Country Stakeholders Research Articles

Strengthening public health professionals in policymaking in the Eastern WHO European region

Abstract Background The collaborative research between EUPHA and WHO aimed to explore factors impacting public health professionals’ (PHP) involvement in health policy processes in the Eastern WHO European Region, addressing barriers, enablers, and capacity-building needs. Methods Utilizing a mixed methodology, the study employed document analysis, scoping review, and interviews to triangulate data, with the document analysis focusing on 4 published Essential Public Health Operations Self-Assessment Reports, the scoping review analysing 15 key articles, and 5 semi-structured interviews providing additional insight from key country stakeholders. Results Core findings revealed significant barriers impeding PHPs' participation in policy processes. Among others, these included limited intersectoral collaboration, shortage of skilled public health (PH) personnel, financial resource constraints and inadequate governance structures. Conversely, several enablers were identified, such as a positive trend in increased intersectoral collaboration and innovative governance structures during Covid-19, the development of more trained PHPs and the utilization of International Health Organisations. The two main capacity building needs reported were the importance of modernizing PH education and promoting intersectoral collaboration. Conclusions This study offers a preliminary overview of how PHPs' involvement in health policy processes in these countries can be enhanced: More intersectoral collaboration, updated PH education curricula and trainings, and governance re-design building on positive trends seen during the pandemic. Following actions are recommended: Creation of an international platform for cross-sectoral PH communication & exchange, direct support for universities and PH researchers, development of comprehensive PH trainings, assistance in forming or strengthening national public health associations and identification & sharing of effective local governance practices. Key messages • This research identifies barriers to PHPs’ participation in Eastern WHO European Region's health policy processes, while highlighting enablers like increased collaboration during Covid-19 to build on. • Recommendations to harness the enablers include clear actions such as creating an international public health platform for interaction and exchange or build-up of national public health associations.

Implementing a chronic disease self-management program in Moldova: a roadmap for sustainability

Abstract Chronic disease self-management programs are evidence-based interventions but achieving their sustainability can be challenging. We propose a roadmap to sustainability that examines the transferability of intervention components and fosters multi-level and multisectoral partnerships. Since 2019, the Swiss Agency for Development and Cooperation’s Healthy Life project, in cooperation with the Ministry of Health of Moldova, has implemented a self-management program in rural communities. At pilot stage, we achieved a 53% increase in participants’ self-efficacy (Palmeirim et al, 2024). To date, the program has reached 1432 beneficiaries in 70 communities. The intervention cost per participant was approximately 74 Euros. Our evidence supported the inclusion of self-management in the national non-communicable disease program 2023-2027. We designed a roadmap to hand over this innovation to Moldovan public health institutions. Firstly, we unpacked the intervention into transferable resources, processes and roles. These included human resources (a network of 140 facilitators), pedagogical resources (culturally adapted facilitator training and self-management workshop content) and key operational processes (coordination, resource management, partnership building, monitoring and evaluation). Then, we convened a national workshop to discuss the transfer of these components to relevant institutions. We emphasized working in a coordinated partnership across institutions for intervention delivery. Finally, we launched a national working group that will work on the operational modalities of this multi-stakeholder partnership. Achieving an enabling policy environment for self-management created favorable conditions and accountability for institutional partnership building. A strategic reflection on our partner ecosystem was key to leverage local and national interests in continuing self-management approaches. Key messages • We have established priorities among transferable intervention components to match country stakeholders’ ability and readiness to sustain innovative approaches. • We are building an institutional partnership across sectors based on complementarity of experience to sustain the delivery of a self-management intervention.

Does negative political coverage affect the completion of cross-border mergers and acquisitions—Evidence from BRICS in the US market

