Enabling Policy Environment Research Articles

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.

Identifying priority double-duty actions to tackle the double burden of malnutrition in infants and young children in Peru: Assessment and prioritisation of government actions by national experts.

Multiple forms of malnutrition coexist in infants and young children (IYC) in Peru. The World Health Organization has proposed double-duty actions (DDAs) to simultaneously address undernutrition and overweight/obesity. We assessed current implementation of- and priority for- government-level actions to tackle multiple forms of malnutrition in IYC in Peru. Mapping of current policy activity was undertaken against 47 indicators of good practice for five DDAs (exclusive breastfeeding, complementary feeding, food marketing, maternal nutrition, preschool nutrition; assessed by 27 indicators) and for the enabling policy environment, i.e., 'infrastructure support' (health in all policies, platforms for interactions, financing, monitoring, governance, leadership; assessed by 20 indicators). Interviews with 16 national experts explored views on the level of and barriers to implementation of DDAs and infrastructure support, as well as their prioritisation based on likely impact and feasibility. The level of implementation of actions was categorised into two groups (agenda setting/formulation vs. implementation/evaluation). Mean scores were generated for prioritisation of DDAs and infrastructure support. Deductive qualitative analysis was undertaken to identify barriers that influence policy implementation. Only 5/27 DDA indicators were reported as fully implemented by all national experts (international code that regulates the marketing of breastmilk substitutes, iron supplementation for IYC, micronutrient powders in IYC, iron/folic acid supplementation in pregnant women, paid maternity leave). Only 1/20 infrastructure support indicator (access to nutrition information) was rated as fully implemented by all experts. Barriers to implementing DDAs and infrastructure support included: legal feasibility or lack of regulations, inadequate monitoring/evaluation to ensure enforcement, commercial influences on policymakers, insufficient resources, shifting public health priorities with the COVID-19 pandemic and political instability. The experts prioritised 12 indicators across all five DDAs and eight infrastructure support indicators. Experts highlighted the need to improve implementation of all DDAs and identified ways to strengthen the enabling policy environment.

Does an Enabling Policy Environment Exist to Manage the Cross-Sectoral “Monkey Problems” of St. Kitts?

Does an Enabling Policy Environment Exist to Manage the Cross-Sectoral “Monkey Problems” of St. Kitts?

Enabling policy environment for water operator partnerships in the Southern African Development Community

AbstractWater service provision has typically been primarily regarded as a government endeavor, especially in developing countries. Various concepts of partnerships have been promoted over the past five decades in the sector, primarily to improve service provision. Among these partnerships, water operator partnerships (WOPs) have been distinguished as a leading concept that promotes easy access to water supply and sanitation. Several WOPs exist worldwide with varying partnership types and characteristics. For WOPs to thrive effectively globally, an enabling environment has to be provided. More so for developing countries that are more susceptible to socio‐economic and climate change factors that affect water service delivery. This paper evaluates the enabling policy environment for WOPs in the Southern African Development Community (SADC) region. Data used for the study include literature from the Global Water Operator Partnerships Alliance (GWOPA) WOPs database, as well as other online resources, enabling a detailed understanding of different case studies in the SADC region on a North–South and South–South basis. It must, however, be noted that data availability on the database is dependent on the utilities engaged in the WOP recording and uploading it, and this affected the scope of the study. The database provided three in‐depth case studies from Mozambique, Tanzania, and Zimbabwe, and extensive literature review provided an additional in‐depth case study from Malawi. Strategies such as water reforms and multi‐stakeholder partnerships are highlighted in aiding the WOPs. Findings show that current policies in the region make provisions for partnerships but are not explicit or exhaustive on the different forms of partnerships. The lack of an intermediate third party in countries such as Malawi negatively affects the relationship between the utilities and, subsequently, the success of the WOP. Strategies such as capacity building and stakeholder participation can assist in creating a more enabling policy environment for WOPs.

The cascade of care for hepatitis C in Victoria, Australia: a data linkage cohort study.

