Relational Harm: On the Divisive Effects of Global Health Volunteering at a Hospital in Rural Zambia.

Drawing on ethnographic research at a hospital in rural Zambia, I show how the presence of white Christian medical volunteers from the United States damaged relations between local health workers and patients. Working from a position of economic and racial privilege, medical volunteers received praise from many patients and residents. However, these positive attitudes incited resentment among many Zambian health workers who felt that their own efforts and expertise were being undervalued or ignored. Focusing on these disrupted relationships, I argue that it is crucial to understand how global health volunteering can produce enduring forms of "relational harm".

Health by the people, again? The lost lessons of Alma-Ata in a community health worker programme in Zambia.

National community health worker (CHW) programmes were central to the vision of primary health care that emerged from the Alma-Ata declaration of 1978. CHWs were identified as agents who could offer basic medical treatment and promote community participation and empowerment. Despite the ambitions of this era, many national CHW programmes were neglected, starved of funding, or discontinued in the decades that followed. These programmes were difficult to sustain in a context of rising debt and structural adjustment, but they also suffered due to poor implementation and a lack of clarity about the role and identity of CHWs. Nevertheless, national CHW programmes have returned to the policy agenda in the past fifteen years and key figures and organisations within global health have begun to argue that they offer a way of strengthening health systems and achieving universal health coverage (UHC). Based on ethnographic research conducted between 2019 and 2020, this article examines a new national CHW programme that has been introduced in Zambia. However, as I show in this article, Zambia's new CHW programme has suffered from many of the same key problems that affected the programmes of the Alma-Ata era: insufficient funding, poor implementation, and a lack of clarity about the role of CHWs. This article shows how these mistakes have been repeated and asks why the lessons of the Alma-Ata era have been lost. Three central problems are identified: national CHW programmes continue to be underfunded and regarded as a "cheap" solution; global health organisations and actors today prioritise technical and quantitative approaches when they design and implement these programmes and therefore overlook the historical experiences and qualitative research of the past thirty years; and, finally, policymakers continue to gloss over the tensions and contradictions within the idea of the "community health worker" itself, creating unclear and unrealistic expectations for CHWs.

Ethics, policy, and politics: A reply to Ashraf et al.

In this reply to Ashraf et al.'s (2021) commentary, I defend my argument that the randomised control trial (RCT) conducted by Ashraf et al. has caused harm in Zambia. I engage with the central points made by Ashraf et al. (2021), but also discuss a broader issue that they chose not to address in their commentary: the politics and ethics of conducting RCTs in countries in the Global South and the political vision of economists who regard RCTs as a solution to poverty and global health problems.

Promising careers? A critical analysis of a randomised control trial in community health worker recruitment in Zambia.

This paper examines an influential randomised control trial (RCT) that aimed to identify how to recruit the best community health workers (CHWs) in Zambia. The economists who designed the RCT found that when they used job advertisement posters that emphasised future career prospects, they attracted applicants who were more "effective" health workers (according to various quantitative measures). The Zambian government accepted this policy advice and recruited thousands of new CHWs using posters that highlighted the career path available. However, since rolling out the programme nationally, the Zambian government has not built a career ladder into this position and the recruitment process has offered false hope to those who were selected. While acknowledging the responsibility of the Zambian government, this paper analyses the role of the RCT in this outcome. Drawing on ethnographic research and interviews conducted between 2019 and 2020, the paper shows how the RCT was flawed. The economists who designed the RCT framed it as a study of "bureaucrats" and "civil servants" and therefore overlooked crucial academic and policy debates about the distinctive role of CHWs - including the well-documented reluctance of governments to offer them careers. By failing to consider the political context of the CHW programme, the economists who designed the RCT provided policy advice that "worked" for the Zambian government in the short-term but which has ultimately been harmful to CHWs. Drawing on this case study, the paper contributes to the growing critical scholarship on RCTs and raises questions about whether these studies objectively improve policymaking, as many of their proponents claim.