High-quality implementation of cross-border mergers and acquisitions (cross-border M&As) is an important pathway for emerging-market multinational enterprises (EMNEs) to enhance their international competitiveness. However, in comparison to developed countries, cross-border M&As by EMNEs are often prohibited by the liability of origin caused by negative political coverage. How and why negative political coverage affect the completion of cross-border M&As by EMNEs? What are the contextual constraints that moderate the impact of negative political coverage on cross-border M&As completion? Based on the “liability of origin” theory, this paper addresses these questions using data from the Zephyr database on cross-border M&As by EMNEs in the United States from 2016 to June 2021 and employing a logit model for estimation. The research findings are as follows: (1) Negative political coverage leads to negative perceptions of emerging market countries by host country stakeholders, creating the liability of origin and stigmatizing the corporate nationality, thereby reducing the success rate of cross-border M&As by EMNEs. (2) Increasing geographical distance leads to information asymmetry, reinforcing the negative impact of negative political coverage on the completion of cross-border M&As by EMNEs. (3) Relevant mergers and acquisitions exacerbate the negative effect of negative political coverage on the success rate of cross-border M&As by EMNEs. (4) Being a publicly traded firm and having successful experience in cross-border M&As both intensify the negative impact of negative political coverage on the success rate of cross-border M&As by EMNEs.

Optimal Allocation Model for Maritime Emergency Resource Considering the Spatial Correlation between Accident Hotspots

For effective maritime traffic emergency rescue (MTER) operations in the event of maritime traffic accidents (MTAs) and to improve rescue efficiency, it is necessary to analyze the MTER synergy problem and the cooperation between port states. First, the spatial information of accidents under the geographic information system data structure is clarified from the global integrated shipping information system of the International Maritime Organization, and the density-based spatial clustering of applications with noise algorithm is used to conduct hotspot mapping analysis of MTAs to establish the clustering and classification of accident characteristics in key areas. Second, the classification characteristics of accident samples are extracted based on spatial information, and the correlation attributes between MTA hotspots are analyzed. Furthermore, by introducing complex network measurement technology, a topological model of the MTER network is established considering the correlation of accident hotspots, and this model is combined with the sample data of MTAs in Southeast Asian waters from 1990 to 2022. Third, the MTER topological network model is quantitatively analyzed under the accident space of Southeast Asia, and the degree of correlation of traffic accidents in key areas is obtained to reveal the inevitable demand for MTER between regions. The results of the analysis show that there is a network correlation between inter-regional accident hotspots, and thus the degree of correlation between accident hotspots needs to be considered for MTER in key areas. Countries in densely connected regions would set up joint rescue exercises and consider rescue assistance between port country stakeholders, thus improving protection for accident emergency responses. The method of complex network topology based on spatial correlation between accident hotspots suggests a new approach for solving the MTER problem.

The Full Value of Vaccine Assessments Concept-Current Opportunities and Recommendations.

For vaccine development and adoption decisions, the 'Full Value of Vaccine Assessment' (FVVA) framework has been proposed by the WHO to expand the range of evidence available to support the prioritization of candidate vaccines for investment and eventual uptake by low- and middle-income countries. Recent applications of the FVVA framework have already shown benefits. Building on the success of these applications, we see important new opportunities to maximize the future utility of FVVAs to country and global stakeholders and provide a proof-of-concept for analyses in other areas of disease control and prevention. These opportunities include the following: (1) FVVA producers should aim to create evidence that explicitly meets the needs of multiple key FVVA consumers, (2) the WHO and other key stakeholders should develop standardized methodologies for FVVAs, as well as guidance for how different stakeholders can explicitly reflect their values within the FVVA framework, and (3) the WHO should convene experts to further develop and prioritize the research agenda for outcomes and benefits relevant to the FVVA and elucidate methodological approaches and opportunities for standardization not only for less well-established benefits, but also for any relevant research gaps. We encourage FVVA stakeholders to engage with these opportunities.

Exploring school food provision programs and links to local foods in Pacific Island countries

