Browsing by Author "Grebe, Eduard"

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    A comparison of self-report and antiretroviral detection to inform estimates of antiretroviral therapy coverage, viral load suppression and HIV incidence in Kwazulu-Natal, South Africa
    (BioMed Central, 2017-09-29) Huerga, Helena; Shiferie, Fisseha; Grebe, Eduard; Giuliani, Ruggero; Farhat, Jihane B; Van-Cutsem, Gilles; Cohen, Karen
    Background: Accurately identifying individuals who are on antiretroviral therapy (ART) is important to determine ART coverage and proportion on ART who are virally suppressed. ART is also included in recent infection testing algorithms used to estimate incidence. We compared estimates of ART coverage, viral load suppression rates and HIV incidence using ART self-report and detection of antiretroviral (ARV) drugs and we identified factors associated with discordance between the methods. Methods: Cross-sectional population-based survey in KwaZulu-Natal, South Africa. Individuals 15–59 years were eligible. Interviews included questions about ARV use. Rapid HIV testing was performed at the participants’ home. Blood specimens were collected for ARV detection, LAg-Avidity HIV incidence testing and viral load quantification in HIV-positive individuals. Multivariate logistic regression models were used to identify socio-demographic covariates associated with discordance between self-reported ART and ARV detection. Results: Of the 5649 individuals surveyed, 1423 were HIV-positive. Median age was 34 years and 76.3% were women. ART coverage was estimated at 51.4% (95%CI:48.5–54.3), 53.1% (95%CI:50.2–55.9) and 56.1% (95%CI:53.5–58.8) using self-reported ART, ARV detection and both methods combined (classified as ART exposed if ARV detected and/or ART reported) respectively. ART coverage estimates using the 3 methods were fairly similar within sex and age categories except in individuals aged 15–19 years: 33.3% (95%CI:23.3–45.2), 33.8% (95%CI:23.9–45.4%) and 44.3% (95%CI:39.3–46.7) using self-reported ART, ARV detection and both methods combined. Viral suppression below 1000cp/mL in individuals on ART was estimated at 89.8% (95%CI:87.3–91.9), 93.1% (95%CI:91.0–94.8) and 88.7% (95%CI:86.2–90.7) using self-reported ART, ARV detection and both methods combined respectively. HIV incidence was estimated at 1.4 (95%CI:0.8–2.0) new cases/100 person-years when employing no measure of ARV use, 1.1/100PY (95%CI:0.6–1.7) using self-reported ART, and 1.2/100PY (95%CI:0.7–1.7) using ARV detection. In multivariate analyses, individuals aged 15–19 years had a higher risk of discordance on measures of ARV exposure (aOR:9.4; 95%CI:3.9–22.8), while migrants had a lower risk (aOR:0.3; 95%CI:0.1–0.6). Conclusions: In KwaZulu-Natal, the method of identifying ARV use had little impact on estimates of ART coverage, viral suppression rate and HIV incidence. However, discordant results were more common in younger individuals. This may skew estimates of ART coverage and viral suppression, particularly in adolescent surveys.
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    AIDS Conspiracy Beliefs and Unsafe Sex in Cape Town
    (Springer Verlag (Germany), 2011) Grebe, Eduard; Nattrass, Nicoli
    This paper uses multivariate logistic regressions to explore: (1) potential socio-economic, cultural, psychological and political determinants of AIDS conspiracy beliefs among young adults in Cape Town; and (2) whether these beliefs matter for unsafe sex. Membership of a religious organisation reduced the odds of believing AIDS origin conspiracy theories by more than a third, whereas serious psychological distress more than doubled it and belief in witchcraft tripled the odds among Africans. Political factors mattered, but in ways that differed by gender. Tertiary education and relatively high household income reduced the odds of believing AIDS conspiracies for African women (but not men) and trust in President Mbeki's health minister (relative to her successor) increased the odds sevenfold for African men (but not women). Never having heard of the Treatment Action Campaign (TAC), the pro-science activist group that opposed Mbeki on AIDS, tripled the odds of believing AIDS conspiracies for African women (but not men). Controlling for demographic, attitudinal and relationship variables, the odds of using a condom were halved amongst female African AIDS conspiracy believers, whereas for African men, never having heard of TAC and holding AIDS denialist beliefs were the key determinants of unsafe sex.