Highly effective hepatitis C therapies are available in Australia. However, people living with hepatitis C face various barriers to accessing care and treatment. To identify gaps in the cascade of care for hepatitis C and generate estimates of the number living with untreated infection according to population group, using a representative longitudinal study population. We linked hepatitis C notification data from Victoria to national pathology, prescribing and death registry data. We assessed receipt of key clinical services in a large cohort who tested positive for hepatitis C from 1 January 2000 to 31 December 2016, with follow-up to 30 June 2018. We estimated the number still living with hepatitis C, adjusting for spontaneous clearance and mortality. The cohort comprised 45 391 people positive for hepatitis C. Of these, 13 346 (29%) received treatment and an estimated 28% (95% confidence interval (CI): 26-30%) were still living with chronic infection at 30 June 2018, with the remainder still living following spontaneous clearance (30%, 95% CI: 29-32%) or having died (12%, 95% CI: 12-12%). Half (50%) of those still living with hepatitis C were born from 1965 to 1980, and 74% first tested positive before 2011. Despite an enabling policy environment and subsidised therapy, many people in this cohort were not treated. Increased measures may be needed to engage people in care, including those who acquired hepatitis C more than 10 years ago.

The urban political ecology of antimicrobial resistance: A critical lens on integrative governance

The objective of this paper is to integrate Urban Political Ecology (UPE) as a theory for identifying under-exposed urban dimensions of Antimicrobial Resistance (AMR). A UPE lens allows us to conceptualize urbanization as a ubiquitous socio-ecological process and an interpretive frame that could inform AMR governance strategies across related contexts by: a) situating AMR risks in relation to urbanization processes shaping social and political co-determinants of such systemic threats as climate change; b) aligning UPE scholarship with One Health (OH) approaches that address AMR to reveal the under-exposed link of AMR to environmental threats and broader structural dimensions that influence these threats; and c) identifying shared AMR and environmental governance pathways that inform the rationale for more equitable governance arrangements. We delineate a context in which the speed and scale of human activity in the larger context of urbanization, driven by global market integration strategies, impacts human-animal-environmental health threats such as AMR. We demonstrate how UPE scholarship can be leveraged to offer theoretical depth to approaches considering the interdependencies of AMR and climate change threats. We then propose a strategic approach focused on identifying shared governance pathways and intersectoral accountability frameworks to address upstream structural drivers of AM-Environmental threats. The co-benefits of a UPE-informed framework to human-animal-environmental health that leverages enabling policy environments to foster a more collaborative, equitable and sustainable approach to address systemic global health threats are clarified. Just as the concept of “health in all policies” emphasized taking health implications into account in all public policy development, the integration of UPE in AMR governance arrangements would emphasize the need to take other sectors into account through an intersectoral whole-of-government approach that fosters shared AMR - climate change governance pathways.

Relationship, governance, and upgrading opportunities in the Shea value Chain: a descriptive analysis from Northern Ghana

ABSTRACT This study explores the relationships between value chain actors in the shea sector in Northern Ghana, the governance mechanism that prevails, and the upgrading opportunities for upstream actors. The value chain analysis (VCA) framework was the main analytical tool employed for this assessment. Participating actors in the shea global value chain were shea kernel producers, shea butter processors, aggregators, and industrial processors and exporters of shea products. The results showed that, although women shea upstream actors (especially shea kernel producers) interface directly with aggregators, the relationship is weak and restricted to spot buying, and arms-length market governance relationship. Although the upstream actors are enthusiastic to upgrade their products, they are constrained by inadequate access to requisite assets, resources, capabilities, and skills. The shea upstream actors were confined to low value-adding segments and activities of the shea-GVC. Industrial processors and exporters appear reluctant to directly support upstream women processors to upgrade through offering credits, technology transfer and skills enhancement. Lowering barriers to upgrading opportunities in the value chain calls for intervention of the government, and support from international development organizations (NGOs), and midstream and downstream actors. Government must create an enabling policy environment that incentivize downstream actors to build capacities of upstream actors.

Applications, Benefits, and Challenges of Genome Edited Crops

The tools of genome editing were described more than a decade ago as promising ways to accelerate crop improvement in addition to applications for human and animal health. Now, a decade later, we are seeing applications of genome editing across a range of different crops and trait combinations that will bring benefits to producers and consumers. Countries around the world are actively engaged in updating regulatory frameworks to govern this new technology adequately. In this paper, we describe recent advances in genome editing tools, review select applications underway, consider the benefits of the technology, and offer a perspective on significant challenges to the success of the use of genome editing. Given an enabling policy environment, genome editing will be an important tool in creating a competitive bioeconomy while addressing major challenges to agriculture and consumers. We offer five recommendations to ensure genome editing in agriculture benefits society

Financial incentive for community health workers, a necessity for achieving universal health coverage: integrated literature review