Providing access to food in schools can serve as a platform for food system transformation, while simultaneously improving educational outcomes and livelihoods. Locally grown and procured food is a nutritious, healthy, and efficient way to provide schoolchildren with a daily meal while, at the same time, improving opportunities for smallholder farmers(1). While there is significant potential for school food provision activities to support healthy dietary behaviours in the Pacific Islands region, there is limited evidence of these types of activities(2), including scope and links to local food production in the region. Therefore, the aim of this scoping study was to understand the current state of school food activities (school feeding, gardening and other food provision activities) and any current, and potential links to local agriculture in the Pacific Islands. A regional mapping activity was undertaken, initially covering 22 Pacific Island countries. The mapping included two steps: 1) a desk based scoping review including peer-reviewed and grey literature (2007-2022) and 2) One-hour semi-structured online Zoom interviews with key country stakeholders. Twelve sources were identified, predominately grey literature (n = 9). Thirty interviews were completed with at least 1 key stakeholder from 15 countries. A variety of school food provision activities were identified, including school feeding programs (n = 16, of varying scale), programs covering both school feeding and school gardens (n = 2), school garden programs (n = 12), and other school food provision activities (n = 4, including taste/sensory education, food waste reduction, increasing canteen capacity for local foods, supply chain distribution between local agriculture and schools). Existing links to local agriculture varied for the different programs. Of the 16 school feeding programs, 8 had a requirement for the use of local produce (policy requirement n = 6, traditional requirement from leaders n = 2). Of the 12 school garden programs, 6 used local or traditional produce in the garden and 5 involved local farmers in varying capacities. Challenges to linking local agriculture into school food provision programs were reported for 17 activities and were context dependent. Common challenges included limited funding, inflation, Covid-19, inadequate produce supply for the scale of program, limited farmer capacity, limited institutional support for local produce, low produce storage life, climatic conditions and disasters, water security, delayed procurement process, and limited professional development and upskilling opportunities. Modernisation and colonisation of food systems resulting in a preference for hyperpalatable foods and challenges in incorporating local produce in a way that is accepted by students was also identified as a challenge. This evidence can be used to develop a pathway to piloting and implementing models of school food provision programs and promoting opportunities for shared learning and collaboration with key stakeholders across the Pacific Islands region.

Evaluation of the use of modelling in resource allocation decisions for HIV and TB

IntroductionGlobally, resources for health spending, including HIV and tuberculosis (TB), are constrained, and a substantial gap exists between spending and estimated needs. Optima is an allocative efficiency modelling tool that...

All politics starts local: Liability of stateness and subnational labor markets

AbstractResearch SummaryState‐controlled acquirers face a liability of stateness (LoS) because host country stakeholders consider them less legitimate and as representatives of foreign political power. We argue that due to LoS, state‐owned enterprises (SOEs) face more regulatory scrutiny in cross‐border acquisitions than comparable private‐owned enterprises (POEs). Applying a voting behavior perspective, we further posit this increased regulatory scrutiny is reduced when acquisitions occur via intermediaries, and in host communities less averse to state ownership due to local labor conditions. Using a sample of cross‐border acquisitions with acquirers from 44 economies and targets in 50 US states, we find that SOEs are 9% more likely to attract additional regulatory scrutiny than POEs. However, this likelihood decreases with indirect acquisitions and in host regions with high unemployment.Managerial SummaryState‐owned enterprises experience challenges in their cross‐border acquisitions because people in host societies do not trust them. As a result, regulatory authorities, such as CFIUS in the United States, subject foreign SOE acquirers to greater scrutiny. However, by acquiring foreign firms through subsidiaries rather than through parent organizations, the state influence becomes less visible, resulting in less regulatory scrutiny. Moreover, local stakeholders are concerned with economic opportunities in their local area, which they prioritize over ideological concerns at time of economic crisis. Consequently, SOE acquirers face less additional scrutiny in local communities with high unemployment. Thus, SOE acquirers can work with local communities to overcome the negative perception they encounter when entering foreign markets.

Application of diagnostic network optimization in Kenya and Nepal to design integrated, sustainable and efficient bacteriology and antimicrobial resistance surveillance networks.

Antimicrobial resistance (AMR) is a major global public health concern, particularly in low- and middle-income countries, which experience the highest burden of AMR. Critical to combatting AMR is ensuring there are effective, accessible diagnostic networks in place to diagnose, monitor and prevent AMR, but many low- and middle-income countries lack such networks. Consequently, there is substantial need for approaches that can inform the design of efficient AMR laboratory networks and sample referral systems in lower-resource countries. Diagnostic network optimization (DNO) is a geospatial network analytics approach to plan diagnostic networks and ensure greatest access to and coverage of services, while maximizing the overall efficiency of the system. In this intervention, DNO was applied to strengthen bacteriology and AMR surveillance network design in Kenya and Nepal for human and animal health, by informing linkages between health facilities and bacteriology testing services and sample referral routes between farms, health facilities and laboratories. Data collected from the target settings in each country were entered into the open-access DNO tool OptiDx, to generate baseline scenarios, which depicted the current state of AMR laboratory networks and sample referral systems in the countries. Subsequently, baselines were adjusted to evaluate changing factors such as samples flows, transport frequency, transport costs, and service distances. Country stakeholders then compared resulting future scenarios to identify the most feasible solution for their context. The DNO analyses enabled a wealth of insights that will facilitate strengthening of AMR laboratory and surveillance networks in both countries. Overall, the project highlights the benefits of using a data-driven approach for designing efficient diagnostic networks, to ensure better health resource allocation while maximizing the impact and equity of health interventions. Given the critical need to strengthen AMR laboratory and surveillance capacity, DNO should be considered an integral part of diagnostic strategic planning in the future.

