Distribution of informal caregiving for older adults living with or at risk of cognitive decline within and beyond family in rural South Africa.

Objectives: Aging populations in rural areas of low and middle-income countries will increasingly need care. However, formal support is severely limited and adult children are frequently unavailable due to morbidity, early mortality, employment and migration. We aimed to describe how care is shared within and between households for older adults in a rural South African setting. Methods: We conducted quantitative interviews with 1012 household members and non-household caregivers of 106 older adults living with or at risk of cognitive decline in rural Mpumalanga, South Africa. Using descriptive statistics and regression analysis, we described how care is shared, with particular attention to generational patterns of care. Results: Informal care for older persons was spread among family, friends, and neighbours, with minimal paid support. This care was mostly provided by female relatives one or two generations younger than the recipient, and unemployed. However, a smaller number of paid caregivers, also mostly female, provided the most intensive care. Spouses commonly took on the role of primary caregiver for their partner. Discussion: In our study, care mainly came from household members due to close family ties and practical considerations, with support from outside the household. This reflects shared history, reciprocal relationships, and easy access to care tasks within the household. A deeper understanding of how informal care for older adults is shared in low- and middle-income countries is essential for developing targeted interventions.

Access to assisted reproductive technologies in sub-Saharan Africa: fertility professionals' views.

Across sub-Saharan Africa, there remains disagreement among local expert providers over the best ways to improve access to assisted reproduction in low-income contexts. Semi-structured qualitative interviews were conducted between 2021 and 2023 with 19 fertility specialists and 11 embryologists and one clinic manager from South Africa, Zimbabwe, Namibia, Kenya, Ethiopia and Uganda to explore issues surrounding access and potential low-cost IVF options. Lack of access to ART was variously conceptualised as a problem of high cost of treatment; lack of public funding for medical services and medication; poor policy awareness and prioritisation of fertility problems; a shortage of ART clinics and well-trained expert staff; the need for patients to travel long distances; and over-servicing within the largely privatised sector. All fertility specialists agreed that government funding for public sector assisted reproduction services was necessary to address access in the region. Other suggestions included: reduced medication costs by using mild stimulation protocols and oocyte retrievals under sedation instead of general anaesthetics. Insufficient data on low-cost interventions was cited as a barrier to their implementation. The lack of skilled embryologists on the continent was considered a major limitation to expanding ART services and the success of low-cost IVF systems. Very few specialists suggested that profits of pharmaceutical companies or ART clinics might be reduced to lessen the costs of treatments.

This is a qualitative study involving interviews conducted between 2021 and 2023 with 19 fertility specialists and 11 embryologists and one clinic manager from South Africa, Zimbabwe, Namibia, Kenya, Ethiopia and Uganda to explore issues surrounding access and potential low-cost IVF options. The study found that across sub-Saharan Africa, clinical providers disagree over the best ways to provide assisted reproduction to improve access and affordability while maintaining high standards of care in low-income contexts. The lack of political, human resource and professional support to succeed in sub-Saharan Africa inhibits the implementation of low-cost initiatives to improve access and affordability. The study affirms the importance of giving more attention to infertility care in sub-Saharan Africa and increasing access and affordability of ARTs in the public health sector; the further development of national policies and professional guidelines; the need for more studies to evaluate low-cost initiatives; clarification of existing controversies about these initiatives; and the need for more training for embryologists in SSA.

Speaking of Hunger: Food Shortages, Poverty and Community Assistance in Urban South Africa.

How people speak of hunger extends beyond statements about food adequacy; people's remarks may reflect experiences of poverty and feelings of vulnerability, and may be used to request help. In this article, we build on the idea of idioms of distress to conceptualize hunger talk as expressing more than an empty belly. We draw on ethnographic data gathered in two settings in South Africa: one a peri-urban area under traditional jurisdiction in the Eastern Cape Province; the other an inner-city suburb of the largest city, Johannesburg, in Gauteng. Hunger-related idioms of distress help illustrate the complex interplay of social, economic, and cultural factors, and allow people to speak of various affective and material aspects of their lives.