Community health workers (CHWs) are vital to achieve universal health coverage (UHC). They have been identified as effective workforce to improve access to primary health care particularly for underserved and hard to reach populations. Lack of appropriate incentives, with resulting high rates of turnover are common challenges in large-scale CHW program. Debates about paying community health workers typically focus on the trade-offs between reliance on volunteerism underpinned by intrinsic motivation of volunteers and the need to recognise and remunerate work fairly. Financial payment for CHWs will also help in increased employment, and women’s economic empowerment, tackling gender-based inequities, as seventy percent of CHWs globally are women. This study reviewed existing literature- published peer reviewed articles and grey literatures on financial incentives for community health workers and program considerations for effective implementation. Synthesis from the relevant studies revealed four relevant themes: need for financial incentives, categories of financial incentives, funding mechanisms for financial incentives and program considerations for effective implementation of financial incentives. The study provides program considerations for effective implementation of financial incentive for community health workers. There is need for countries to review their community health worker program design and establish enabling policy environment and implementation mechanisms for realistic and appropriate financial incentives for the community health workers based on their workload, responsibilities, and local context. Appropriate tools should be used to model the community health workers working hours which will guide in determining fair and commensurate renumeration and effective monitoring system established.

A functional dynamic framework for understanding new government-market relationships of smart energy transitions in China

The urgency for China to attain carbon neutrality has driven the world’s largest carbon-emitting nation to seek more effective climate and energy policies. The adoption of smart grid (SG) technologies, aimed at enabling and accelerating the shift from fossil fuel-dependent energy systems to more sustainable ones, has garnered mounting policy interest in China. However, the full potential of SG development has yet to be realised amidst the ongoing electricity market reforms in the country. A key but largely unanswered question pertains to how and the extent to which the evolving dynamics between the government and the market have influenced SG advancements. This paper aims to develop and apply an integrated framework of policy mixes and functional dynamics for smart energy transitions, and apply it to reanalyse a case study of SG policy developments in China. Our study entails a synthesis of primary research findings, shedding light on how electricity market reforms create institutional contexts within which new government-market dynamics emerge and condition the progress of SGs in China. Our study reveals that the Chinese government has adopted a controlled dynamic approach to modulate the relationships between the government and the market within the power sector. This approach has both facilitated the creation of an enabling policy environment and imposed certain barriers to SG developments. The dominance of state-owned incumbents have on the one hand created state-driven market demand, reduction in technology costs and the influence of utility-led policy networks, but on the other hand, placing constraints on the growth of SG technologies. Our policy recommendations: China needs to formulate and implement SG policies which can effectively overcome key barriers which include under-developed regulatory frameworks, utilities’ disincentives to invest in renewable energy, and insufficiency in end-user engagements.

A qualitative assessment on the acceptability of providing cash transfers and social health insurance for tuberculosis-affected families in Ho Chi Minh City, Vietnam.

To achieve the Sustainable Development Goal's targets of universal health coverage (UHC) and poverty reduction, interventions are required that strengthen and harmonize both UHC and social protection. Vietnam is committed to achieving financial protection and over 90% of the general population has enrolled in its social health insurance (SHI) scheme. However, an estimated 63% of tuberculosis (TB)-affected households in Vietnam still face catastrophic costs and little is known about the optimal strategies to mitigate the costs of TB care for vulnerable families. This study assessed the acceptability of a social protection package containing cash transfers and SHI using individual interviews (n = 19) and focus group discussions (n = 3 groups). Interviews were analyzed through framework analysis. The study's main finding indicated that both conditional and unconditional cash transfers paired with SHI were acceptable, across six dimensions of acceptability. Cash transfers were considered beneficial for mitigating out-of-pocket expenditure, increasing TB treatment adherence, and improving mental health and general well-being, but the value provided was inadequate to fully alleviate the economic burden of the illness. The conditionality of the cash transfers was not viewed by participants as inappropriate, but it increased the workload of the TB program, which brought into question the feasibility of scale-up. SHI was viewed as a necessity by almost all participants, but people with TB questioned the quality of care received when utilizing it for auxiliary TB services. Access to multiple sources of social protection was deemed necessary to fully offset the costs of TB care. Additional research is needed to assess the impact of cash transfer interventions on health and economic outcomes in order to create an enabling policy environment for scale-up.

