Ownership Of Programs Research Articles

The politics and practice of initiating a public health postgraduate programme in three universities in sub-Saharan Africa: the challenges of alignment and coherence

BackgroundIn-country postgraduate training programme in low and middle income countries are widely considered to strengthen institutional and national capacity. There exists dearth of research about how new training initiatives in public health training institutions come about. This paper examines a south-south collaborative initiative wherein three universities based in Ethiopia, Rwanda and Mozambique set out to develop a local based postgraduate programme on health workforce development/management through partnership with a university in South Africa.MethodsWe used a qualitative case study design. We conducted semi-structured interviews with 36 key informants, who were purposively recruited based on their association or proximity to the programme, and their involvement in the development, review, approval and implementation of the programme. We gathered supplementary data through document reviews and observation. Thematic analysis was used and themes were generated inductively from the data and deductively from literature on capacity development.ResultsUniversity A successfully initiated a postgraduate training programme in health workforce development/management. University B and C faced multiple challenges to embed the programme. It was evident that multiple actors underpin programme introduction across institutions, characterized by contestations over issues of programme feasibility, relevance, or need. A daunting challenge in this regard is establishing coherence between health ministries’ expectation to roll out training programmes that meet national health priorities and ensure sustainability, and universities and academics’ expectations for investment or financial incentive. Programme champions, located in the universities, can be key actors in building such coherence, if they are committed and received sustained support. The south-south initiative also suffers from lack of long term and adequate support.ConclusionsAgainst the background of very limited human capacity and competition for this capacity, initiating the postgraduate programme on health workforce development/management proved to be a political as much as a technical undertaking influenced by multiple actors vying for recognition or benefits, and influence over issues of programme feasibility, relevance or need. Critical in the success of the initiative was alignment and coherence among actors, health ministries and universities in particular, and how well programme champions are able to garner support for and ownership of programme locally. The paper argues that coherence and alignment are crucial to embed programmes, yet hard to achieve when capacity and resources are limited and contested.

Preferences of livestock owners for sharing the cost of brucellosis control in Tajikistan

In the context of significant public health benefits of brucellosis control and shrinking public resources for livestock vaccination, this paper considers the willingness of small ruminant livestock owners to pay for vaccination of their animals against brucellosis. The willingness to pay is estimated through a binary choice contingent valuation approach using data from a rural household survey specially designed for this purpose. The survey was conducted in southern Tajikistan, one of its poorest regions, in March 2009. The study used a non-parametric method for estimating the willingness to pay and a parametric (Probit) model for identifying determinants. The results show that households, including poor households, were willing to pay for continuing vaccination of their sheep and goats against brucellosis. Controlling for other attributes of willingness to pay, there was practically no correlation between willingness to pay and household asset level. This means both poor and rich alike are willing to pay for the service. On the other hand, the results also show that the willingness to pay was comparatively higher in households with relatively higher levels of education of adult females. This suggests that an awareness campaign targeted at female members of households would enhance the ownership and coverage of cost recovery programs and should form an integral part of any efforts towards introducing financial participation from sheep and goat owners for brucellosis vaccination.

Community-Based Health Planning and Services Plus programme in Ghana: A qualitative study with stakeholders in two Systems Learning Districts on improving the implementation of primary health care.

BackgroundIn 1999, Ghana introduced the Community-Based Health Planning and Services (CHPS) as the key primary health care strategy. In this study, we explored the challenges, capacity development priorities, and stakeholder perspectives on improving the CHPS concept as it has been fraught with a myriad of challenges since its inception. Our study is the outcome of the national programme for strengthening the implementation of CHPS Initiative in Ghana (CHPS+) introduced in 2017.MethodsThis exploratory research was a qualitative study conducted in two Systems Learning Districts (SLDs) of CHPS+ in the Volta Region of Ghana from March to May, 2018. Four focus group discussions and two general discussions were conducted among 60 CHPS+ stakeholders made up of health workers and community members. Data analyses were conducted using conceptual content analysis. Statements of the participants were presented as quotes to substantiate the views expressed.ResultsNegative attitude, high attrition, inadequacy and unavailability of health professionals at post when needed were challenges associated with the health professionals. Late referrals, lack of proper community entry and engagement, non-availability of essential logistics, distance of CHPS compounds from communities, and inadequate funding were challenges associated with the health system. Lack of community ownership of the CHPS programme, lack of security at CHPS compounds, and late reporting of cases by the community members were also realised as challenges emanating from the community members. Priority areas for capacity development of health workers identified included logistics management, community entry and engagement, emergency delivery, managing referrals at the CHPS level, and resuscitation of newborns.ConclusionHealth-worker, community, and health systems-based challenges inhibit the implementation of CHPS in Ghana. Capacity development of health professionals and continuous community engagement are avenues that can improve implementation of the programme.