Gender and equity considerations in AMR research: a systematic scoping review.

Research on gender and antimicrobial resistance (AMR) beyond women's biological susceptibility is limited. A gender and equity lens in AMR research is necessary to promote gender equality and support the effectiveness, uptake, and sustainability of real-world AMR solutions. We argue that it is an ethical and social justice imperative to include gender and related intersectional issues in AMR research and implementation. An intersectional exploration of the interplay between people's diverse identities and experiences, including their gender, socio-economic status, race, disability, age, and sexuality, may help us understand how these factors reinforce AMR risk and vulnerability and ensure that interventions to reduce the risk of AMR do not impact unevenly. This paper reports on the findings of a systematic scoping review on the interlinkages between AMR, gender and other socio-behavioural characteristics to identify priority knowledge gaps in human and animal health in LMICs. The review focused on peer-reviewed and grey literature published between 2017 and 2022. Three overarching themes were gendered division of caregiving roles and responsibilities, gender power relations in decision-making, and interactions between gender norms and health-seeking behaviours. Research that fails to account for gender and its intersections with other lines of disadvantage, such as race, class and ability, risks being irrelevant and will have little impact on the continued and dangerous spread of AMR. We provide recommendations for integrating an intersectional gender lens in AMR research, policy and practice.

Conceptualisations of "good care" within informal caregiving networks for older people in rural South Africa.

Good care in social policy statements is commonly implied as familial and person-centred, provided by family members and focused on upholding the autonomy, dignity and respect of the care recipient. Policy consideration of the relational nature of caregiving, the sociomaterial determinants of good care, the practical knowledge of caregivers and responsibilities of the state, is limited. Drawing on the ethics of care theory and a care ecology framework, which conceptualises the dynamic interactions between formal and informal care "systems," we analysed ethnographic data of the interactions of 21 caregivers and their older care recipients in South Africa to understand how they conceptualised good care. Conceptualisations of good care included: having the right, altruistic and reciprocal, motivations; providing care frequently and consistently; and demonstrating hope for a better future through practical action. Caregivers also considered restricting autonomy a feature of good care, when doing so was perceived to be in the care recipient's best interest. Conceptualisations of good care were influenced by but also countered policy and cultural ideals. When they subverted policy values and practices, by overriding autonomy, for instance, caregivers' conceptualisations reflected their practical experiences of caregiving amidst gross material inadequacies, underpinned by deficiencies in the formal care system. We highlight the need for policies, interventions and theories of care that focus broadly on the care ecology and particularly on the "carescape" (formal care system). We advocate relational approaches that consider and balance the needs, desires and rights of caregivers and care recipients, and recognise caregivers' experiential knowledge, rather than person-centred approaches that focus exclusively on the care recipient.

Ethnographic understandings of sexual and reproductive health and HIV care for adolescents in Blantyre, Malawi.

Sexual and reproductive health (SRH) care and support are provided to adolescents living with HIV, with the aim to build safer sex negotiation skills, sexual readiness and reproductive preparedness while reducing unintended pregnancies and sexually transmitted infections. We consider how different settings might either constrain or facilitate access to resources and support. Ethnographic research was conducted in Malawi in teen club clinic sessions at an enhanced antiretroviral clinic from November 2018 to June 2019. Twenty-one individual and five group interviews were conducted with young people, caregivers, and healthcare workers, and were digitally recorded, transcribed, and translated into English for thematic analysis. Drawing on socio-ecological and resilience theories, we considered the different ways in which homes, schools, teen club clinics, and community settings all functioned as interactional, relational, and transformational spaces to allow young people to talk about and receive information on sexuality and health. Young people perceived that comprehensive SRH support enhanced their knowledge, sexual readiness, and reproductive preparedness. However, their desire to reproduce at an early age complicated their adoption of safer sex negotiation skills and SRH care. Engaging and talking about SRH and related issues varied according to physical and social space, suggesting the value of multiple locations for support and resources for young people with HIV.