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    Civil society and the state in Uganda’s AIDS response
    (2014-07-06) Grebe, Eduard
    This paper investigates state-civil society relations in the Ugandan AIDS response through a critical exploration of the history of Uganda’s ‘multi-sectoral’ and ‘partnership’ approaches, particularly as it pertains to The AIDS Support Organisation (TASO). It finds that the Ugandan government’s reputation for successful prevention campaigns is not necessarily deserved, and that the effectiveness of civil society is limited by an authoritarian political culture. Despite these limitations, however, state-civil society partnership did contribute to the emergence of a relatively effective coalition for action against HIV/AIDS. Donors were essential in encouraging the emergence of this coalition, but have also inadvertently undermined the emergence of strong and independent civil society voices able to hold the Ugandan state accountable.
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    Civil society leadership in the struggle for AIDS treatment in South Africa and Uganda
    (2012) Grebe, Eduard; Nattrass, Nicoli
    This thesis is an attempt to theorise and operationalise empirically the notion of ‘civil society leadership’ in Sub-Saharan Africa. ‘AIDS leadership,’ which is associated with the intergovernmental institutions charged with coordinating the global response to HIV/AIDS, is both under-theorised and highly context-specific. In this study I therefore opt for an inclusive framework that draws on a range of approaches, including the literature on ‘leadership’, institutions, social movements and the ‘network’ perspective on civil society mobilisation. This framework is employed in rich and detailed empirical descriptions (‘thick description’) of civil society mobilisation around AIDS, including contentious AIDS activism, in the key case studies of South Africa and Uganda. South Africa and Uganda are widely considered key examples of poor and good leadership (from national political leaders) respectively, while the Treatment Action Campaign (TAC) and The AIDS Support Organisation (TASO) are both seen as highly effective civil society movements. These descriptions emphasise ‘transnational networks of influence’ in which civil society leaders participated (and at times actively constructed) in order to mobilise both symbolic and material resources aimed at exerting influence at the transnational, national and local levels.
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    Complexity and the human sciences: beyond reductionism and relativism
    (2011) Grebe, Eduard
    We are faced with a fundamental problem for any science of complexity. To render the complex world understandable it is necessary to simplify it, but how can we render the complex simple without losing that which is distinctive and interesting about it? If complex systems are indeed ‘irreducible’ and therefore cannot be represented in ‘simple’ analytical models (Cilliers, 1998:9), is scientific reflection on complex systems doomed to be uninteresting reductions that can never grasp what is truly important? And if we insist on the irreducibility of complexity, can we avoid superfi- cial accounts that are prone to relativist interpretations? This is a problem with which Paul was well-acquainted, which is why he dealt extensively with models of complex systems in his book, and also explicitly addressed their epistemological in his Inaugural Lecture “Do modest positions have to be weak?”. He seemed comfortable on the tightrope between reductionism on the one hand and paralysing relativism on the other.
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    Contingency, contestation and hegemony: The possibility of a non-essentialist politics of the left
    (SAGE Publications, 2010) Grebe, Eduard
    Two major developments of the last two decades have radically undermined traditional justifications of leftist politics: the failure of 20th-century `socialist' experiments, and what might be termed the deessentializing movement in contemporary philosophy. However, the social injustices that animated revolutionary thinkers in many respects remain, and some have arguably worsened in the era of globalized capitalism. This article investigates whether it is possible to articulate a new theoretical underpinning for progressive politics that nevertheless avoids the essentialist moves of Marxism. Ethico-political readings of Derrida - one of the most influential anti-essentialist thinkers - are compared to Ernesto Laclau's attempts at formulating a post-Marxist progressive politics built around the notions of `hegemony' and `radical democracy'. Laclau's intervention in the Marxist tradition is to deconstruct its traditional categories so as to take account of contingency; his intervention in deconstruction is to introduce what in this article is described as `contestation', so as to provide a more coherent account of the political. The article concludes that neither deconstruction nor radical democracy provides an adequate basis for poltical action, but that the latter's account of the political is a meaningful development of the theoretical schema articulated by the former and does point to the possibility of a non-essentialist progressive politics.