Accountability in development: from aid effectiveness to development ethics

ABSTRACTAdoption of the Millennium Development Goals triggered much discussion among donor states, multilateral institutions, and developing countries towards changing dysfunctional patterns of interaction that seemed to put the MDGs at risk from their inception. Initially in these high-level discussions, accountability was understood in a state-centric way, primarily as accountability to donors. This needed to be modified with the shift towards developing-country ownership of development strategies and programs. Yet an even greater change was in store when civil society organizations were included in the discussions, since their focus was on accountability to project-affected persons and communities. Hence a new and irreducible conception of accountability came on stage. I characterize this as accountability to the subjects of development and show how it is required and justified by development ethics, based on values of agency and justifiability. This results in a dual standard for accountability: reducing stakeholders’ vulnerability to harmful and inequitable outcomes, and ensuring the justifiability of development projects to affected persons and communities.

Health Care Systems in Africa: Achievements, Challenges and Policy Implications for Achieving Sustainable Development Goal 3

The overall objective of the study is analysis of the health outcomes and the challenges of the health care systems in Africa under the dominant neoliberal regimes. Despite the limitations of neoliberal policies, the health care outcomes in Africa have been encouraging: infant, under five, and maternal mortality rates have declined significantly, while access to maternal and child health care services, family planning and to skilled birth attendants has improved. However, African countries still have faced several challenges (i)rising non-communicable disease burden, (ii) inadequate governments' budgetary expenditures, (iii) high out-of-pocket payments, (iv) shortage of health professionals, (v) low quality health care services (vi) low client satisfaction with the services provided.In commercial-oriented health care systems of Africa, there is inverse health care in which the poor with the highest health care needs receive the lowest while the rich with the lowest health care needs but with the highest means receive the highest. In order reverse the situation and to achieve the health-related SDG 3by 2030, the following interventions are suggested (i)A shift from neoliberal policy stance to developmental state approach and ensure ownership and management of health programs that will enhance effectiveness of the health care systems and achievement of SDG3 by 2030. (ii) Enhancement of inclusive economic growth through increased investments so that African countries' governments will be able to allocate at least 5% GDP to the health care services which are accessible by all. (iii) Publically financed health care is the only means to achieve universal health coverage. To this end, expansion of fiscal space and increased budgetary expenditure on health care through mobilization of adequate domestic resources will eventually ensure achievement of SDG3.(iv) Introduction of mandatory health insurance to protect individuals from catastrophic expenditures while paving the way towards universal health coverage (v) Strengthening primary health care and ensure cost-effective and high impact interventions (vi) Increase public investment in health-related education to create awareness and as part of preventive measures for desired behavioral change among the public.(vii) External debt cancelation and rechanneling the proceeds to health care.

Effective Aid for Hitting the Bull's Eye Comment on "It's About the Idea Hitting the Bull's Eye": How Aid Effectiveness Can Catalyse the Scale-up of Health Innovations".

This article studies how six key aid effectiveness principles for "Hitting the bull’s eye" can bring about the scale up of maternal and newborn health (MNH) interventions. These key principles are based on accepted international agreements such as the Paris Declaration on Aid Effectiveness. The results indicate that the six principles should be a guide for recipient countries to take ownership of the development process and work with donors to plan effective coordination structures. Countries that take ownership will be able to work with donors and implementers to not only test new interventions that address pressing challenges to deliver quality MNH care but also include the successful knowledge transfer and handover of these interventions, the effective integration of the new intervention as part of the country’s health system and a costed scale-up plan. The article could have been strengthened with clear and actionable recommendations for the three countries to improve their ownership of donor-funded assistance, but it showed that there is need to change how aid is delivered and that embracing and applying these principles will help countries take ownership of MNH programs and lead the dialog and effective scale up with those involved. The authors should be commended on taking the lead in the field of aid effectiveness, and encouraged to conduct quantitative and further qualitative measurements of the application of their findings in the three counties included in the study.

