in 2013 that the rates of malaria morbidity have reduced over the years. As compared to 40.6 percent in 2008, the rates stood at 27 percent in 2012 (World Health Organisation, Consultation on Developing a Multisectoral Approach to Malaria World Health Organization, 2013). The problem of malaria is addressed in Cameron through a National strategic Plan, which includes strategies to fight malaria with the aid of: “(a) Vector control ( use of Use of Long-lasting insecticide treated bed net (LLINs) and Indoor Residual Spraying); (b) Malaria Prevention in pregnancy ( using of intermittent preventive treatment); (c) Case management ( diagnosis and treatment); and (d) behavioural and Change Communication” (World Health Organisation, Consultation on Developing a Multisectoral Approach to Malaria World Health Organization, 2013). The strategies mentioned above are part of the policy transfer initiatives that have happened in Cameroon. According to the abovementioned report of the WHO, there is a definite and significant decrease in malaria contraction and deaths in Cameroon.
Policy transfer has become increasingly common in the health sector. Particularly, this has a lot of relevance for the developing nations of the world, who benefit from the knowledge and experience of policy making in the developed countries and by international organisations. Policy transfer in the developing countries may be both voluntary as well as negotiated. Cameroon’s case in the context of its fight against malaria evidences initially a voluntary policy transfer and when that failed, a negotiated policy transfer under the frameworks of Global Health Partnerships. The Roll Back Malaria programme is an example of that initiative. Cameroon has implemented this programme under its national health strategy for fighting malaria. It is a partnership between Cameroon’s national government, WHO, UNICEF and civil organisations in Cameroon. The malaria cases in Cameroon have significantly gone down since the launch of this programme. In that sense, it can be said that to some extent the policy transfer to combat malaria has been successful in Cameroon. Policy transfer is an important and effective method of creating policy initiatives through the experience and expertise of others. In Cameroon’s case, it is seen that as compared to national initiatives, especially in developing or poor nations, policy transfer can be helpful to combat serious public health issues.
The first important question for those advocating or writing about community development programmes, is as asked by Blackstock (2005), “What or who is the community in community based tourism?” The answer is deeply contested especially in the postcolonial narrative because the power to define community, especially in the global South, is usually vested in the Western perspectives and ideas. Regardless of the contested versions of what community means, participatory models that take community into confidence have found support in different corners of the world. For Bhattacharya (2004), community development had two components: community is basically solidarity of peoples with shared values, norms and identity; and development is essentially an agency or even autonomy, which can defined as:
the capacity of the people to order their world, the capacity to create, reproduce, change and live according to their own meaning systems, to have to power to define themselves as opposed to being defined by others (Bhattacharya, 2004, p.12).
Thus, for Bhattacharyya (2004) it was important that people be given the opportunity to be producers of their own life chances; an opportunity to voice their needs and demands; and participation must be encouraged at every opportunity. Many community development projects may not really take into consideration the actual needs of the community that they seek to represent. In the global South, this problem is compounded by postcolonial narratives that shape the community development programmes from the perspective of how the community is to be represented to the tourists, actual non participation of the community itself and the drive and push of the tourism industry, which is more profits driven. Aslam et al (2016) take a critical viewpoint of whether there can be achievements in sustainable tourism. They argue that the global south or developing regions of the world is where tourism is rapidly growing and these regions cannot be ignored. Friedman says: citizens around the world have begun to search for an alternative development that is less tied to the dynamics of industrial capitalism. Emancipatory movements have emerged to push for a more positive vision of the future…and in a series pursuit of a balanced natural environment, gender equality, the abolition of racism and the eradication of grinding poverty (1987, p.10). Blackstock (2005) argues that tourism depends on the goodwill of the residents and that has become the basis for broader issues in community development and participatory planning. In fact, as she points out, “community development explicitly seeks to dismantle barriers to participation and develop emancipatory collective responses to local issue” (Blackstock, 2005, p.50). For Blackstock (2005, p.50), the most basic critique against the community development programmes is that it diverges from the ‘ethos of community development’ and instead risks becoming what can only be called a ‘community development imposter’. This happens in three ways: first, through a focus on sustaining tourism development and meeting community needs leads to a lack of transformative potential; second, by treating communities as homogenous blocks instead of the varied groups of people that they really are; and third, by ignoring the extent to which local decisions are situated within broader ideological contexts and this really affects their power to affect change (Mair, 2014, p.54). Undoubtedly, community development and participatory planning bases itself on grounds of betterment of the community. However these methods are not without their critiques. These critiques have been important in bringing attention to the “potential for tourism planning process that engages the community to fall apart or simply to reinforce the power structures that are already in place” (Mair, 2014, p.52). This goes to the root of whether stakeholder participation has been