Rooted Water Collectives in a Modernist and Neoliberal Imaginary: Threats and Perspectives for Rural Water Commons

Water schemes that rely on user (co-) ownership and collective action have been described in the irrigation sector for a long time. Still, interest in such forms of (co-) investment in the domestic/multiple use sector is more recent. To address the persisting issue of rural water service, (what has been coined) self-supply is proclaimed to be a (supposedly) low-cost, sustainable manner to attain the Sustainable Development Goals (SDGs). User (co-) investments are to be promoted and realized through the creation of an enabling policy environment and development of, and training on, low-cost technologies through government and NGO support and private sector-steered access to such technologies. In this article, we apply the Rooted Water Collectives (RWC) framework to describe two such schemes, one in South Africa and one in Switzerland. The data collection followed an action research methodology, with the main author being involved in interventions in all three schemes. We show here that these collectives create positions of purpose within societies and that what motivates people is to help themselves and contribute to the greater good of the community. This article shows that interventions to foster and sustain such collective actions that follow a neoliberal/modernist imaginary negatively affect their viability since these collectives, through their other-than-capitalist interactions, form part of and depend on an alternative imaginary. We conclude that interventions aiming to strengthen forms of collective action can only succeed if they recognize contextuality, unequal power relationships, and grass-rooted forms of interdependence and collaboration, and actively build on and work toward such alternative, more convivial imaginaries.

Drivers of Scale and Sustainability of Food Safety Interventions in Informal Markets: Lessons from the Tanzanian Dairy Sector

Food safety is critical but poorly addressed in African countries. A food safety training and certification intervention piloted in Kenya, India, Tanzania, and Nigeria was scaled and sustained in India but not the African countries. There is limited knowledge about how contextual factors facilitated or limited the scale and sustainability of the intervention in African countries. This research analysed the reach and contextual drivers of scale and sustainability of the intervention in Tanzania’s informal dairy sector four years post-implementation to draw lessons around the scale and sustainability of such interventions in African contexts. We utilized a convergence mixed method study design. We compiled data using document review, surveys with dairy traders, and key informant interviews with key dairy stakeholders. The intervention reach was limited. Critical incentives for traders and intervention implementers to engage with the intervention were lacking due to the absence of government commitment to support the intervention through policy. The traders and intervention implementers also lacked adequate capacities, compromising intervention delivery. For the intervention to achieve scale and sustainability in Tanzania and similar contexts, governments must be committed to food safety and provide enabling policy environments. The interventions must also consider the capacities of the beneficiaries and implementers.

Revolutionizing Agrotechnology: Meeting Global Food Demand through Sustainable and Precision Farming Innovations

Indonesia's status as the world's fourth most populous country underscores the importance of its contribution to global food security. However, this important role comes with a series of challenges that are exacerbated by changing climate dynamics, decreasing arable land, and the inherent inefficiencies of traditional farming techniques. Balancing the need to increase productivity with the imperative to preserve the environment is a formidable challenge that necessitates a paradigm shift in agricultural practices. However, these benefits are accompanied by barriers such as knowledge gaps, financial constraints, and infrastructure limitations, which need to be effectively addressed to utilise the full potential of these technologies. This research underscores the need for a holistic and context-sensitive approach. Effective knowledge dissemination, customised financing mechanisms, improved infrastructure, and supportive policy frameworks are essential to foster the adoption and implementation of innovative practices. In addition, the research highlights the importance of collaboration among various stakeholders, including farmers, policymakers, researchers and industry players, to collectively address challenges and capitalise on opportunities. The implications of this research extend beyond the borders of Indonesia. The findings provide insights that resonate with other developing countries facing similar challenges in agricultural transformation. By bridging knowledge gaps, promoting equitable access to technology, and fostering an enabling policy environment, countries can unlock the potential of the agrotechnology revolution to meet global food needs while maintaining the ecological balance of our planet. As the world grapples with the challenges of food security in an era of climate change, this research contributes valuable knowledge to build a more sustainable and resilient future for agriculture and humanity.

The Emergence of Large-Scale Bioethanol Utilities: Accelerating Energy Transitions for Cooking

