Stakeholder perceptions of aid coordination implementation in the Zambian health sector

Results-Based Financing for Health: A Case Study of Knowledge and Perceptions Among Stakeholders in a Donor-Funded Program in Zambia

The lack of a fully developed results-based financing model before implementation of a program in the health sector begins can lead to difficulty in communicating about the program to different actors involved and delay components of implementation.

In 2015, the Zambian government and the Swedish International Development Cooperation Agency (Sida) signed an agreement in which Sida committed to funding a program for Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAH). The program includes a results-based financing (RBF) model that aims to reward Zambian districts for improved district-wide results on relevant indicators with additional funding. We aimed to describe stakeholders' knowledge of the RBF model and perceptions of the incentive structure during the first 18 months of the program's implementation. This study illuminates the possible pitfalls of implementing an RBF scheme without giving attention to all necessary steps of the process. A qualitative case study was used and included a review of documents, in-depth interviews, and observations. From February–April 2017, we conducted 37 in-depth interviews, representing the views of 12 development partner agencies, government departments, and health facility staff throughout Zambia. We used a qualitative framework analysis. Findings show that the Zambian government and Sida had different perceptions on what levels of the health system RBF will incentivize and that most districts and hospital administrators interviewed were unaware of the indicators that the RBF was part of the RMNCAH program at all. The lack of knowledge about the RBF scheme among respondents suggests the possibility that the model did not ultimately have the necessary preconditions to create an effective incentive structure. These results demonstrate the need for improved communication between stakeholders and the importance of sufficiently planning an RBF model before implementation.

Regional government concerns in health services in remote areas: Case study on special capitation policies in North Bengkulu Regency

The Minister of Health Regulation No. 52 of 2016 states that the tariff for first-level health services in remote areas and islands is determined based on special capitation tariffs, which is greater than the usual capitation tariffs. In North Bengkulu there is a primary health care that does not include a special capitation even though the criteria are the same as the primary health care that received it. The perception of stakeholders involved is needed to see whether the determination of criteria for disadvantaged areas for recipients of special capitation funds is in accordance with existing regulations or not.The study was based on in-depth interviews with 6 respondents from 6 institutions (Local Government, Regional Secretary, Health Office, the BPJS health branch office, and two Primary health care). The local government does not help question that matter to BPJS or help in other ways so that health care that do not receive special capitation funds can still provide optimal services like other remote health care. This study found the lack of socialization about health services in remote areas to non-health officials in local governments is the causes of weak support by local governments. This research shows that the application of central policies without joint review and verification with local stakeholders can lead to unproductive situations. Local governments should also look for solutions so that health care in remote areas that do not receive special capitation funds continue to run optimally.

Barriers to the National Onchocerciasis Control Programme at operational level in Cameroon: a qualitative assessment of stakeholders' views

Background

The global burden of onchocerciasis is the heaviest in sub-Saharan Africa. Studies have shown the importance of the role of Community-Directed Distributors (CDDs) and nurses in onchocerciasis control, but little is known about their experience in implementing onchocerciasis control programmes. Our aim was to document the barriers that CDDs and local health administrators face in implementing onchocerciasis control activities.

Methods

We conducted a qualitative survey consisting of 16 in-depth interviews and 8 focus group discussions (FGDs) across three health districts of Cameroon. We interviewed a total of 9 local health officials at the district and Health Area levels, and 7 CDDs. Eight FGDs were conducted with CDDs and Health Committee members.

Results

The major barriers to the implementation of Community Directed Treatment with Ivermectin that we identified were linked and interrelated. Examples of these barriers included: contextual factors (geographical and cultural background), top-to-bottom planning, insufficient human and material resources, and lack of transparency in the management of the programme’s funds.

Conclusions

The CDTI at operational level still faces many obstacles which negatively affect therapeutic coverages. This can lead to the non-adhesion of the communities to the programme, consequently jeopardizing the sustainability of the onchocerciasis elimination programme. We recommend that the national programme planners put in place a transparent management and planning system for onchocerciasis elimination activities, with better communication with local programme stakeholders.

Integrated primary health care in low- and middle-income countries: a double challenge

Background

The lack of primary healthcare integration has been identified as one of the main limits to programs’ efficacy in low- and middle-income countries. This is especially relevant to the Millennium Development Goals, whose health objectives were not attained in many countries at their term in 2015. While global health scholars and decision-makers are unanimous in calling for integration, the objective here is to go further and contribute to its promotion by presenting two of the most important challenges to be met for its achievement: 1) developing a “crosswise approach” to implementation that is operational and effective; and 2) creating synergy between national programs and interventions driven by non-State actors.