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    Development and social policy reform in Uganda: the slow emergence of a social protection agenda (1986-2014)
    (2014) Grebe, Eduard; Mubiru, John Bosco
    This paper provides a broad overview of the evolution of development and welfare policy-and the politics surrounding-it in Uganda, but focuses primarily on the increasing prominence of social protection, especially cash transfers, on the domestic political agenda. It analyses both how and why the development and social policy agendas almost fully excluded social protection prior to 2002, but then increasingly embraced it, especially since 2006. Non-contributory social assistance in the form of cash transfers have not traditionally played a significant role in Ugandan development and poverty reduction policy, with policymakers tending to focus on economic growth as a source of prosperity (expected to extend to all sections of society), with opponents seeing cash transfers (and social assistance more broadly) as unaffordable and counter-productive 'hand-outs' that create dependence on the state and disincentivise productive work. From the early 2000s donors, sections of the bureaucracy and civil society promoted cash transfers with limited success. But after 2006, systematic promotion of cash transfers started to bear fruit, and from 2010 a largely donor-funded cash transfer pilot scheme known as the Social Assistance Grants for Empowerment (SAGE) programme has been implemented in fourteen districts (with a fifteenth added in 2013). The paper describes the evolution of Ugandan development policy and highlight the political factors that have in the past been obstacles to social protection programmes featuring prominently on the development agenda (including the predominant socio-economic development paradigm, negative elite attitudes, resistance from conservative technocrats and lack of familiarity among key decision-makers) and examine how these have increasingly been overcome by the proponents of social protection. While donors have played a critical role in the promotion of social protection and cash transfers, other actors-including civil society and social development bureaucrats-and macropolitical factors (including electoral competition, changing international development discourse, emerging evidence from other countries, etc.), have also contributed to increased domestic political support. We conclude that the very existence of SAGE and the politics surrounding the pilot indicate a significant change in attitudes among a large proportion of policy-makers, including some historically sceptical technocrats, and political leaders, but that resistance is likely to continue from certain quarters and that the future of cash transfers remains uncertain.
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    Donor agenda-setting, bureaucratic advocacy and cash transfers in Uganda (2002-2013)
    (2014) Grebe, Eduard
    This paper focuses on donors and-in particular-bureaucrats as agents of change in welfare policy reform processes in Uganda between 2002 and 2013. It shows how donors managed to establish cash transfers on the development policy agenda (but failed to gain sufficient political support for implementation), and 'recruit' a group of supportive social development bureaucrats in the Ministry of Gender, Labour and Social Protection after 2002. From 2006, domestic political support increased markedly, in no small part owing to both continued donor support and bureaucratic advocacy. Bureaucrats increasingly became the frontline advocates of policy reform-acting both as the agents of a donor agenda and, increasingly, an autonomous constituency strongly supportive of cash transfers within the Ugandan state. This bureaucratic 'buy-in' was an essential contributor to the increasing prominence of cash transfers in policy debates and in securing political support for the eventual implementation of a cash transfer pilot scheme from 2010. These bureaucrats actively lobbied other sections of the bureaucracy and members of the political elite. The paper contends that they-with donor support-succeeded in constructing a coalition in support of cash transfers, comprising sections of the bureaucracy (including some finance and planning technocrats), civil society organisations and political leaders in both the legislature and executive. This coalition enjoyed sufficient influence to secure the approval and successful implementation of a cash transfer pilot, as well as to firmly establish a national tax-funded social pension on the domestic political agenda by 2013.
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    The evolution of social protection policy in Ghana’s ‘Fourth Republic’: Contributory social insurance reform and limited social assistance for the ‘extreme poor’ under NPP and NDC governments, 2000-2014
    (2015-08) Grebe, Eduard
    During the 2000s, Ghana introduced substantial social protection policy reforms. The contributory pensions system was reformed from a single statutory defined-benefit scheme and a colonial-era unfunded scheme for civil servants to a new system with additional mandatory and voluntary privately-administered ‘tiers’ augmenting the statutory scheme. A new contributory national health insurance scheme was introduced in 2003. Several forms of social assistance targeted at the (largely rural) poor, including a school feeding programme, ‘capitation grants’ to expand free primary education and the flagship Livelihood Empowerment Against Poverty (LEAP) cash transfer scheme were introduced. All of these reforms were initiated under John Kufuor (of the New Patriotic Party, NPP), who had defeated Jerry Rawlings (and his National Democratic Convention, NDC) in 2000. When the NDC returned to power in 2008, it continued the implementation of NPP-initiated reforms, modestly expanded cash transfers and maintained broadly similar economic and social policy.