Awareness and experiences on core outcome set development and use amongst stakeholders from low- and middle- income countries: An online survey.

Harmonization of outcomes to be measured in clinical trials can reduce research waste and enhance research translation. One of the ways to standardize measurement is through development and use of core outcome sets (COS). There is limited involvement of low- and middle-income country (LMIC) stakeholders in COS development and use. This study explores the level of awareness and experiences of LMIC stakeholders in the development and use of COS. We conducted an online survey of LMIC stakeholders. Three existing COS (pre-eclampsia, COVID-19, palliative care) were presented as case scenarios, and respondents asked to state (with reason(s)) if they would or would not use the COS if they were working in that area. Quantitative data were analyzed descriptively while qualitative data were analyzed thematically. Of 81 respondents, 26 had COS experience, 9 of whom had been involved in COS development. Personal research interests and prevalence of disease are key drivers for initiation/participation in a given COS project. Most respondents would use the COS for pre-eclampsia (18/26) and COVID-19 (19/26) since the development process included key stakeholders. More than half of the respondents were not sure or would not use the palliative care COS as they felt stakeholder engagement was limited and it was developed for a different resource setting. Respondents reported that use of COS can be limited by (i) feasibility of measuring the outcomes in the COS, (ii) knowledge on the usefulness and availability of COS and (iii) lack of wide stakeholder engagement in the COS development process including having patients and carers in the development process. To ensure the development and use of COS in LMICs, collaborations are essential in awareness raising on COS utility, training, and COS development. The COS also needs to be made accessible in locally understandable languages and feasible to measure in LMICs.

Sustainable development goals and multisectoral collaborations for child health in Cambodia: a qualitative interview study with key child health stakeholders

ObjectivesMultisectoral collaboration highlighted as key in delivering on the Sustainable Development Goals (SDGs), but still little is known on how to move from rhetoric to action. Cambodia has made remarkable...

Exploring Shigella vaccine priorities and preferences: Results from a mixed-methods study in low- and middle-income settings

BackgroundShigella is the leading bacterial cause of diarrheal mortality in children and can cause long-term effects on growth and development. No licensed Shigella vaccines currently exist but several promising candidates are in development and could be available in the next five years. Despite Shigella being a well-known public health target of the World Health Organization for decades, given current burden estimates and competing preventable disease priorities in low-income settings, whether the availability of an effective Shigella vaccine will lead to its prioritization and widespread introduction among countries at highest risk is unknown. MethodsWe conducted a mixed-methods study of national stakeholders and healthcare providers in five countries in Asia and Africa and regional stakeholders in the Pan American Health Organization to identify preferences and priorities for forthcoming Shigella vaccines. ResultsIn our study of 89 individuals, diarrhea was the most frequently mentioned serious health concern for children under five years. Antimicrobial resistance (AMR) was more often considered very concerning than diarrhea or stunting. Shigella awareness was high but not considered a serious health concern by most stakeholders. Most participants were willing to consider adding a new vaccine to the routine immunization schedule but expressed reservations about a Shigella vaccine because of lower perceived burden relative to other preventable diseases and an already crowded schedule; interest was highest among national stakeholders in countries receiving more financial support for immunization. The priority of a Shigella vaccine rose when participants considered vaccine impacts on reducing stunting and AMR. Participants strongly preferred oral and combination vaccines compared to injectable and a single-antigen presentations, citing greater perceived community acceptability. ConclusionsThis study provides a critical opportunity to hear directly from country and regional stakeholders about health priorities and preferences around new vaccines. These findings should inform ongoing Shigella vaccine development efforts and eventual vaccine introduction and implementation planning.