Shock Therapy, Social Engineering, and Financial Discipline: What Does an Increasingly Financialized World Mean for Democratic Participation?

Over the last several decades, the Bretton Woods Institutions have come to be drivers of policy in the realms of economic liberalization and development, exceeding their original mandates of fostering monetary cooperation and facilitating post-war reconstruction. The structural adjustment programs of the World Bank and the International Monetary Fund have engendered mixed results–delivering some countries from financial crises, while inciting riots and compounding state failure in others. Such varied experiences suggest there is some disconnect between the conditions to lending promulgated by these institutions and the realities on the ground. This Note will trace the evolution of high conditionality lending vis-à-vis a number of nations and argue that a relationship between participatory democracy and structural adjustment programs should be forged in the interest of successful lending and authentic national ownership of programs.

Harmonization of community health worker programs for HIV: A four-country qualitative study in Southern Africa.

BackgroundCommunity health worker (CHW) programs are believed to be poorly coordinated, poorly integrated into national health systems, and lacking long-term support. Duplication of services, fragmentation, and resource limitations may have impeded the potential impact of CHWs for achieving HIV goals. This study assesses mediators of a more harmonized approach to implementing large-scale CHW programs for HIV in the context of complex health systems and multiple donors.Methods and findingsWe undertook four country case studies in Lesotho, Mozambique, South Africa, and Swaziland between August 2015 and May 2016. We conducted 60 semistructured interviews with donors, government officials, and expert observers involved in CHW programs delivering HIV services. Interviews were triangulated with published literature, country reports, national health plans, and policies. Data were analyzed based on 3 priority areas of harmonization (coordination, integration, and sustainability) and 5 components of a conceptual framework (the health issue, intervention, stakeholders, health system, and context) to assess facilitators and barriers to harmonization of CHW programs. CHWs supporting HIV programs were found to be highly fragmented and poorly integrated into national health systems. Stakeholders generally supported increasing harmonization, although they recognized several challenges and disadvantages to harmonization. Key facilitators to harmonization included (i) a large existing national CHW program and recognition of nongovernmental CHW programs, (ii) use of common incentives and training processes for CHWs, (iii) existence of an organizational structure dedicated to community health initiatives, and (iv) involvement of community leaders in decision-making. Key barriers included a wide range of stakeholders and lack of ownership and accountability of non-governmental CHW programs. Limitations of our study include subjectively selected case studies, our focus on decision-makers, and limited generalizability beyond the countries analyzed.ConclusionCHW programs for HIV in Southern Africa are fragmented, poorly integrated, and lack long-term support. We provide 5 policy recommendations to harmonize CHW programs in order to strengthen and sustain the role of CHWs in HIV service delivery.

Understanding the Process of Community Capacity-Building: A Case Study of Two Programs in Yunnan Province, China

Summary In recent decades, development discourse has increasingly acknowledged the importance of participation and ownership of development programs at the local level. As the discourse has advanced, terms such as community-driven development and community capacity-building (CCB) have become widely used and attracted significant funding. Yet, despite the prominent place CCB has come to occupy in development discourse and practice, relatively little attention has been given to the process of capacity-building at the level of the community, particularly as it is understood by key protagonists. The authors present a descriptive case-study of two CCB programs in Yunnan, China, examining how capacity is understood by the key protagonists at the level of individuals, institutions, and communities, and which capacities are identified as built at each level. The authors show that while there are expected differences in the perceptions of the CCB process and outcomes at different levels, there are also clear overlaps, and that capacities develop simultaneously at different levels, in an interactive and mutually reinforcing manner. The results suggest that the interconnection across levels may be very important to study further. This study helps fill a gap in the CCB literature and contributes insights that could improve the effectiveness of community development projects. In addition, it provides insight into the specific case of CCB in China, where literature has tended to focus on institutional capacity and relationships between civil society organizations and the government rather than process and outcomes at the community level.