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    Institutions of Integrity and the Integrity of Institutions: Integrity and ethics in the politics of developmental leadership
    (2011) Grebe, Eduard; Woermann, Minka
    In current debate, many developmental problems are attributed to the failure of leadership and, in particular, to the absence of either ‘ethical leadership’ or ‘integrity in leadership’. But what is ‘ethical leadership’? What is ‘developmental integrity’? How is it achieved? And what are the conditions for sustaining it? The existing research on these questions is limited, and the primary objective of this study is accordingly to develop a conceptual framework for thinking about integrity in developmental contexts, not only at the level of individual behaviour, but also at the level of institutions. The core argument is that integrity and ethical leadership for development is not simply a matter of defining and enforcing codes of conduct (or of combating corruption). Instead, developmental integrity is the outcome of the interaction between (1) individual integrity (i.e. the moral choices of individuals); (2) institutions of integrity (the moral ‘codes’ and norms of behaviour, including legal rules); and (3) the integrity of institutions (institutions that are coherent, perceived as legitimate and that effectively promote development). While the research is therefore primarily theoretical and conceptual, it is intended to help policy-makers think clearly about ethics and integrity in relation to developmental issues
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    Interpreting HIV diagnostic histories into infection time estimates: analytical framework and online tool
    (2019-10-26) Grebe, Eduard; Facente, Shelley N; Bingham, Jeremy; Pilcher, Christopher D; Powrie, Andrew; Gerber, Jarryd; Priede, Gareth; Chibawara, Trust; Busch, Michael P; Murphy, Gary; Kassanjee, Reshma; Welte, Alex
    Abstract Background It is frequently of epidemiological and/or clinical interest to estimate the date of HIV infection or time-since-infection of individuals. Yet, for over 15 years, the only widely-referenced infection dating algorithm that utilises diagnostic testing data to estimate time-since-infection has been the ‘Fiebig staging’ system. This defines a number of stages of early HIV infection through various standard combinations of contemporaneous discordant diagnostic results using tests of different sensitivity. To develop a new, more nuanced infection dating algorithm, we generalised the Fiebig approach to accommodate positive and negative diagnostic results generated on the same or different dates, and arbitrary current or future tests – as long as the test sensitivity is known. For this purpose, test sensitivity is the probability of a positive result as a function of time since infection. Methods The present work outlines the analytical framework for infection date estimation using subject-level diagnostic testing histories, and data on test sensitivity. We introduce a publicly-available online HIV infection dating tool that implements this estimation method, bringing together 1) curatorship of HIV test performance data, and 2) infection date estimation functionality, to calculate plausible intervals within which infection likely became detectable for each individual. The midpoints of these intervals are interpreted as infection time ‘point estimates’ and referred to as Estimated Dates of Detectable Infection (EDDIs). The tool is designed for easy bulk processing of information (as may be appropriate for research studies) but can also be used for individual patients (such as in clinical practice). Results In many settings, including most research studies, detailed diagnostic testing data are routinely recorded, and can provide reasonably precise estimates of the timing of HIV infection. We present a simple logic to the interpretation of diagnostic testing histories into infection time estimates, either as a point estimate (EDDI) or an interval (earliest plausible to latest plausible dates of detectable infection), along with a publicly-accessible online tool that supports wide application of this logic. Conclusions This tool, available at https://tools.incidence-estimation.org/idt/ , is readily updatable as test technology evolves, given the simple architecture of the system and its nature as an open source project.
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    Leaders, networks and coalitions in the AIDS response: A comparison of Uganda and South Africa
    (2009) Grebe, Eduard
    This paper examines the question of AIDS leadership in Africa by means of a comparative study of two prominent civil society organisations that have been leaders in their respective countries' AIDS responses: The AIDS Support Organisation (TASO) in Uganda and the Treatment Action Campaign (TAC) in South Africa. Since an effective AIDS response requires cooperative collective action on the part of a wide range of actors at all levels of society, AIDS leadership can be seen as the ability to mobilise successful AIDS response coalitions to overcome these complex collective action problems. While TASO and the TAC (and the contexts within which they operate) differ in important respects, the comparison can help us come to a number of general conclusions with respect to the conditions under, and process by which, effective AIDS response coalitions come about.