Main body

The argument for urgently addressing this double challenge is illustrated by drawing on observations made and lessons learned during a four-year research project (2011–2014) evaluating the effects of interventions against malaria in Burkina Faso. The way interventions were framed was mostly vertical, leaving little room for local adaptation. In addition, many non-governmental organizations intervened and contributed to a fragmented and heteronomous health governance system. Important ethical issues stem from how interventions against malaria were shaped and implemented in Burkina Faso. To further explore this issue, a scoping literature review was conducted in August 2016 on the theme of integrated primary healthcare. It revealed that no clear definition of the concept has been advanced or endorsed thus far. We call for caution in conceptualizing it as a simple juxtaposition of different tasks or missions at the primary care level. It is time to go beyond the debate around selective versus comprehensive approaches or fragmentation versus cohesion. Integration should be thought of as a process to reconcile these tensions.

Conclusions

In the context that characterizes many low- and middle-income countries today, better aid coordination and public health systems strengthening, as promoted by multisectoral approaches, might be among the best options to sustainably and ethically integrate primary healthcare interventions.

Community Involvement in Health Systems Strengthening to Improve Global Health Outcomes: A Review of Guidelines and Potential Roles

Definitions of health systems strengthening (HSS) have been limited in their inclusion of communities, despite evidence that community involvement improves program effectiveness for many health interventions. We review 15 frameworks for HSS, highlighting how communities are represented and find few delineated roles for community members or organizations. This review raises the need for a cohesive definition of community involvement in HSS and well-described activities that communities can play in the process. We discuss how communities can engage with HSS in four different areas-planning and priority-setting; program implementation; monitoring, evaluation, and quality improvement; and advocacy-and how these activities could be better incorporated into key HSS frameworks. We argue for more carefully designed interactions between health systems policies and structures, planned health systems improvements, and local communities. These interactions should consider local community inputs, strengths, cultural and social assets, as well as limitations in and opportunities for increasing capacity for better health outcomes.

Effects of donor proliferation in development aid for health on health program performance: A conceptual framework

Development aid for health increased dramatically during the past two decades, raising concerns about inefficiency and lack of coherence among the growing number of global health donors. However, we lack a framework for how donor proliferation affects health program performance to inform theory-based evaluation of aid effectiveness policies. A review of academic and gray literature was conducted. Data were extracted from the literature sample on study design and evidence for hypothesized effects of donor proliferation on health program performance, which were iteratively grouped into categories and mapped into a new conceptual framework. In the framework, increases in the number of donors are hypothesized to increase inter-donor competition, transaction costs, donor poaching of recipient staff, recipient control over aid, and donor fragmentation, and to decrease donors' sense of accountability for overall development outcomes. There is mixed evidence on whether donor proliferation increases or decreases aid volume. These primary effects in turn affect donor innovation, information hoarding, and aid disbursement volatility, as well as recipient country health budget levels, human resource capacity, and corruption, and the determinants of health program performance. The net effect of donor proliferation on health will vary depending on the magnitude of the framework's competing effects in specific country settings. The conceptual framework provides a foundation for improving design of aid effectiveness practices to mitigate negative effects from donor proliferation while preserving its potential benefits.

Harmonisation and standardisation of health sector and programme reviews and evaluations - how can they better inform health policy dialogue?

BACKGROUND

Health sector and programme performance assessments provide a rich source of contextual data directly linked to implementation of programmes and can inform health policy dialogue, planning and resource allocation. In seeking to maximise this opportunity, there are challenges to overcome. A meeting convened by the World Health Organization African Region discussed the strengths, weaknesses and challenges to harmonising and standardising health sector and programme performance assessments, as well as use of evidence from such processes in decision making. This article synthesises the deliberations which emerged from the meeting. Discussing these in light of other literature we propose practical options to standardising health sector and programme performance assessment and improve realisation of using evidence in decision making.

DISCUSSION

Use of evidence generated from health sector and programme performance assessments into regular country processes of sectoral monitoring, dialogue and policy modification is crucial. However, this process faces several challenges. Identified challenges were categorised under several themes, namely the weak institutional capacities for monitoring and evaluation in reference to weak health information systems, a lack of tools and skills, and weak accountability mechanisms; desynchronised planning timeframes between programme and overall health sector strategies; inadequate time to undertake comprehensive and good quality performance assessment; weak mechanisms for following up on implementation of recommendations; lack of effective stakeholder participation; and divergent political aspirations.

