Prospective policy analysis-a critical interpretive synthesis review

Most policy analysis methods and approaches are applied retrospectively. As a result, there have been calls for more documentation of the political-economy factors central to health care reforms in real-time. We sought to highlight the methods and previous applications of prospective policy analysis (PPA) in the literature to document purposeful use of PPA and reflect on opportunities and drawbacks. We used a critical interpretive synthesis (CIS) approach as our initial scoping revealed that PPA is inconsistently defined in the literature. While we found several examples of PPA, all were researcher-led, most were published recently and few described mechanisms for engagement in the policy process. In addition, methods used were often summarily described and reported on relatively short prospective time horizons. Most of the studies stemmed from high-income countries and, across our sample, did not always clearly outline the rationale for a PPA and how this analysis was conceptualized. That only about one-fifth of the articles explicitly defined PPA underscores the fact that researchers and practitioners conducting PPA should better document their intent and reflect on key elements essential for PPA. Despite a wide recognition that policy processes are dynamic and ideally require multifaceted and longitudinal examination, the PPA approach is not currently frequently documented in the literature. However, the few articles reported in this paper might overestimate gaps in PPA applications. More likely, researchers are embedded in policy processes prospectively but do not necessarily write their articles from that perspective, and analyses led by non-academics might not make their way into the published literature. Future research should feature examples of testing and refining the proposed framework, as well as designing and reporting on PPA. Even when policy-maker engagement might not be feasible, real-time policy monitoring might have value in and of itself.

Policy networks and competing interests in the development of the Mexican sugar-sweetened beverages tax

INTRODUCTION

Sugar taxes threaten the business models and profits of the food and beverage industry (F&BI), which has sought to avert, delay or influence the content of health taxes globally. Mexico introduced a sugar-sweetened beverage (SSB) tax in 2014 and other regulatory measures to improve population diets. This paper examines how policy networks emerged within and affected the development and implementation of the Mexican SSB tax.

METHODS

This qualitative study analyses 31 interviews conducted with key stakeholders involved in the soda tax policy process and 145 documents, including grey literature and peer-reviewed literature. The policy network approach was used to map contacts, interconnections, relationships and links between the state, civil society and commercial actors involved in the SSB tax. These findings were used to examine the responsiveness, participation and accountability of the soda tax policy formulation.

RESULTS

Complex interconnections were identified between state and non-state actors. These included advisory relationships, financial collaborations and personal connections between those in high-level positions. Relationships between the government and the F&BI were not always disclosed. International organisations and academics were identified as key financial or technical supporters of the tax. Key governance principles of participation, responsiveness and accountability were undermined by some of these relationships, including the participation of non-state actors in policy development and the powerful role of the F&BI in evaluation and monitoring.

CONCLUSION

This case study exemplifies the importance of links and networks between actors in health policymaking. The F&BI influence endangers the primary aim of the SSB tax to protect health. The identified links highlight the normalisation of connections among actors with competing aims and interests toward health, thereby jeopardising attempts to tackle obesity rates.

Using evidence in mental health policy agenda-setting in low- and middle-income countries: a conceptual meta-framework from a scoping umbrella review

The purpose of this article is to close the gap in frameworks for the use of evidence in the mental health policy agenda-setting in low- and middle-income countries (LMICs). Agenda-setting is important because mental health remains a culturally sensitive and neglected issue in LMICs. Moreover, effective evidence-informed agenda-setting can help achieve, and sustain, the status of mental health as a policy priority in these low-resource contexts. A scoping 'review of reviews' of evidence-to-policy frameworks was conducted, which followed preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Nineteen reviews met the inclusion criteria. A meta-framework was developed from analysis and narrative synthesis of these 19 reviews, which integrates the key elements identified across studies. It comprises the concepts of evidence, actors, process, context and approach, which are linked via the cross-cutting dimensions of beliefs, values and interests; capacity; power and politics; and trust and relationships. Five accompanying questions act as a guide for applying the meta-framework with relevance to mental health agenda-setting in LMICs. This is a novel and integrative meta-framework for mental health policy agenda-setting in LMICs and, as such, an important contribution to this under-researched area. Two major recommendations are identified from the development of the framework to enhance its implementation. First, given the paucity of formal evidence on mental health in LMICs, informal evidence based on stakeholder experience could be better utilized in these contexts. Second, the use of evidence in mental health agenda-setting in LMICs would be enhanced by involving a broader range of stakeholders in generating, communicating and promoting relevant information.