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    Networks of influence: A theoretical review and proposed approach to AIDS treatment activism
    (2008) Grebe, Eduard
    The topic of AIDS activism cuts across disciplines, is complex, under-theorised, and does not lend itself to neat theoretical explication. Furthermore, the story of the relationship between activism and the broad societal response to the HIV/AIDS epidemic is still emerging, is deeply contextual, and its analysis requires rich empirical description. But since such a project is necessarily shaped by prior theoretical assumptions, this paper reviews a set of potential approaches for their explicatory potential and ability to inform an ethically engaged discussion. These approaches are broadly categorised as the sociology of political contention (most specifically social movement theory) and the political philosophy of civil society (including notions of global civil society). The focus is on the transnational dimension of activism, which has been especially critical in AIDS activism. I argue for a network approach to political contention and for a conception of transnational networks as ’networks of influence’ that incorporate a wide range of actors, including (but not restricted to) the activists normally referred to in transnational advocacy networks. Such an approach is better able to account for the transnational dimension than traditional sociological approaches that exhibit a domestic and state-centric bias. Furthermore (following Keck and Sikkink), I propose a focus on transnational networks as formations that are capable of leveraging powerful actors, information flows and symbolic and accountability politics, but go beyond simplistic formulations such as the ’boomerang pattern’. I conclude that only such an approach — and a willingness to be guided by the empirical and historical reality of AIDS activism — will allow us to make sense of the phenomenon.
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    The politics of social protection in a competitive African democracy: Explaining social protection policy reform in Ghana (2000-2014)
    (2015-08) Grebe, Eduard
    The Kufuor (New Patriotic Party) administration of 2000-2008 implemented substantial reforms of the contributory social insurance system (including the introduction of a national health insurance scheme and a new ‘three tier’ pensions system), and introduced a range of social assistance schemes targeted at the ‘extreme poor’. This paper analyses the factors that drove policy reform and the broad cross-party consensus that emerged despite highly competitive elections. Electoral dynamics played a significant role, and this is reflected in the political ‘messaging’ and ‘branding’ of parties and candidates during election campaigns, although there is little evidence of the political salience of social protection. Other important factors include a complex set of ‘agendas’ from actors including domestic bureaucrats, international agencies and donors, as well as politicians. These interacted in complex ways with elite alignments that have favoured or worked against pro-poor policy reform at various stages. The paper draws on studies of election campaigns and political parties, electoral dynamics, the ‘political settlement’ in Ghana and public opinion data.
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    Prevalence and determinants of AIDS conspiracy and AIDS denialist beliefs and implications for risky sexual behaviour among young adults in Cape Town, South Africa
    (2010) Nattrass, Nicoli; Grebe, Eduard
    This paper explores the prevalence of AIDS conspiracy beliefs (about the origin of AIDS) and AIDS denialist beliefs amongst young adults in Cape Town. Since there is some evidence that AIDS conspiracy beliefs are associated with risky sex – in particular, a greater likelihood of reporting sex without a condom (Bogart & Thorburn Bird 2003; Bogart & Thorburn 2005) – the relationship between these beliefs and condom use is thoroughly investigated. It also explores the socio-economic correlates of these beliefs and the potential effect of civil society mobilisation around HIV/AIDS on both conspiracy and denial beliefs and on sexual behaviour. The data analysis was conducted on near-final data from the 2009 wave of the Cape Area Panel Study (CAPS). The dataset comprises 3 142 respondents between the ages of 19 and 35 from all races and income groups, but mostly Africans and Coloureds (42% and 49% of respondents respectively). To the best of our knowledge, this is the first analysis of its kind (apart from a preliminary analysis presented in October 2009, on which this paper is partly based) that is able to take into account both the race and class dimension of these beliefs and their implications for sexual behaviour (Nattrass 2009) and the first to investigate the relationship between the activities of the prominent South African AIDS activist organisation, Treatment Action Campaign (TAC), and conspiracy/denial beliefs as well as sexual risk-taking. The paper is also distinctive in separating out AIDS conspiracy beliefs (about the origin of AIDS) from AIDS denialist beliefs. This is because these beliefs do not necessarily fit logically together, and in any case appear to appeal to different social bases and ‘oppositional transcripts’.