Expanding youth employment in the Arab Region and Africa

The low level and adverse trends of youth employment in Africa and in the Middle East in the last decade are key driving factors of poverty, stress migration, frustration and political instability. There needs to be a sense of urgency to change the situation. How can employment, especially for youth, be created rapidly in these regions? The paper discusses different policies for the generation of mass employment of both skilled and unskilled labor. The sectoral priorities differ within the regions, with rural and agricultural jobs playing a more significant role in Sub-Saharan Africa (SSA). Both SSA and the Arab region show potentials for large scale public works programs. Un-orthodox economic policy actions are called for due to the pressing nature of the youth unemployment situation. These policies should aim at generating productive employment improving skills, and can be implemented both at the central and at the local level. Countries should be responsible for ownership, accountability and self-monitoring of policies and programs. Large scale international funding support should be considered when planning, implementation and supervision are actually credible and results oriented.

Expanding Youth Employment in the Arab Region and Africa

The low level and adverse trends of youth employment in Africa and in the Middle East in the last decade are key driving factors of poverty, stress migration, frustration and political instability. There needs to be a sense of urgency to change the situation. How can employment, especially for youth, be created rapidly in these regions? The paper discusses different policies for the generation of mass employment of both skilled and unskilled labor. The sectoral priorities differ within the regions, with rural and agricultural jobs playing a more significant role in Sub-Saharan Africa (SSA). Both SSA and the Arab region show potentials for largescale public works programs. Un-orthodox economic policy actions are called for due to the pressing nature of the youth unemployment situation. These policies should aim at generating productive employment improving skills, and can be implemented both at the central and at the local level. Countries should be responsible for ownership, accountability and self-monitoring of policies and programs. Large scale international funding support should be considered when planning, implementation and supervision are actually credible and results oriented.

"During early implementation you just muddle through": factors that impacted a statewide arthritis program's implementation.

The need to scale-up effective arthritis self-management programs is pressing as the prevalence of arthritis increases. The CDC Arthritis Program funds state health departments to work with local delivery systems to embed arthritis programs into their day-to-day work. To encourage organizational ownership and sustainability of programs, funding is restricted to offset program start-up costs. The purpose of this study was to identify factors that impacted the success of implementing an evidence-based arthritis self-management program, funded by the CDC Arthritis Program, into the Oregon Extension Service. We interviewed staff and partners involved in implementation who had and had not successfully delivered Walk With Ease (N=12) to identify barriers and facilitators to scaling-up. Document analysis of administrative records was used to triangulate and expand on findings. Delivery goals defined by the funder were not met in Year 1: only 3 of the expected 28 programs were delivered. Barriers to implementation included insufficient planning for implementation driven by pressure to deliver programs and insufficient resources to support staff time. Facilitators included centralized administration of key implementation activities and staffs' previous experience implementing new programs. The importance of planning and preparing for implementation cannot be overlooked. Funders, however, eager to see deliverables, continue to define implementation goals in terms of program reach, exclusive of capacity-building. Lack of capacity-building can jeopardize staff buy-in, implementation quality, and sustainability. Based on our findings coupled with support from implementation literature, we offer recommendations for future large-scale implementation efforts operating under such funding restrictions.

Alternative financing mechanisms for ART programs in health facilities in Uganda: a mixed-methods approach

BackgroundSub-Saharan Africa is heavily dependent on global health initiatives (GHIs) for funding antiretroviral therapy (ART) scale-up. There are indications that global investments for ART scale-up are flattening. It is unclear what new funding channels can bridge the funding gap for ART service delivery. Many previous studies have focused on domestic government spending and international funding especially from GHIs. The objective of this study was to identify the funding strategies adopted by health facilities in Uganda to sustain ART programs between 2004 and 2014 and to explore variations in financing mechanisms by ownership of health facility.MethodsA mixed-methods approach was employed. A survey of health facilities (N = 195) across Uganda which commenced ART delivery between 2004 and 2009 was conducted. Six health facilities were purposively selected for in-depth examination. Semi-structured interviews (N = 18) were conducted with ART Clinic managers (three from each of the six health facilities). Statistical analyses were performed in STATA (Version 12.0) and qualitative data were analyzed by coding and thematic analysis.ResultsMultiple funding sources for ART programs were common with 140 (72%) of the health facilities indicating at least two concurrent grants supporting ART service delivery between 2009 and 2014. Private philanthropic aid emerged as an important source of supplemental funding for ART service delivery. ART financing strategies were differentiated by ownership of health facility. Private not-for-profit providers were more externally-focused (multiple grants, philanthropic aid). For-profit providers were more client-oriented (fee-for-service, insurance schemes). Public facilities sought additional funding streams not dissimilar to other health facility ownership-types.ConclusionOver the 10-year study period, health facilities in Uganda diversified funding sources for ART service delivery. The identified alternative funding mechanisms could reduce dependence on GHI funding and increase local ownership of HIV programs. Further research evaluating the potential contribution of the identified alternative financing mechanisms in bridging the global HIV funding gap is recommended.