Acceptability and feasibility of tuberculosis and diabetes mellitus bidirectional screening and joint treatment services in Malawi: a cross-sectional study and a policy document review

OBJECTIVES

A cross-sectional and a policy document review study was performed to investigate perceived acceptability and feasibility to implementing different integration measures for tuberculosis (TB) and diabetes mellitus (DM) healthcare among healthcare workers (HCWs) and health managers, and to describe policy influence through a policy documents review in Malawi.

SETTING

The survey was performed at eight hospitals, ministry of health offices and 10 non-governmental organisations. We collected data in March and April 2021.

PARTICIPANTS

Of 95 HCWs and health managers invited; 92 participated. 21/92 (23%) were female, and 17/92 (18%) participants were from clinics that piloted the integrated care for TB and DM.

OUTCOME MEASURES

We described awareness levels on TB/DM comorbidity, perceptions and experiences in TB/DM care. Furthermore, development processes and contents of included documents were analysed.

RESULTS

16/17 (94%) of HCWs from clinics piloting integrated care and 65/75 (86%) HCWs from hospitals that do not use integrated care for TB and DM responded that integrated care was acceptable and feasible. In qualitative data, shortage of resources, inadequate information sharing were common themes. We included seven relevant documents for the analysis. On development process and content, six of seven documents were scored ≥70%. In these documents, DM is a recognised risk factor for TB, and integration of healthcare services for infectious diseases and non-communicable diseases is recommended, however, these documents lacked information specifically on integrated care for TB and DM.

CONCLUSION

In this study, we identified inadequate information sharing, and lack of resources as major factors impeding implementation of integration of services, however, awareness on TB/DM comorbidity was high.

Experiences, barriers, and facilitators of health data use among performance monitoring teams (PMT) of health facilities in Eastern Ethiopia: A qualitative study

BACKGROUND

Routine health data is crucial in decision-making and improved health outcomes. Despite the significant investments in improving Ethiopia's Performance Monitoring Team (PMT), there is limited evidence on the involvement, implementation strategies, and facilitators and barriers to data utilization by these teams responding to present and emerging health challenges. Therefore, this study aimed to explore the PMT experiences, facilitators, and barriers to information use in healthcare facilities in Eastern Ethiopia.

METHOD

This study employed a phenomenological study design using the Consolidated Framework for Implementation Research (CFIR) to identify the most relevant constructs, aiming to describe the data use approaches at six facilities in Dire Dawa and Harari regions in July 2021. Key informant interviews were conducted among 18 purposively selected experts using a semi-structured interview guide. Thematic coding analysis was applied using a partially deductive approach informed by previous studies and an inductive technique with the creation of new emerging themes. Data were analyzed thematically using ATLAS.ti.

RESULTS

Study participants felt the primary function of PMT was improving health service delivery. This study also revealed that data quality, performance, service quality, and improvement strategies were among the major focus areas of the PMT. Data use by the PMT was affected by poor data quality, absence of accountability, and lack of recognition for outstanding performance. In addition, the engagement of PMT members on multiple committees negatively impacted data use leading to inadequate follow-up of PMT activities, weariness, and insufficient time to complete responsibilities.

CONCLUSION

Performance monitoring teams in the health facilities were established and functioning according to the national standard. However, barriers to operative data use included PMT engagement with multiple committees, poor data quality, lack of accountability, and poor documentation practices. Addressing the potential barriers by leveraging the PMT and existing structures have the potential to improve data use and health service performance.

Policy space and pro-health equity national policymaking: a case study of Myanmar during political transition (2006-16)

Health equity is central to achieving sustainable development goals and COVID-19 has emphasized its importance. Ensuring health equity is prominent in policy discussions and decision-making is a critical challenge in all countries. Understanding the policy space for actors to promote health equity in the policy process may help to strengthen prioritization of equity in policy and programme discussions and decisions. Authors developed a conceptual framework for policy space based on a narrative literature review. This comprised five key elements and their associated factors, i.e. context, policy circumstances, policy characteristics, actor engagement and policy spaces. Authors then applied it in Myanmar during a period of political transition, using a qualitative case study design. Findings showed that political transition provided an important 'policy window' to develop more equitable health policy in Myanmar. Changing policy circumstances offered opportunities for advancing pro-equity policy. However, lack of visibility of health equity and long-standing inequalities were important challenges to policy space. Within a changing context, actors at individual and organizational levels used a range of policy spaces to advance pro-equity health policy. Learning from using the framework in Myanmar was incorporated into a revised framework. Application of this revised framework could provide valuable insights into the opportunities to promote a pro-health equity approach across policy and programme discussions and decision-making for actors trying to promote equity in other transition and non-transition contexts.