Examining Cryptocurrency Use among Muslim Affiliated Terrorists: Case Typology and Regulatory Challenges in Southeast Asian Countries

Many policymakers and scholars have discussed concerns regarding terrorist group use of cryptocurrency in recent years. While some argue that the threat is still limited, others argue that the current usage of cryptocurrency does not match the entirety of features that terrorist groups require and desire. In the end, it is still critical to recognize that the cryptocurrency used for terrorist financing frequently depends on several influencing factors. This study aims to (i) investigate the utilization of cryptocurrency by Moslem-affiliated terrorists in Southeast Asia; (ii) map the case typology of cryptocurrency use in Southeast Asian terrorist funding; (iii) describe the regulatory challenges raised in Southeast Asia. This research is a type of doctrinal legal one using the statute, case, and conceptual approaches. The results of this study acknowledge the limited but increasing risk of terrorist financing by cryptocurrency over the 2015-2022 timeframe in Southeast Asia. Furthermore, the existing typology of cases uses smurfing and structuring techniques with high and medium levels of risk. This research ends by recommending actions that Southeast Asian country stakeholders can take to reduce the potential of cryptocurrency usage in terrorist funding by harmonizing their counter-terrorist financing regulatory approaches and implementing investigative best practices.

The association of corporate social responsibility and sustainable consumption and production patterns: The mediating role of green supply chain management

Sustainable consumption and production pattern (SCPP) in the food supply chain is the key agenda of the sustainable development goals (SDGs). However, the entire globe may be falling short of its goals for the 2030 agenda as expected. The role of each member country, local businesses, and several supply chain stakeholders is crucial to the feasibility of achieving SCPP. Despite this, emerging countries and small- and medium-sized enterprises (SMEs) in evolving industries still encounter significant challenges in realizing this objective. Therefore, the goal of this study is to close that gap by investigating how SCPP can be fulfilled. This research examined how corporate social responsibility (CSR) practices affect various stakeholders as well as green supply chain management (GSCM) in driving SCPP. It takes a quantitative approach, collecting the main information through a questionnaire-based survey. Respondents are individuals who have managerial roles in selected companies. In total, 466 valid response sheets were collected. SmartPLS (version 3.3.2) has been used to investigate the hypothesized relations. This research revealed that CSR (both internal & external) had a significant and beneficial influence on GSCM and SCPP. Besides, the findings indicate that GSCM is positively and significantly related to SCPP. This research contributes to the existing literature on SCPP by presenting a combined framework that has been empirically operationalized via the lenses of social cognitive theory, stakeholder theory, and resource-based view (RBV) theory. Additionally, it proposes a novel method for gaining SCPP using SMEs in the food supply chain in evolving markets as an experimental field of study that has not been sufficiently investigated in recent literature. It also suggests theoretical and managerial implications for different groups of stakeholders, making an important contribution not only to the firms’ sustainability, entities engaged in the supply chain, and society at large, but also to the application of SDGs.

Evaluating COVID-19-Related Disruptions to Effective Malaria Case Management in 2020-2021 and Its Potential Effects on Malaria Burden in Sub-Saharan Africa.

The COVID-19 pandemic has led to far-reaching disruptions to health systems, including preventative and curative services for malaria. The aim of this study was to estimate the magnitude of disruptions in malaria case management in sub-Saharan Africa and their impact on malaria burden during the COVID-19 pandemic. We used survey data collected by the World Health Organization, in which individual country stakeholders reported on the extent of disruptions to malaria diagnosis and treatment. The relative disruption values were then applied to estimates of antimalarial treatment rates and used as inputs to an established spatiotemporal Bayesian geostatistical framework to generate annual malaria burden estimates with case management disruptions. This enabled an estimation of the additional malaria burden attributable to pandemic-related impacts on treatment rates in 2020 and 2021. Our analysis found that disruptions in access to antimalarial treatment in sub-Saharan Africa likely resulted in approximately 5.9 (4.4-7.2 95% CI) million more malaria cases and 76 (20-132) thousand additional deaths in the 2020-2021 period within the study region, equivalent to approximately 1.2% (0.3-2.1 95% CI) greater clinical incidence of malaria and 8.1% (2.1-14.1 95% CI) greater malaria mortality than expected in the absence of the disruptions to malaria case management. The available evidence suggests that access to antimalarials was disrupted to a significant degree and should be considered an area of focus to avoid further escalations in malaria morbidity and mortality. The results from this analysis were used to estimate cases and deaths in the World Malaria Report 2022 during the pandemic years.