Addressing coloniality of power to improve HIV care in South Africa and other LMIC.

We describe the appropriateness and potential for effectiveness of three strategic approaches for improving HIV care in South Africa: community-based primary healthcare, local/community-based stakeholder engagement, and community-engaged research. At their core, these approaches are related to overcoming health inequity and inequality resulting from coloniality of power's heterogenous structural processes impacting health care in many low- and middle-income countries (LMIC). We turn to South Africa, a middle-income country, as an example. There the HIV epidemic began in the 1980s and its ending is as elusive as achieving universal healthcare. Despite impressive achievements such as the antiretroviral treatment program (the largest in the world) and the country's outstanding cadre of HIV experts, healthcare workers and leaders, disadvantaged South Africans continue to experience disproportionate rates of HIV transmission. Innovation in global public health must prioritize overcoming the coloniality of power in LMIC, effected through the imposition of development and healthcare models conceived in high-income countries (HIC) and insufficient investment to address social determinants of health. We advocate for a paradigm shift in global health structures and financing to effectively respond to the HIV pandemic in LMIC. We propose ethically responsive, local/community-based stakeholder engagement as a key conceptual approach and strategy to improve HIV care in South Africa and elsewhere. We join in solidarity with local/community-based stakeholders' longstanding efforts and call upon others to change the current status quo characterized by global public health power concentrated in HIC.

Risk, lifestyle and non-communicable diseases of poverty.

Common discourse in public health and preventive medicine frames non-communicable diseases, including cardiovascular and metabolic diseases, as diseases of 'lifestyle'; the choice of terminology implies that their prevention, control and management are amenable to individual action. In drawing attention to global increases in the incidence and prevalence of non-communicable disease, however, we increasingly observe that these are non-communicable diseases of poverty. In this article, we call for the reframing of discourse to emphasize the underlying social and commercial determinants of health, including poverty and the manipulation of food markets. We demonstrate this by analysing trends in disease, which indicate that diabetes- and cardiovascular-related DALYS and deaths are increasing particularly in countries categorized as low-middle to middle levels of development. In contrast, countries with very low levels of development contribute least to diabetes and document low levels of CVDs. Although this might suggest that NCDs track increased national wealth, the metrics obscure the ways in which the populations most affected by these diseases are among the poorest in many countries, and hence, disease incidence is a marker of poverty not wealth. We also illustrate variations in five countries - Mexico, Brazil, South Africa, India and Nigeria - by gender, and argue that these differences are associated with gender norms that vary by context rather than sex-specific biological pathways.We tie these trends to shifts in food consumption from whole foods to ultra-processed foods, under colonialism and with continued globalization. Industrialization and the manipulation of global food markets influence food choice in the context of limited household income, time, and household and community resources. Other factors that constitute risk factors for NCDs are likewise constrained by low household income and the poverty of the environment for people with low income, including the capacity of individuals in sedentary occupations to engage in physical activity. These contextual factors highlight extremely limited personal power over diet and exercise. In acknowledging the importance of poverty in shaping diet and activity, we argue the merit in using the term non-communicable diseases of poverty and the acronym NCDP. In doing so, we call for greater attention and interventions to address structural determinants of NCDs.

Social innovation in health: strengthening Community Systems for Universal Health Coverage in rural areas.