Human resources for health strategies adopted by providers in resource-limited settings to sustain long-term delivery of ART: a mixed-methods study from Uganda.

BackgroundHuman resources for health (HRH) constraints are a major barrier to the sustainability of antiretroviral therapy (ART) scale-up programs in Sub-Saharan Africa. Many prior approaches to HRH constraints have taken a top-down trend of generalized global strategies and policy guidelines. The objective of the study was to examine the human resources for health strategies adopted by front-line providers in Uganda to sustain ART delivery beyond the initial ART scale-up phase between 2004 and 2009.MethodsA two-phase mixed-methods approach was adopted. In the first phase, a survey of a nationally representative sample of health facilities (n = 195) across Uganda was conducted. The second phase involved in-depth interviews (n = 36) with ART clinic managers and staff of 6 of the 195 health facilities purposively selected from the first study phase. Quantitative data was analysed based on descriptive statistics, and qualitative data was analysed by coding and thematic analysis.ResultsThe identified strategies were categorized into five themes: (1) providing monetary and non-monetary incentives to health workers on busy ART clinic days; (2) workload reduction through spacing ART clinic appointments; (3) adopting training workshops in ART management as a motivation strategy for health workers; (4) adopting non-physician-centred staffing models; and (5) devising ART program leadership styles that enhanced health worker commitment.ConclusionsFacility-level strategies for responding to HRH constraints are feasible and can contribute to efforts to increase country ownership of HIV programs in resource-limited settings. Consideration of the human resources for health strategies identified in the study by ART program planners and managers could enhance the long-term sustainment of ART programs by providers in resource-limited settings.

Transitioning to Country Ownership of HIV Programs in Rwanda

Agnes Binagwaho and colleagues describe how Rwanda achieved country ownership of its HIV programs.

Country Ownership And Gavi Transition: Comprehensive Approaches To Supporting New Vaccine Introduction.

Since the mid-2000s low- and lower-middle-income countries have been focusing on developing and using evidence for immunization policy making, with an increasing emphasis on cost-effectiveness analysis, program costing, and financial flows-particularly for the introduction of newer, more expensive vaccines. While this is critical to informing decisions, countries still need to increase national immunization investment and explore innovative approaches to augment financing of immunization programs. The need for increased financing is especially strong in countries transitioning from support by Gavi, the Vaccine Alliance. With increased fiscal space to finance health and immunization programs as a result of improved economic performance, low- and lower-middle-income countries can reach the health status enjoyed by wealthier nations within a generation. However, new strategies and approaches related to domestic resources for immunization programs are needed to achieve this goal. Governments will need to increase their investments and modify existing external immunization financing arrangements if country ownership of immunization programs and the full promise of new vaccines are to be realized.

Routes Countries Can Take To Achieve Full Ownership Of Immunization Programs.

A goal of the Global Vaccine Action Plan, led by the World Health Organization, is country ownership by 2020, defined here as the point when a country fully finances its routine immunization program with domestic resources. This article reports the progress made toward country ownership in twenty-two lower- and lower-middle-income countries engaged in the Sabin Vaccine Institute's Sustainable Immunization Financing Program. We focus on new practices developed in the key public institutions concerned with immunization financing, budget and resource tracking, and legislation, using case studies as examples. Our analysis found that many countries are undertaking new funding mechanisms to reach financing goals. However, budget transparency remains a problem, as only eleven of the twenty-two countries have performed sequential analyses of their immunization program budgets. Promisingly, six countries (Cameroon, the Republic of the Congo, Nepal, Nigeria, Senegal, and Uganda) are creating new national immunization funding sources that are backed by legislation. Seven countries already have laws regarding immunization, and new immunization legislative projects are under way in thirteen others.