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    Transnational mobilisation on access to medicines: The global movement around the imatinib mesylate case and its roots in the AIDS movement
    (2014) Grebe, Eduard; Low, Marcus
    Starting in 2006, a patent dispute emerged in India with significant implications for global access to medicine. An application by Novartis for a 'new formulation' patent on the beta crystalline form of the cancer drug imatinib mesylate was rejected. Novartis responded by challenging the legality of provisions designed to protect access to medicines in India's patent legislation. A global activist movement emerged in defence of these aspects of Indian patent legislation mainly because the challenge threatened access to medicine at a systemic level, given India's critical role as a supplier of generic medicines to developing countries. The mobilisation described in this paper exploited existing activist networks and broader 'networks of influence' built during prior campaigns conducted around access to antiretroviral drugs. AIDS activists consequently played a key role in the global mobilisation around the imatinib mesylate dispute, aimed at generating public outrage and political pressure against Novartis's challenge to Indian patent law. A critical 'broker' in these transnational networks is identified as the medical charity M�dicins sans Fronti�res (MSF), and specifically its dedicated medicines access campaign, which linked disparate activist groups together, disseminated information and mobilised AIDS activists across the world in support of the Indian patent flexibilities. In 2013 the Indian Supreme Court upheld the relevant sections of the law, representing a significant victory for the international medicines access movement. This movement illustrates the power of transnational mobilisation to help bring about 'moral consensus' and to deploy influence and social power at the global level sufficient to overcome substantial corporate power. But we also argue that both the emergence of the 'global AIDS movement' and the emergence of a transnational social movement around the imatinib mesylate dispute depended on a set of historical circumstances that are unlikely to persist and that the broader medicines access movement therefore faces significant challenges to its sustainability and future success.
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    Transnational networks of influence in South African AIDS treatment activism
    (2008) Grebe, Eduard
    It is often asserted that civil society participation contributes to successful HIV/AIDS policy formulation and implementation. However, the relationship between civil society advocacy or activism and the broader societal response is complex, under-theorised and probably varies significantly between countries. Any analysis of AIDS activism must therefore employ deeply contextual and rich empirical description. One of the world’s most prominent AIDS activist movements, the Treatment Action Campaign (TAC), emerged in South Africa, where the scale of the epidemic and the government’s resistance to evidence-based responses (such as antiretroviral treatment) resulted in the disease becoming highly politicised. The TAC is widely credited with the dramatic policy turnaround in South Africa. This study draws on a range of conceptual and theoretical frameworks — among them the sociology of social movements, the political philosophy of civil society and the study of ‘transnational advocacy networks’ to investigate the TAC’s operation and the source of its apparent success. It proposes a conception of transnational networks as ‘networks of influence’, including (but not limited to) the actors normally referred to in transnational advocacy networks. The study relies on extensive interviews with key TAC leaders, and offers a detailed account of the TAC’s building and leveraging of networks of influence to affect HIV/AIDS policy. These informal but robust networks have been built and maintained largely by a small group of key individuals within the organisation, and are often (but not always) built on strong ties of trust (sometimes predating participation in the TAC). Network participants include AIDS activists (particularly in the US), local and international scientists, individuals within allied civil society organisations, members of South Africa’s political elite and individuals within state institutions. It is concluded that these networks of influence are key to explaining the TAC’s success.
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    The Treatment Action Campaign's Struggle for AIDS Treatment in South Africa: Coalition-building Through Networks
    (Taylor and Francis, 2011) Grebe, Eduard
    The Treatment Action Campaign (TAC), South Africa's � and probably the world's � most prominent AIDS activist movement, emerged in the context of state-supported AIDS denialism and government resistance to evidence-based responses such as antiretroviral treatment. TAC's forceful campaigns against denialism and in favour of the provision of antiretroviral drugs are widely lauded and even credited with the dramatic policy turnaround in South Africa. This study draws on extensive interviews with TAC leaders and members to provide a detailed historical narrative of the emergence and impact of TAC, while employing a range of theoretical approaches to help explain its influence. It describes how TAC's founders drew on their experiences and networks from the anti-apartheid struggle to build the movement and construct new local and international support networks in order to gain influence. It concludes that TAC succeeded in leveraging 'networks of influence' (which also included scientists, bureaucrats and politicians) to contribute to the formation of a moral consensus on treatment access and the construction of an inclusive coalition that pursued policy change. DOI:? 10.1080/03057070.2011.608271