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.

Policy Adoption and the Implementation Woes of the Intersectoral First 1000 Days of Childhood Initiative, In the Western Cape Province of South Africa

BACKGROUND

There is a growing interest in implementing intersectoral approaches to address social determinants especially within the Sustainable Development Goals (SDGs) era. However, there is limited research that uses policy analysis approaches to understand the barriers to adoption and implementation of intersectoral approaches. In this paper we apply a policy analysis lens in examining implementation of the first thousand days (FTD) of childhood initiative in the Western Cape province of South Africa. This initiative aims to improve child outcomes through a holistic intersectoral approach, referred to as nurturing care.

METHODS

The case of the FTD initiative was constructed through a triangulated analysis of document reviews (34), in depth interviews (22) and observations. The analysis drew on Hall's 'ideas, interests and institutions' framework to understand the shift from political agendas to the implementation of the FTD.

RESULTS

In the Western Cape province, the FTD agenda setting process was catalysed by the increasing global evidence on the life-long impacts of brain development during the early childhood years. This created a window of opportunity for active lobbying by policy entrepreneurs and a favourable provincial context for a holistic focus on children. However, during implementation, the intersectoral goal of the FTD got lost, with limited bureaucratic support from service-delivery actors and minimal cross-sector involvement. Challenges facing the health sector, such as overburdened facilities, competing policies and the limited consideration of implementation realities (such as health providers' capacity), were perceived by implementing actors as the key constraints to intersectoral action. As a result, FTD actors, whose decision-making power largely resided in health services, reformulated FTD as a traditional maternal-child health mandate. Ambiguity and contestation between key actors regarding FTD interventions contributed to this narrowing of focus.

CONCLUSION

This study highlights conditions that should be considered for the effective implementation of intersectoral action - including engaging cross-sector players in agenda setting processes and creating spaces that allow the consideration of actors' interests especially those at service-delivery level. Networks that prioritise relationship building and trust can be valuable in allowing the emergence of common goals that further embrace collective interests.

Systematic Literature Review of Climate Change Governance Activities of Environmental Nongovernmental Organizations in Southeast Asia

Environmental nongovernmental organizations (ENGOs) are considered key players for engendering good climate change governance to address both climate change and sustainable development. The participation of ENGOs in climate change governance occurs in a four-phase policy cycle. They include (1) identification of policy options, (2) policy formulation, (3) policy implementation, and (4) policy monitoring and evaluation. The ENGOs, however, have been criticized for their lack of effectiveness, and their roles in tackling climate change remain unclear. To date, the study on the roles and activities of Southeast Asian ENGOs in climate change governance has been under-researched. This study, therefore, applies a systematic literature review of 19 published articles from Scopus and Web of Science-indexed journal to understand the current state of the Southeast Asian ENGOs participation in climate change governance based on the four-phase policy cycle. The findings show that the ENGOs in Southeast Asia are involved directly and indirectly in climate change governance. They are significant actors in the implementation of the climate change policy, but they play a minimal role in the formulation of said policy. It implies that they could also be a vital partner to the government in the climate change governance process as they can bring effective policy improvements. Lastly, this review will recommend future avenues of research for scholars.

Reaching the Hard to Reach in Thailand: Eliminating Mother-To-Child HIV Transmission

Thailand is the first country in the Asia-Pacific region to be validated by the World Health Organization as having eliminated mother-to-child transmission (MTCT) of HIV. The Thai government made health-and specifically addressing the HIV/AIDS crisis-a political priority. The Thailand experience, from the emergence of the HIV/AIDS epidemic in the 1980s through the present, provides an important case study of successful MTCT elimination. To eliminate MTCT requires that health interventions reach those who are hardest to reach: the poorest of the poor, geographically distant and rural, and marginalized. This policy report highlights key factors for successfully reaching the hard to reach in Thailand, including the importance of national public policy as well as investments in health care infrastructure, such as access to antenatal care, the creation of effective monitoring and surveillance systems, and strengthening local health capacity. Increased availability and affordability of antiretroviral therapies was also critical to Thailand's success in addressing MTCT. The Thailand case offers important policy lessons for achieving universal health. This policy report draws on secondary research and key informant interviews in Thailand to highlight factors for success in eliminating MTCT of HIV.