EPIC Studies: Governments Finance, On Average, More Than 50 Percent Of Immunization Expenses, 2010–11

Governments in resource-poor settings have traditionally relied on external donor support for immunization. Under the Global Vaccine Action Plan, adopted in 2014, countries have committed to mobilizing additional domestic resources for immunization. Data gaps make it difficult to map how well countries have done in spending government resources on immunization to demonstrate greater ownership of programs. This article presents findings of an innovative approach for financial mapping of routine immunization applied in Benin, Ghana, Honduras, Moldova, Uganda, and Zambia. This approach uses modified System of Health Accounts coding to evaluate data collected from national and subnational levels and from donor agencies. We found that government sources accounted for 27-95 percent of routine immunization financing in 2011, with countries that have higher gross national product per capita better able to finance requirements. Most financing is channeled through government agencies and used at the primary care level. Sustainable immunization programs will depend upon whether governments have the fiscal space to allocate additional resources. Ongoing robust analysis of routine immunization should be instituted within the context of total health expenditure tracking.

Listening to aid recipients in ‘aid-development’ debate: Findings from ‘the listening project’ and jerge-tal village in Kyrgyzstan

Foreign aid is an important aspect in understanding human development in aid-dependent societies. Original assessments of aid are generally based on the viewpoints of aid agencies, while the opinions of aid recipients often remain ignored. This perpetuates inconsistencies in understanding foreign aid, leaving a knowledge gap. In-depth analysis of aid efforts and recipients’ perceptions can shed light on the advantages/limitations of such aid, and enable appropriate development-oriented strategies. This article brings new empirics to bear on the foreign aid debate. It builds on ‘The Listening Project’ (LP), which has explored the ideas and insights of those on the receiving end of foreign aid. Inspired by “listening to people” approach, this article demonstrates the central importance of explicating empirical data and including such findings in the debate on foreign aid and development. Presenting empirical evidence on aid reception in the village of Jerge-Tal, Kyrgyzstan, the author examines whether and how feedback from aid recipients is in line with the patterns and recommendations of the LP. Both these studies add to the growing literature on foreign aid for development by virtue of “listening to aid recipients” in donor–recipient relations. The conducted benchmark analysis reveals that the characteristics of aid provisions in Jerge-Tal village comply with the patterns and common assessments discovered by ‘The Listening Project’. Key findings relate to greater opportunities for public participation, ownership and coordination of the aid programs and development projects. Aid recipients of LP stress the issues of appropriate knowledge on aid-recipient societies; of aid as “business model” with irrational allocation of budget and recruitment of recipients that creates “project societies” instead of the intended civil societies. The study of aid recipients in Jerge-Tal village brings an example of aid-recipient empowerment and participation in development achieved through cooperation with international and local aid agencies together with the Kyrgyz state. Potential policy implications refer to the fostering of collaborative activities between aid agencies, aid recipients and state institutions as a condition for effective aid management and coordination.

State Environmental Expenditures and Their Correlation with Seven Econometric Factors

Most states assume administrative ownership of federal environmental programs and tailor them to match their special jurisdictional needs. However, with primacy comes a performance obligation and, given declining federal EPA budgets and staffing levels, the monitoring and enforcement burdens associated with environmental regulations have shifted to the states. As the most visible regulatory and administrative force responsible for protecting the nation’s environment, the ability of state DEPs, DEQs, and DECs to effectively serve its citizens and constructively interact with the regulated community is critically dependent on the resources made available to it. Without adequate funding, the compliance and enforcement components of state environmental agency programs become mere paper tigers – threatening but ineffectual and without real substance. What factors influence the amount of spending states direct towards environmental programs? For the purposes of this paper, non-capital environmental expenditures between 2000 and 2009, adjusted to 2010 dollars, were chosen as the dependent variable for 49 states, exclusive of Hawaii because of its unique ecological and economic setting. Seven data sets were selected as independent variables; those possibly explaining or accounting for a state’s environmental spending choices. These include: population, total state expenditures, Gross State Product or GSP, the manufacturing and mining sectors of Gross State Product (M&M GSP), unemployment rates, total amounts (in pounds) of chemicals regulated by the Toxic Release Inventory (TRI) for discharges to air (fugitive and point source) and surface water, and health ranking score by state. A Pearson’s product moment correlation coefficient was used to compare environmental expenditures for each state with the seven data sets. Population (in 15 states), GSP (in 21 states), M&M GSP (in 12 states) and total state expenditures (in 17 states) are the independent variables that seem to have the most connection with environmental expenditures. Each of these ties directly to the overall financial capacity of a state and they are roughly split in defining positive and negative relationships between the variables.