CONCLUSION

The question of what performance assessment is for in a country must be asked and answered clearly if the utility of these processes is to be realised. Standardising programme and sector reviews offers numerable opportunities that need to be maximised. Identified challenges need to be overcome through strengthened Ministry of Health leadership, effective stakeholder engagement and institutionalising follow-up mechanisms for agreed recommendations. In addition, health sector performance assessments need to be institutionalised as part of the accountability mechanism, and they must be planned for and funding secured within annual budget and medium term expenditure frameworks.

Harmonisation and standardisation of health sector and programme reviews and evaluations - how can they better inform health policy dialogue?

BACKGROUND

Health sector and programme performance assessments provide a rich source of contextual data directly linked to implementation of programmes and can inform health policy dialogue, planning and resource allocation. In seeking to maximise this opportunity, there are challenges to overcome. A meeting convened by the World Health Organization African Region discussed the strengths, weaknesses and challenges to harmonising and standardising health sector and programme performance assessments, as well as use of evidence from such processes in decision making. This article synthesises the deliberations which emerged from the meeting. Discussing these in light of other literature we propose practical options to standardising health sector and programme performance assessment and improve realisation of using evidence in decision making.

DISCUSSION

Use of evidence generated from health sector and programme performance assessments into regular country processes of sectoral monitoring, dialogue and policy modification is crucial. However, this process faces several challenges. Identified challenges were categorised under several themes, namely the weak institutional capacities for monitoring and evaluation in reference to weak health information systems, a lack of tools and skills, and weak accountability mechanisms; desynchronised planning timeframes between programme and overall health sector strategies; inadequate time to undertake comprehensive and good quality performance assessment; weak mechanisms for following up on implementation of recommendations; lack of effective stakeholder participation; and divergent political aspirations.

CONCLUSION

The question of what performance assessment is for in a country must be asked and answered clearly if the utility of these processes is to be realised. Standardising programme and sector reviews offers numerable opportunities that need to be maximised. Identified challenges need to be overcome through strengthened Ministry of Health leadership, effective stakeholder engagement and institutionalising follow-up mechanisms for agreed recommendations. In addition, health sector performance assessments need to be institutionalised as part of the accountability mechanism, and they must be planned for and funding secured within annual budget and medium term expenditure frameworks.

Improved harmonisation from policy dialogue? Realist perspectives from Guinea and Chad

Background

Harmonisation is a key principle of the Paris Declaration. The Universal Health Coverage (UHC) Partnership, an initiative of the European Union, the Government of Luxembourg and the World Health Organization, supported health policy dialogues between 2012 and 2015 in identified countries in the WHO African Region. The UHC Partnership has amongst its key objectives to strengthen national health policy development. In Guinea and Chad, policy dialogue focused on elaborating the national health plan and other key documents. This study is an analytical reflection inspired by realist evaluative approaches to understand whether policy dialogue led to improved harmonisation amongst health actors in Guinea and Chad, and if so, how and why.

Methods

Interviews were conducted in Guinea and Chad with key informants at the national and sub-national government levels, civil society, and development partners. A review of relevant policy documents and reports was added to data collection to construct a full picture of the policy dialogue process. Context-mechanism-outcome configurations were used as the realist framework to guide the analysis on how participants’ understanding of what policy dialogue was and the way the policy dialogue process unfolded led to improved harmonisation.

Results

Improved harmonisation as a result of policy dialogue was perceived to be stronger in Guinea than in Chad. While in both countries the participants held a shared view of what policy dialogue was and what it could achieve, and both policy dialogue processes were considered to be well implemented (i.e., well-facilitated, evidence-based, participatory, and consisted of recurring meetings and activities), certain contextual factors in Chad tempered the view of harmonisation as having improved. These were the pre-existence of dialogic policy processes that had exposed the actors to the potential that policy dialogue could have; a focus on elaborating provincial level strategies, which gave the sense that the process was more bottom-up; and the perception that there were acute resource constraints, which conditioned partners’ interactions.

Conclusions

Policy dialogue improves harmonisation in terms of fostering information exchange amongst partners; however, it does not appear to influence the operational procedures of the actors. This has implications for aid effectiveness.