BACKGROUND: In seeking the attainment of Universal Health Coverage (UHC), there has been a renewed emphasis on the role of communities. This article focuses on social innovation and whether this concept holds promise to enhance equity in health services to achieve UHC and serve as a process to enhance community engagement, participation, and agency. METHODS: A cross-country case study methodology was adopted to analyze three social innovations in health in three low- and middle-income countries (LMICs): Philippines, Malawi, and Colombia. Qualitative methods were used in data collection, and a cross-case analysis was conducted with the aid of a simplified version of the conceptual framework on social innovation as proposed by Cajaiba-Santana. This framework proposes four dimensions of social innovation as a process at different levels of action: the actors responsible for the idea, the new idea, the role of the institutional environment, and the resultant changes in the health and social system. RESULTS: The study found that each of the three social innovation case studies was based on developing community capacities to achieve health through community co-learning, leadership, and accountability. The process was dependent on catalytic agents, creating a space for innovation within the institutional context. In so doing, these agents challenged the prevailing power dynamics by providing the communities with respect and the opportunity to participate equally in creating and implementing programs. In this way, communities were empowered; they were not simply participants but became active agents in conceptualizing, implementing, monitoring, and sustaining the social innovation initiatives. CONCLUSION: The study has illustrated how three creative social innovation approaches improved access and quality of health services for vulnerable rural populations and increased agency among the intervention communities. The processes facilitated empowerment, which in turn supported the sustained strengthening of the community system and the achievement of community goals in the domain of health and beyond.

Containing COVID-19 and the social costs on human rights in African countries.

Multiple social interventions were introduced to contain the COVID-19 pandemic across Africa, limiting social engagement, school and workplace attendance, and travel. In anticipation of negative economic consequences and social impact, many governments introduced cash transfers, social pensions, food aid, and utility and tax waivers. However, people living precariously and/or under conditions of structural vulnerability were often unable to access to this support. A rapid review was undertaken on COVID-19 and the effects of interventions on human rights in African countries, examining primary studies, editorial notes, opinion papers, and literature reviews, with focus on qualitative approaches and discussions. In examining the links between health, human rights and non-pharmaceutical interventions on vulnerable populations, the review identified that: (1) people who were vulnerable were excluded from or not adequately represented in policy responses to COVID-19; (2) the precarious socio-economic conditions of these populations were not adequately addressed by dominant policy responses; and (3) only partial support was offered to those whose relationship with the state was ambiguous or conditional, so compromising human rights. Interactions between health, human rights, and underlying social and economic conditions amplified poor health and impoverishment of those who were already vulnerable. The challenge is to find a balance between stopping the spread of COVID-19 and the protection of human rights; to implement population-specific responses to supplement uniform public health responses; and to address causes (structural vulnerability) rather than symptoms. There is a need to plan rather than react to pandemics, and to co-construct interventions with rather than delivering instructions to populations. These recommendations serve as instruments to be considered when designing new policies, to incorporate a human rights perspective in responses to current and future pandemics.

Reproductive materialism and justice for women with abortion care needs in Uganda.

While reproductive health justice is often assumed to be inherent in reproductive health interventions, the nature of injustices, and the reasons for and mechanisms of concealment, are often unclear. In this article, we draw on an ethnography of priority setting and healthcare practice in eastern Uganda to illuminate these injustices and the mechanisms of concealement. We focus on discursive practices as the mechanisms through which power is activated and navigated, such that health practitioners are able to evade state surveillance and retribution. While language discourses conceal and normalise reproductive health injustices, discursive practices of care and priority setting enable reproductive controls to be navigated in ways that amplify these injustices and create new ones. In interventions, precarious conditions that impact women's reproductive health and living circumstances are often overlooked or concealed. We illustrate the convergence of biopower and necropolitical strategies to illuminate these conditions. Using the concept of reproductive materialism, we show how neoliberalism cultivates particular conditions of everyday life, in which populations are positioned as instruments for pecuniary motives, and normative controls are used to further financial gain.

The double-edged role of accessed status on health and well-being among middle- and older-age adults in rural South Africa: The HAALSI study.