Thalassemia care in Nepal: In dire need of improvement.

Thalassemia care in Nepal: In dire need of improvement.

What constitutes equitable data sharing in global health research? A scoping review of the literature on low-income and middle-income country stakeholders’ perspectives

IntroductionDespite growing consensus on the need for equitable data sharing, there has been very limited discussion about what this should entail in practice. As a matter of procedural fairness and...

Institutional Environment Pressures Perceived by Bilateral Development Cooperation Agency's Constituents

Public organisations have rarely been the subjects of neo-institutional research. Intra-organisational behaviour has also been under-researched. This study examined how four distinct groups of Bilateral Development Cooperation Agency's staff perceive institutional environment pressures from home and host countries. One-hundred thirty-one valid responses obtained through an online survey were analysed. Staff in both the headquarters and overseas offices felt a powerful home country accountability pressure. This tendency is prominent for management staff. The test results, as seen through the lens of a neo-institutional perspective, suggest that overseas office staff prioritise accountability to home country stakeholders over that to host country stakeholders.

State-facilitated Industrial Parks in the Belt and Road Initiative: Towards a framework for understanding the localization of the Chinese development model

Industrial parks are a cornerstone of Chinese infrastructure development, both domestically and overseas. We examine how they are localized through negotiations and contestations by host country stakeholders using the cases of Indonesia’s Morowali Industrial Park and the Malaysia China Kuantan Industrial Park. Negotiations involving Chinese and host country goals, norms, and agendas co-produced those parks. Both were sited in relatively undeveloped areas. Chinese firms brought in new technology and built infrastructure, albeit not without socio-environmental impacts. In Indonesia, the political elites’ goals of achieving import substitution industrialization resulted in their bartering access to high-grade nickel ore for better extraction technology and upgraded smelting capacity. In Malaysia, a market-oriented government insisted on bringing investments to the underdeveloped state of Pahang, resulting in a park that imports ore, manufactures steel products, and exports goods to the rest of the world. The analysis produced a framework that shows how the state-led model of Chinese industrial parks exported through the Belt and Road Initiative is an example of “directed improvisation,” an adaptive model that is localized through two levels of host country processes – negotiations and contestations, which in turn produce feedbacks towards corporate governance and the host country environment. This model, however, gives host country actors enormous influence over the outcome of such projects.

“We should be at the table together from the beginning”: perspectives on partnership from stakeholders at four research institutions in sub-Saharan Africa

BackgroundGlobal health research partnerships have been scrutinised for how they operate and criticised for perpetuating inequities. Guidance to inform fair partnership practice has proliferated and the movement to decolonise global health has added momentum for change. In light of this evolving context, we sought in this study to document contemporary experiences of partnership from the perspective of stakeholders in four sub-Saharan African research institutions.MethodsWe conducted qualitative interviews with 20 stakeholders at research institutions in four countries in anglophone eastern and southern Africa. Interview questions were informed by published guidance on equitable research partnerships. Data was analysed through an iterative process of inductive and deductive coding, supported by NVivo software.ResultsEarly-career, mid-career and senior researchers and research administrators from four sub-Saharan African research institutions described wide-ranging experiences of partnership with high-income country collaborators. Existing guidelines for partnership provided good coverage of issues that participants described as being the key determinants of a healthy partnership, including mutual respect, role clarity and early involvement of all partners. However, there was almost no mention of guidelines being used to inform partnership practice. Participants considered the key benefits of partnership to be capacity strengthening and access to research funding. Meanwhile, participants continued to experience a range of well-documented inequities, including exclusion from agenda setting, study design, data analysis and authorship; and relationships that were exploitative and dominated by high-income country partners’ interests. Participants also reported emerging issues where their institution had been the prime recipient of funds. These included high-income country partners being unwilling to accept a subordinate role and failing to comply with reporting requirements.ConclusionsInsights from stakeholders in four sub-Saharan African research institutions suggest that contemporary global health research partnerships generate considerable benefits but continue to exhibit longstanding inequities and reveal emerging tensions. Our findings suggest that long-term support targeted towards institutions and national research systems remains essential to fulfil the potential of research led from sub-Saharan Africa. High-income country stakeholders need to find new roles in partnerships and stakeholders from sub-Saharan Africa must continue to tackle challenges presented by the resource-constrained contexts in which they commonly operate.