Expansion in access to clean cooking in Sub-Saharan Africa remains well below the UN’s Sustainable Development Goal objectives. In particular, clean and modern forms of cooking have struggled to attract commercial funding at scale. The use of bioethanol in cooking is not new, but until recently, its application has been confined exclusively to small-scale projects. However, a new bioethanol cooking utility in Kenya has now reached mass-market adoption, serving more than 950,000 households with cooking fuel since its launch in late 2019. Its success was made possible by a significant investment in technology to facilitate safe, convenient, and affordable fuel distribution. It is funded by climate finance, which is based on bioethanol fuel replacing the charcoal normally used for cooking; a leading cause of African deforestation. This development is so recent that it has not been widely discussed in the academic literature. More broadly, the health, environmental, and economic impacts of bioethanol for cooking have not been systematically assembled in one place. The main aim of this study is to identify how KOKO Networks has managed to overcome the traditional barriers to scalability, achieving impacts with bioethanol for accelerating energy transitions for cooking. The results show that bioethanol for cooking supports 13 out of 17 SDGs and has significant positive impacts on health, the environment, and the wider economy. The affordability of bioethanol has been made possible because of KOKO Investments in high-tech electronic fuel dispensing machines and through the use of climate financing. KOKO relies both on local and imported fuel to offer reliability and security of supply, as well as to grow commercial bioethanol demand to support the growth of the local bioethanol industry. Bioethanol for cooking also suffers from unfavorable tax regimes. This is because historically, in many countries, ethanol has been imported for use in the beverage industry. In addition, an appropriate commercial supply chain and delivery model which boosts the scalability of business and offers customer convenience is essential. For these conditions to take place, an enabling policy environment is key.

Role of multilateral development organizations, public and private investments in aquaculture subsector in Kenya

Rapid population and economic growth, increased health benefits of aquatic food, and changes in lifestyles and preferences as a result of rapid urbanization and globalization are all contributing to the rapid growth of aquaculture production in Kenya. Despite significant investment efforts from the national and devolved governments as well as donors and international organizations, smallholder aquaculture production is yet to result in a significant increase in incomes and improved food and nutrition security. We conducted a scoping review to investigate the roles of multilateral development organizations, international financial institutions, and public and private investments in Kenya’s aquaculture subsector. We draw on lessons learned from previous projects implemented at the national, county, and farm levels to make recommendations for sustainable aquaculture intensification in Kenya. To unlock Kenya’s aquaculture potential and improve its food and nutrition status, deliberate efforts must be made to create a conducive environment for public and private investment in the industry. First, there is a need to coordinate and clearly articulate the roles and responsibilities among devolved and national governments, donors, and financial institutions through public-private partnerships to ensure optimal allocation of financial, human, and infrastructure resources. Second, more collaborative research should be devoted to the design and construction of climate smart culture systems, developing new species to guarantee supply of high-quality products; developing and scaling low-cost and highly nutritious fish feeds based on novel ingredients; and enhancing resilient livelihoods through innovative aquaculture practices and market linkages to create employment opportunities for youth and women. Finally, the national and devolved governments should create an enabling policy environment through tax incentives and regulatory reforms to combat climate change, protect nature and biodiversity, sustain livelihoods, and mainstream food and nutrition initiatives into the design and implementation of future aquaculture projects.

Agribusiness and Supply Chain Development Policies in Nepal: A Review from Temporal Dynamics

A critical review of agriculture policies during different plan periods, aligned with political changes, has been conducted out to understand the shift in priorities, technology transfer ,support products, and private sector engagement. Firstly, in the 1950s, the policies were influenced by the first five-year plan and focused on the import and dissemination of technology. During the three decades of the Panchayat era, there was an emphasis on state mechanisms for technology transfer, agribusiness, and research, with limited incentives for the private sector. After 1990, agricultural policy products followed a path of liberalization and focused on defining the state’s role and promoting pluralism. This period witnessed the establishment of a wide range of private and cooperative-led agribusinesses, although their growth was hindered by political conflict. Subsequently, policies began to incorporate priorities such as nutrition security, comparative advantage, competitiveness, climate change adaptation, agrobiodiversity conservation, and sustainability. However, with the federalization of the state and establishment of a three-tier governance system in 2015, agriculture policies, priorities and strategies a became fragmented, diversified, and localized, and lack harmonization. This review demonstrates that agriculture policies were largely influenced by domestic political developments and structural changes at the international level. Nonetheless, a consistent focus on increasing production and productivity, as well as achieving food security and self-sufficiency, can be observed.. Throughout all policy periods, supply chain development, a crucial component of agribusiness, received limited prioritization, which remains a major impediment to agricultural transformation. Despite seven decades of policy evolution, Nepal has been unable to create an enabling policy environment to attract significant private and cooperative sector investments that could drive substantial growth in agribusiness. This situation calls for further research in the field of policy formulation capacity among the three tiers of government to foster agribusiness and promote supply chain development for agricultural transformation.