Background: Social capital theory conceptualizes accessed status (the socioeconomic status of social contacts) as interpersonal resources that generate positive health returns, while social cost theory suggests that accessed status can harm health due to the sociopsychological costs of generating and maintaining these relationships. Evidence for both hypotheses has been observed in higher-income countries, but not in more resource-constrained settings.We therefore investigated whether the dual functions of accessed status on health may be patterned by its interaction with network structure and functions among an older population in rural South Africa. Method: We used baseline survey data from the HAALSI study ("Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa") among 4,379 adults aged 40 and older. We examined the direct effect of accessed status (measured as network members' literacy), as well as its interaction with network size and instrumental support, on life satisfaction and self-rated health. Results: In models without interactions, accessed status was positively associated with life satisfaction but not self-rated health. Higher accessed status was positively associated with both outcomes for those with fewer personal contacts. Interaction effects were further patterned by gender, being most health-protective for women with a smaller network and most health-damaging for men with a larger network. Conclusions: Supporting social capital theory, we find that having higher accessed status is associated with better health and well-being for older adults in a setting with limited formal support resources. However, the explanatory power of both theories appears to depending on other key factors, such as gender and network size, highlighting the importance of contextualizing theories in practice.

Reproductive travel to, from and within sub-Saharan Africa: A scoping review.

Scholarly interest in reproductive travel has increased in recent years, but travel within, to and from the African continent has received much less attention. We reviewed the literature on cross-border reproductive travel to and from countries of sub-Saharan Africa in order to understand the local forms of this trade. Access to fertility care remains deeply stratified, which is an ongoing concern in a region with some of the highest rates of infertility. We found a wide variety of reasons for reproductive travel, including a lack of trusted local clinics. Destinations were chosen for reasons including historical movements for medical treatment broadly, diasporic circulations, pragmatic language reasons, and ties of former colonial relations. We describe the unique tempos of treatment in the region, ranging from some intended parents staying in receiving countries for some years to the short-term contingent support networks that reprotravellers develop during their treatment and travel. Unique to the region is the movement of medical professionals, such as the 'fly-in, fly-out' clinic staff to deliver fertility care. Future research should include practices and movements to presently neglected 'reprohubs', particularly Kenya and Nigeria; the impact of pandemic-related lockdowns and border closures on the movements of intended parents, reproductive assistors and reproductive material; and the impact of low-cost protocols on treatment access within the region. This scoping review provides insight into the relevant work on cross-border reproductive care in sub-Saharan Africa, where a unique combination of access factors, affordability, and sociocultural and geopolitical issues fashion individuals' and couples' cross-border reproductive travel within, to and from Africa.

What factors shape quality of life for women affected by gynaecological cancer in South, South East and East Asian countries? A critical review.

BACKGROUND: Gynaecological cancers are among the most prevalent cancers worldwide, with profound effects on the lives of women and their families. In this critical review, we explore the impacts of these cancers on quality of life (QOL) of women in Asian countries, and highlight areas for future inquiry. METHODS: A systematic search of the literature was conducted in six electronic databases: Web of Science, Scopus, Global Health (CAB Direct), PsycINFO (Ovid), EBMR (Ovid), and Medline (Ovid). Screening resulted in the inclusion of 53 relevant articles reporting on 48 studies. RESULTS: Most studies were conducted in high and upper-middle income countries in East Asia and used quantitative approaches. Women had predominantly been diagnosed with cervical or ovarian cancer, and most had completed treatment. Four key interrelated domains emerged as most relevant in shaping QOL of women affected by gynaecological cancer: support, including identified needs, sources and forms; mental health, covering psychological distress associated with cancer, risk and protective factors, and coping strategies; sexual function and sexuality, focused on physiological, emotional and relational changes caused by gynaecological cancers and treatments, and the impacts of these on women's identities; and physical health, covering the physical conditions associated with gynaecological cancers and their impacts on women's daily activities. CONCLUSION: QOL of women affected by gynaecological cancer is shaped by their mental and physical health, support, and changes in sexual function and sexuality. The limited number of studies from lower- and middle-income countries in South and Southeast Asia highlights important knowledge gaps requiring future research.