effectively implemented in community development programmes. Bramwell (2004) listed three strategies to ensure better stakeholder protection. These three strategies include: increased inclusion of communities so that the participatory panning is done in the most democratic manner; ensuring the non-participants too are able to build their institutional capacities and self-confidence; and consulting all parties, whether or not they are actively involved or not (Bramwell, 2004, p.542). Vrasti (2013) writes about Guatemala and how community development programmes have shaped in the region. She says that the experience of volunteer tourism has helped to distance tourism from ecological destruction, economic exploitation and commercial orientation of the modern mass tourism (p.56). Volunteer tourism allows experiences away from the urbanised and industrial world of the first world countries and offers a view of a different world to travellers from the Western world. In Vrasti’s (2013) viewpoint, this alternate world is that of cultural exchange, which is governed by “transnational responsibility and charitable ambitions”, which makes tourism a commodity that is beyond reproach. However, as she points out with respect to Guatemala’s experience, this is really not the case. Volunteer tourism is not really above reproach from the consumerist point of view. She writes that: Volunteering in Guatemala failed to elicit the care and compassion that I had expected from a grassroots philanthropic enterprise. Volunteers could understand neither the purpose of their work projects, nor the problems they were supposed to address…..The affective response volunteering produced instead drew upon a romantic longing for authentic meaning and spiritual renewal, deeply lodged in the consciousness of affluent Western consumers and produced a multicultural appreciation for the “poor but happy” lifestyle of the developing populations. If the town of San Andres was not poor enough for volunteers to demonstrate their humanitarian sensibilities, it at least was small enough to allow tourists to ‘fall in love’ with the local people and culture. As was to be expected, this sentimental education had its nefarious consequences (Vrasti, 2013, p.56). Vrasti’s writing is an important indicator of the need for critical viewpoints on community development programmes in the context of tourism. - Self-Other binary & power relation context It is interesting that postcolonialism has seen the power of narrative on indigenous culture to be with the Western people. Therefore, the indigenous peoples have been objectified and made to be mute spectators, while others define their own culture. As far as the Western narrative is concerned, it may itself be heavily loaded with a narrative that focusses on invention of the exotic, rather than the reality. So much so that those natives who are Westernised, are viewed by the Westerners as “inventors of themselves and false representatives of their authentic and primitive cultures” (Friedman, 1998). In part, the growing worldwide popularity of indigenous people’s arts and culture and artefacts, is to blame. Here, the demand from tourism is to partake of that authentic art and culture and when denied that opportunity there is a feeling of being cheated as far as the tourist is concerned. In such a situation, the ability of the indigenous peoples to interpret their own cultures, to defend the integrity of their cultures and to receive the compensation for the use and enjoyment of their cultural manifestations by tourists becomes very contested (d’Hauteserre, 2008, p.241), because it takes away the power to define. It is worthwhile to note what Hall had to say about this: Colonisation so refigured the terrain, that, ever since, the idea of a world of separate identities, of isolated or separable or self-sufficient cultures and economies, has been obliged to yield to a variety of paradigms, designed to capture these different but related forms of relationship, interconnection and discontinuity (1996, pp.252-3). Thus, difficulty of divorcing definitions of peoples from the pre conceived Western notions of authenticity of indigenous culture and peoples. This can also be seen with the example of the way Africans, ‘authentic’ and ‘westernised’ are defined from a Western perspective. A real African is someone who still lives in the bush and goes naked. It is this real African that the tourist wants to experience for the satisfaction of the need for the exotic. Never mind that more and more Africans, like people elsewhere in the world are not in the bushes. However the postcolonial definitions of primitive peoples and cultures demand that image to be realised. The problem is that such places and peoples are not really the same as how they are represented in literature, and this leads to disenchantment. Marmol (2014) writes about the Catalan Pyrenees and how the realities of the place may contrast with the more romanticised narrative that channels the rural authenticity of the place. She goes on to compare this with the narratives of other such romanticised places in the world where “Western representations of rural society as an ancient but a continuing way of life has acted as a myth that has concealed local and historical specificities” (Marmol, 2014). For Marmol, this need to romanticise and idealise the rural past has been strategically cultivated and institutionalised in order to feed a regionalist political agenda and she calls this ‘heritage politics’. Talking of the Catalan region, she points out that the tourism in the region has developed in the last 30 years with a specific agenda. As a process of enchantment, tourists have been enticed into the region by transforming attractions that feed from romantic traditions and bucolic perspectives (Marmol, 2014). This is interesting because Marmol shifts the liability for maintenance of the myth of rural charm on the hosts and not on the visitors. Santos (2014) is even more evocative in describing the chasm between the past and the present realities. He writes about the use of theme parks that are centred around the past colonial lands and the power of imagery that creates and reinforces ideas about the colonised land. He also speaks about the different world outside of these themes that changed long time ago.
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