Managing water scarcity via rainwater harvesting system in Kathmandu Valley, Nepal: People's awareness, implementation challenges and way forward

More than 750 million people in developing countries do not have access to better water sources and over 2.6 billion people lack basic sanitation. Transition towards more sustainable urban water management is an urgent need because supply of water in rapidly urbanized areas like the Kathmandu Valley (KV) of Nepal is deficient. Supporting such a transition requires the development of alternative methods such as rainwater harvesting (RWH) system, recycling, desalination, wastewater reuse, etc. Using semi-structured questionnaires for 403 households (203 users and 200 non-users of the RWH system) of KV, this study critically examines the major developments taken place in Nepal in the RWH system, measures the RWH awareness index, identifies the implementation challenges and provides managerial solutions. Measuring the awareness index in users and the non-users of the RWH system in terms of the four dimensions (financial, socio-environmental, technical and institutional), we found that the user groups are more aware of the issues of water and climate change (CC) than the non-users. Around 70% of our respondents suggested that the scarcity of water, user's self-commitment and cost-friendly technology, among others can help to address the RWH system challenges. Possible reasons of differences in attitude, behaviors and perceptions of RWH system users and non-users are discussed and managerial solutions are provided. Promoting the use of rainwater harvesting in the KV would require a multi-stakeholder approach that involves collaboration between the government, NGOs, and the private sector to create an enabling policy environment and provide the necessary resources to promote and scale up rainwater harvesting initiatives.

Opportunity and Survival in the Urban Informal Food Sector of Namibia

Literature on participation in the informal food sector in cities of the Global South is conventionally characterized by a survivalist or opportunistic perspective. The main difference is that opportunists, in contrast to survivalists, are motivated by entrepreneurial choice rather than necessity and see opportunities for economic and social advancement in the sector. Recent studies in Brazil and India conclude that research on informal sector participation requires a “both/and” rather than “either/or” approach. The main problem this paper addresses is whether the “both/and” model is also applicable in the African context. This is the first study to investigate the issue in the informal food sector of an African city; in this case, the capital city of Namibia, Windhoek. The paper evaluates five potential ways of distinguishing between survivalist and opportunistic food vendors and concludes that entrepreneurial motivation (EM) provides the most useful set of metrics. Selected EM responses are then used to construct four regression models—two survivalist and two opportunistic—in order to determine which individual and business characteristics are most strongly and consistently associated with survivalism and opportunism. Few vendors are both survivalist and opportunistic in orientation. There is a possibility of survivalists becoming more opportunistic over time but the models do not confirm this hypothesis. Apart from differences in EM, there are many similarities between the two groups and both would therefore benefit from a more enabling policy environment. The primary distinguishing business characteristic is the enterprise type with street food vendors most likely to be opportunistic. Ironically, it is street vendors who are seen as unsightly, unhealthy, and uncontrollable, and face the most difficult operating environment.

"We just have to help": Community health workers' informal task-shifting and task-sharing practices for hypertension and diabetes care in Nigeria.

Nigeria's skilled health professional health workforce density is insufficient to achieve its national targets for non-communicable diseases (NCD) which include 25% reduction in the prevalence of diabetes and hypertension, particularly at the primary health care (PHC) level. This places a great demand on community health workers (CHWs) who constitute the majority of PHC workers. Traditionally, CHWs are mainly involved in infectious diseases programmes, and maternal and child health services. Their involvement with prevention and control of NCDs has been minimal. With government prioritization of PHC for combating the rising NCD burden, strengthening CHWs' skills and competencies for NCD care delivery is crucial. We conducted a mixed methods study to explore the roles and practices of CHWs in the delivery of hypertension and diabetes care at PHC facilities in four states (two each in northern and southern regions) in Nigeria. We reviewed the National Standing Orders that guide CHWs' practices at the PHC facilities and administered a survey to 76 CHWs and conducted 13 focus groups (90 participants), and in-depth individual interviews with 13 CHWs and 7 other local and state government stakeholders. Overall, we found that despite capacity constraints, CHWs frequently delivered services beyond the scope of practice stipulated in the National Standing Orders. Such informal task-shifting practices were primarily motivated by a need to serve the community. While these practices may partially support health system functions and address unmet need, they may also lead to variable care quality and safety. Several factors could mitigate these adverse impacts and strengthen CHW roles in the health system. These include a stronger enabling policy environment to support NCD task-sharing, investment in continuous capacity building for CHWs, improved guidelines that can be implemented at the point of care, and improved coordination processes between PHC and higher-level facilities.