Multiple factors shape the quality of life of women affected by gynaecological cancers in Asian countries as elsewhere. We identified 53 articles reporting on 48 studies, most conducted in high- and upper-middle income East Asian countries, with much less attention to women in lower income countries in South and Southeast Asia. Most studies used quantitative research methods to gain an understanding of the impact on women diagnosed with cervical or ovarian cancer who had completed treatment. Women's quality of life was shaped by their mental and physical health, their support needs, and the changes they experienced in sexual function and sexuality.

Protocol: the complexity of informal caregiving for Alzheimer's disease and related dementias in rural South Africa.

BACKGROUND:  With aging, many people develop Alzheimer's disease or related dementias (ADRD) as well as chronic physical health problems. The consequent care needs can be complicated, with heavy demands on families, households and communities, especially in resource-constrained settings with limited formal care services. However, research on ADRD caregiving is largely limited to primary caregivers and high-income countries. Our objectives are to analyse in a rural setting in South Africa: (1) how extended households provide care to people with ADRD; and (2) how the health and wellbeing of all caregivers are affected by care roles. METHODS:  The study will take place at the Agincourt health and socio-demographic surveillance system site of the MRC/Wits Rural Public Health and Health Transitions Research Unit in Mpumalanga Province, northeast South Africa. We will recruit 100 index individuals predicted to currently have ADRD or cognitive impairment using data from a recent dementia survey. Quantitative surveys will be conducted with each index person's nominated primary caregiver, all other household members aged over 12, and caregiving non-resident kin and non-kin to determine how care and health are patterned across household networks. Qualitative data will be generated through participant observation and in-depth interviews with caregivers, select community health workers and key informants. Combining epidemiological, demographic and anthropological methods, we will build a rich picture of households of people with ADRD, focused on caregiving demands and capacity, and of caregiving's effects on health. DISCUSSION:  Our goal is to identify ways to mitigate the negative impacts of long-term informal caregiving for ADRD when formal supports are largely absent. We expect our findings to inform the development of locally relevant and community-oriented interventions to improve the health of caregivers and recipients, with implications for other resource-constrained settings in both higher- and lower-income countries.

PROXEMICS, COVID-19, AND THE ETHICS OF CARE IN SOUTH AFRICA.

In South Africa, lockdown and its excesses have opened up questions on the limits of an ethics of care, whose ethics are privileged, how care is delivered, and what care means. We show how an ethics of proxemics and its operationalization as distance highlight everyday inequalities and limit the provision of care. Constraints on physical distancing in line with public health measures intended to limit the spread of the coronavirus echo the controls enforced under apartheid, showing how inequality is both embodied and legally entrenched.

Service Use and Resilience among Adolescents Living with HIV in Blantyre, Malawi.

INTRODUCTION: Adolescents living with HIV (ALHIV) experience social and health challenges that warrant the provision of services and relational support to build resilience. Little is known about how social, community and health services help. We examine formal and alternative service use by and resilience of ALHIV participating in an enhanced teen-club clinic (TCC) programme. DESCRIPTION: TCC is an adolescent-centred differentiated care model offering a 'one-stop-shop' for HIV/Sexual and Reproductive Health (SRH) services to ALHIV. A survey was conducted with 406 ALHIV to determine frequency of use and satisfaction with services. In addition, we conducted 26 in-depth interviews with ALHIV, 12 group discussions with 144 caregivers, and observations of workshops held for 35 health workers to capture multiple perspectives on service use and relational support systems for adolescent's wellbeing. DISCUSSION: About 70% of ALHIV were concurrently clients of three or more services. The multi-method analysis showed variations on risks, range of services, frequency of use and satisfaction. Interview data reflected complex factors influencing access to formal services, and caregivers and adolescents also sought alternative care from spiritual and traditional healers. CONCLUSION: Adolescent centred-approaches have the potential to enhance resilience promoting resources and outcomes. A multi-sectoral approach to service use and provision is critical to inform adolescent intervention programs and wellbeing.