Policy analysis of the Iranian Health Transformation Plan in primary healthcare

BACKGROUND

Health systems reform is inevitable due to the never-ending changing nature of societal health needs and policy dynamism. Today, the Health Transformation Plan (HTP) remains the major tool to facilitate the achievements of universal health coverage (UHC) in Iran. It was initially implemented in hospital-based setting and later expanded to primary health care (PHC). This study aimed to analyze the HTP at the PHC level in Iran.

METHODS

Qualitative data were collected through document analysis, round-table discussion, and semi-structured interviews with stakeholders at the micro, meso and macro levels of the health system. A tailored version of Walt & Gilson's policy triangle model incorporating the stages heuristic model was used to guide data analysis.

RESULTS

The HTP emerged through a political process. Although the initiative aimed to facilitate the achievements of UHC by improving the entire health system of Iran, little attention was given to PHC especially during the first phases of policy development - a gap that occurred because politicians were in a great haste to fulfil a campaign promise.

CONCLUSIONS

Health reforms targeting UHC and the health-related Sustainable Development Goals require the political will to improve PHC through engagements of all stakeholders of the health system, plus improved fiscal capacity of the country and financial commitments to implement evidence-informed initiatives.

Exploring effectiveness of different health financing mechanisms in Nigeria; what needs to change and how can it happen?

BACKGROUND

Various attempts to examine health financing mechanisms in Nigeria highlight the fact that there is no single mechanism that fits all contexts and people. This paper sets out findings of an in-depth assessment of different health financing mechanisms in Nigeria.

METHODS

The study was undertaken in the Federal Capital territory of Nigeria and two States (Niger and Kaduna). Data were collected through review of government documents, and in-depth interviews of purposively selected respondents. Data analysis was guided by a conceptual framework which draws from various approaches for assessing health financing mechanisms. Data was examined for current practices, what needs to change and how the change can happen.

RESULTS

Health financing mechanisms in Nigeria do not operate optimally. Allocation and use of resources are neither evidence-based nor results-driven. Resources are not allocated equitably or in a manner that minimizes wastage and improves efficiency. None of the mechanisms effectively protects individuals/households from catastrophic health expenditure. Issues with social health insurance cut across legal frameworks and use of Health Maintenance Organisations (HMOs) as purchasers. The concomitant effect is that attainment of Universal Health Coverage is greatly compromised. In order to improve efficiency of health financing mechanisms, government needs to allocate more funds for purchasing health services; this spending must be based on evidence (strategic), and appropriately tracked. The legislation that established National Health Insurance Scheme should be amended such that social health insurance becomes mandatory for all citizens. Implementation of the latter should be complemented by revision of benefit package, strict oversight and regulation of HMOs.

CONCLUSION

In order to improve health financing in the country, legal and regulatory frameworks need to be revised. Efficient utilization of resources could be improved through strategic purchasing arrangements and strict oversight.

Understanding political priority development for public health issues in Turkey: lessons from tobacco control and road safety

BACKGROUND

Tobacco use and road traffic injuries are major public health problems in Turkey. During the last decade, the former issue received political priority in the country, while the latter did not despite the immense health and economic burden that road traffic injuries pose on the Turkish population. Political priority can facilitate the attainment of public health goals. Unfortunately, however, limited cross-case analyses exist to help us understand why it emerges for certain public health issues but fails to develop for others in low- and middle-income countries.

METHODS

This study utilised Kingdon's Multiple Streams Framework to explore the political priority development process in Turkey. A cross-case analysis was conducted, using data gathered from three different sources, namely key informant interviews (n = 42), documents (n = 307) and online self-administered surveys (n = 153). The Wilcoxon-Mann-Whitney test was also employed to examine whether the relationships within the tobacco control and road safety networks differed significantly.

RESULTS

In Turkey, political priority emerges when four streams - problem, policy, political and global - converge while a policy window is open. While these findings are largely consistent with the Multiple Streams Framework, this study also shed light on (1) the need to consider global health treaties for urgent public health issues as these instruments can accentuate global norms and standards, (2) the disproportionate strength of the political stream, (3) the need to develop in-depth understanding of national political context, (4) the importance of fostering meaningful ties between global and domestic health networks, and (5) the need for policy network cohesion.