Coordination of the health policy dialogue process in Guinea: pre- and post-Ebola

Background

Policy dialogue can be defined as an iterative process that involves a broad range of stakeholders discussing a particular issue with a concrete purpose in mind. Policy dialogue in health is increasingly being recognised by health stakeholders in developing countries, as an important process or mechanism for improving collaboration and harmonization in health and for developing comprehensive and evidence-based health sector strategies and plans. It is with this perspective in mind that Guinea, in 2013, started a policy dialogue process, engaging a plethora of actors to revise the country’s national health policy and develop a new national health development plan (2015–2024). This study examines the coordination of the policy dialogue process in developing these key strategic governance documents of the Guinean health sector from the actors’ perspective.

Methods

A qualitative case study approach was undertaken, comprising of interviews with key stakeholders who participated in the policy dialogue process. A review of the literature informed the development of a conceptual framework and the data collection survey questionnaire. The results were analysed both inductively and deductively.

Results

A total of 22 out of 32 individuals were interviewed. The results suggest both areas of strengths and weaknesses in the coordination of the policy dialogue process in Guinea. The aspects of good coordination observed were the iterative nature of the dialogue and the availability of neutral and well-experienced facilitators. Weak coordination was perceived through the unavailability of supporting documentation, time and financial constraints experienced during the dialogue process. The onset of the Ebola epidemic in Guinea impacted on coordination dynamics by causing a slowdown of its activities and then its virtual halt.

Conclusions

The findings herein highlight the need for policy dialogue coordination structures to have the necessary administrative and institutional support to facilitate their effective functioning. The findings also point to the need for further research on the practical and operational aspects of national dialogue coordination structures to determine how to best strengthen their capacities.

Power and Agenda-Setting in Tanzanian Health Policy: An Analysis of Stakeholder Perspectives

BACKGROUND

Global health policy is created largely through a collaborative process between development agencies and aid-recipient governments, yet it remains unclear whether governments retain ownership over the creation of policy in their own countries. An assessment of the power structure in this relationship and its influence over agenda-setting is thus the first step towards understanding where progress is still needed in policy-making for development.

METHODS

This study employed qualitative policy analysis methodology to examine how health-related policy agendas are adopted in low-income countries, using Tanzania as a case study. Semi-structured, in-depth, key informant interviews with 11 policy-makers were conducted on perspectives of the agenda-setting process and its actors. Kingdon's stream theory was chosen as the lens through which to interpret the data analysis.

RESULTS

This study demonstrates that while stakeholders each have ways of influencing the process, the power to do so can be assessed based on three major factors: financial incentives, technical expertise, and influential position. Since donors often have two or all of these elements simultaneously a natural power imbalance ensues, whereby donor interests tend to prevail over recipient government limitations in prioritization of agendas. One way to mediate these imbalances seems to be the initiation of meaningful policy dialogue.

CONCLUSION

In Tanzania, the agenda-setting process operates within a complex network of factors that interact until a "policy window" opens and a decision is made. Power in this process often lies not with the Tanzanian government but with the donors, and the contrast between latent presence and deliberate use of this power seems to be based on the donor ideology behind giving aid (defined here by funding modality). Donors who used pooled funding (PF) modalities were less likely to exploit their inherent power, whereas those who preferred to maintain maximum control over the aid they provided (ie, non-pooled funders) more readily wielded their intrinsic power to push their own priorities.

Aid alignment: a longer term lens on trends in development assistance for health in Uganda

Background

Over the past decade, development assistance for health (DAH) in Uganda has increased dramatically, surpassing the government’s own expenditures on health. Yet primary health care and other priorities identified in Uganda’s health sector strategic plan remain underfunded.

Methods

Using data available from the Creditor Reporting System (CRS), National Health Accounts (NHA), and government financial reports, we examined trends in how donors channel DAH and the extent to which DAH is aligned with sector priorities. The study follows the flow of DAH from the donor to the implementing organization, specifying the modality used for disbursing funds and categorizing funds based on program area or support function.

Findings

Despite efforts to improve alignment through the formation of a sector-wide approach (SWAp) for health in 1999 and the creation of a fund to pool resources for identified priorities, increasingly DAH is provided as short-term, project-based support for disease-specific initiatives, in particular HIV/AIDS.

Conclusion

These findings highlight the need to better align external resources with country priorities and refocus attention on longer-term sector-wide objectives.