Where regulation is weak, medicine transactions can be characterised by uncertainty over the drug quality and efficacy, with buyers shouldering the greater burden of risk in exchanges that are typically asymmetric. Drawing on in-depth interviews (N = 220) and observations of medicine transactions, plus interviews with regulators (N = 20), we explore how people in Ghana negotiate this uncertainty and come to trust a medicine enough to purchase or ingest it. We identify two mechanisms – attempts to mitigate uncertainty through seeking observable signs of quality and attempts to reduce informational asymmetry – that underpin cognitive assessments of a medicine's trustworthiness. However, these ‘cognitive’ forms of trust assessment have limited traction where uncertainty is high and trustworthiness remains unknowable, so a third mechanism comes into play: one based on affective relationships within which transactions are socially embedded. Even these, however, cannot eliminate uncertainty, because of the dispersed and under-regulated nature of wider supply chains. In conclusion, we reflect on the need for careful research on actors' practices and decision-making across supply chains to inform more effective policy and regulation.

In contexts where healthcare regulation is weak and levels of uncertainty high, how do patients decide whom and what to trust? In this paper, we explore the potential for using Signalling Theory (ST, a form of Behavioural Game Theory) to investigate health-related trust problems under conditions of uncertainty, using the empirical example of ‘herbal clinics’ in Ghana and Tanzania. Qualitative, ethnographic fieldwork was conducted over an eight-month period (2015–2016) in eight herbal clinics in Ghana and ten in Tanzania, including semi-structured interviews with herbalists (N = 18) and patients (N = 68), plus detailed ethnographic observations and twenty additional key informant interviews. The data were used to explore four ST-derived predictions, relating to herbalists' strategic communication (‘signalling’) of their trustworthiness to patients, and patients' interpretation of those signals. Signalling Theory is shown to provide a useful analytical framework, allowing us to go beyond the primary trust problem addressed by other researchers – cataloguing observable indicators of trustworthiness – and providing tools for tackling the trickier secondary trust problem, where the trustworthiness of those indicators must be ascertained. Signalling Theory also enables a basis for comparative work between different empirical contexts that share the underlying condition of uncertainty.

In 2012, the WHO launched its Global Surveillance and Monitoring System (GSMS) for substandard and falsified medicines, with the aim of improving the quality of reporting and using the data to inform post-market surveillance and build regulatory capacity. However, from a regulatory governance perspective, its effectiveness depends on the willingness and ability of actors ‘on the ground’ to identify, report and investigate possible infringements and to enforce penalties. This paper presents findings from 27 interviews with representatives of agencies charged with regulating pharmaceutical markets and 4 interviews with pharmaceutical industry representatives in Tanzania. Their experiences provide important insights into how the theorised mechanism between reporting and a reduction in undesirable behaviours can play out in a low-income context, revealing hidden assumptions about regulator behaviour and motivations. A combination of chronic under-resourcing, information gaps and enforcement challenges conspires to limit the efforts of local regulators to achieve the GSMS goals, shedding new light on the relationship between apparent ‘misconduct’ and structural constraints.

An affirmative action programme, established by the Fair Employment (Northern Ireland) Act 1989, has been an important attempt to ensure 'fair participation' in employment for both Catholics and Protestants in Northern Ireland since 1990. The programme includes detailed monitoring of the community background of employees and requires employers to undertake remedial action where fair participation is not evident. Agreements were concluded between the regulatory agency and many employers specifying what affirmative action measures were required. Based on the annual monitoring returns submitted between 1990 and 2005, this article evaluates the effectiveness of the affirmative action programme in promoting fair employment participation using fixed effects models. The analysis shows that there has been a general shift towards workforce integration in Northern Ireland but the increase of under-represented groups in agreement concerns is greater than in concerns with no agreement. The success of agreements, however, is limited to certain industrial sectors and medium-sized enterprises. © The Author(s) 2012

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