Strengthening the Mentorship and Leadership Capacity of HIV/AIDS and Tuberculosis Researchers in South Africa.

Programs to increase emerging and established HIV and tuberculosis (TB) researchers' capacity to be more effective leaders and mentors are urgently needed in low- and middle-income countries (LMICs). Although conceptual frameworks of mentoring and mentoring toolkits have been developed by and for researchers in LMIC settings, few mentor training programs have been implemented and evaluated in these settings. We created, implemented, and evaluated a 9-month, certificate-level mentorship training program to strengthen the pipeline of HIV and TB researchers in South Africa. Differentiating features of the program included careful contextualization of mentorship tools and approaches, inclusion of a leadership curriculum to improve participant ability to work effectively in teams and organizations, and attention to processes that promote interinstitutional collaboration in mentorship. Twelve mid-career researchers graduated from the first cohort of the program. Among participants, we observed significant longitudinal improvement in mentorship competencies, increased numbers of network connections in multiple domains of collaboration, and high levels of satisfaction. We anticipate that the program description and results will be useful to researchers, research institutions, and funders seeking to build research mentorship and leadership capacity in LMIC settings.

Planetary healthy publics after COVID-19.

COVID-19 is a sign of a global malaise. The pandemic is an outcome of what we term a planetary dysbiosis, for which underlining drivers include inequality and the exploitation and extraction of human and non-human labours. The implication is that the usual fixes to outbreaks of infectious diseases (ie, surveillance, pharmaceutical measures, and non-pharmaceutical measures) will be insufficient without a thorough reappraisal of and investment in planetary health. Given the heterogeneity and diversity of environments and populations, we envisage these actions as a matter for the generation of new kinds of public, requiring widespread and multiple forms of engagement to generate lasting solutions. We use and extend the concept of healthy publics to suggest a movement that can start to reclaim planetary health as a collective and ongoing issue.

Community participation in the collaborative governance of primary health care facilities, Uasin Gishu County, Kenya.

INTRODUCTION: Community participation in the governance of health services is an important component in engaging stakeholders (patients, public and partners) in decision-making and related activities in health care. Community participation is assumed to contribute to quality improvement and goal attainment but remains elusive. We examined the implementation of community participation, through collaborative governance in primary health care facilities in Uasin Gishu County, Western Kenya, under the policy of devolved governance of 2013. METHODS: Utilizing a multiple case study methodology, five primary health care facilities were purposively selected. Study participants were individuals involved in the collaborative governance of primary health care facilities (from health service providers and community members), including in decision-making, management, oversight, service provision and problem solving. Data were collected through document review, key informant interviews and observations undertaken from 2017 to 2018. Audio recording, notetaking and a reflective journal aided data collection. Data were transcribed, cleaned, coded and analysed iteratively into emerging themes using a governance attributes framework. FINDINGS: A total of 60 participants representing individual service providers and community members participated in interviews and observations. The minutes of all meetings of five primary health care facilities were reviewed for three years (2014-2016) and eight health facility committee meetings were observed. Findings indicate that in some cases, structures for collaborative community engagement exist but functioning is ineffective for a number of reasons. Health facility committee meetings were most frequent when there were project funds, with discussions focusing mainly on construction projects as opposed to the day-to-day functioning of the facility. Committee members with the strongest influence and power had political connections or were retired government workers. There were no formal mechanisms for stakeholder forums and how these worked were unclear. Drug stock outs, funding delays and unclear operational guidelines affected collaborative governance performance. CONCLUSION: Implementing collaborative governance effectively requires that the scope of focus for collaboration include both specific projects and the routine functioning of the primary health care facility by the health facility committee. In the study area, structures are required to manage effective stakeholder engagement.