CONCLUSIONS

Findings from this study can be used by advocates striving to promote public health issues in other similar contexts.

Setting performance-based financing in the health sector agenda: a case study in Cameroon

BACKGROUND

More than 30 countries in sub-Saharan Africa have introduced performance-based financing (PBF) in their healthcare systems. Yet, there has been little research on the process by which PBF was put on the national policy agenda in Africa. This study examines the policy process behind the introduction of PBF program in Cameroon.

METHODS

The research is an explanatory case study using the Kingdon multiple streams framework. We conducted a document review and 25 interviews with various types of actors involved in the policy process. We conducted thematic analysis using a hybrid deductive-inductive approach for data analysis.

RESULTS

By 2004, several reports and events had provided evidence on the state of the poor health outcomes and health financing in the country, thereby raising awareness of the situation. As a result, decision-makers identified the lack of a suitable health financing policy as an important issue that needed to be addressed. The change in the political discourse toward more accountability made room to test new mechanisms. A group of policy entrepreneurs from the World Bank, through numerous forms of influence (financial, ideational, network and knowledge-based) and building on several ongoing reforms, collaborated with senior government officials to place the PBF program on the agenda. The policy changes occurred as the result of two open policy windows (i.e. national and international), and in both instances, policy entrepreneurs were able to couple the policy streams to effect change.

CONCLUSION

The policy agenda of PBF in Cameroon underlined the importance of a perceived crisis in the policy reform process and the advantage of building a team to carry forward the policy process. It also highlighted the role of other sources of information alongside scientific evidence (eg.: workshop and study tour), as well as the role of previous policies and experiences, in shaping or influencing respectively the way issues are framed and reformers' actions and choices.

Responding to non-communicable diseases in Zambia: a policy analysis

BACKGROUND

Non-communicable diseases (NCDs) are an emerging global health concern. Reports have shown that, in Zambia, NCDs are also an emerging problem and the government has begun initiating a policy response. The present study explores the policy response to NCDs by the Ministry of Health in Zambia using the policy triangle framework of Walt and Gilson.

METHODS

A qualitative approach was used for the study. Data collected through key informant interviews with stakeholders who were involved in the NCD health policy development process as well as review of key planning and policy documents were analysed using thematic analysis.

RESULTS

The government's policy response was as a result of international strategies from WHO, evidence of increasing disease burden from NCDs and pressure from interest groups. The government developed the NCD strategic plan based on the WHO Global Action Plan for NCDs 2013-2030. Development of the NCD strategic plan was driven by the government through the Ministry of Health, who set the agenda and adopted the final document. Stakeholders participated in the fine tuning of the draft document from the Ministry of Health. The policy development process was lengthy and this affected consistency in composition of the stakeholders and policy development momentum. Lack of representative research evidence for some prioritised NCDs and use of generic targets and indicators resulted in the NCD strategic plan being inadequate for the Zambian context. The interventions in the strategic plan also underutilised the potential of preventing NCDs through health education. Recent government pronouncements were also seen to be conflicting the risk factor reduction strategies outlined in the NCD strategic plan.

CONCLUSION

The content of the NCD strategic plan inadequately covered all the major NCDs in Zambia. Although contextual factors like international strategies and commitments are crucial catalysts to policy development, there is need for domestication of international guidelines and frameworks to match the disease burden, resources and capacities in the local context if policy measures are to be comprehensive, relevant and measurable. Such domestication should be guided by representative local research evidence.

Countdown to 2015 country case studies: systematic tools to address the "black box" of health systems and policy assessment

BACKGROUND

Evaluating health systems and policy (HSP) change and implementation is critical in understanding reproductive, maternal, newborn and child health (RMNCH) progress within and across countries. Whilst data for health outcomes, coverage and equity have advanced in the last decade, comparable analyses of HSP changes are lacking. We present a set of novel tools developed by Countdown to 2015 (Countdown) to systematically analyse and describe HSP change for RMNCH indicators, enabling multi-country comparisons.

METHODS

International experts worked with eight country teams to develop HSP tools via mixed methods. These tools assess RMNCH change over time (e.g. 1990-2015) and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, we present results from Tanzania and Peru, two of eight Countdown case studies.

RESULTS

The Policy and Programme Timeline tool shows that Tanzania's RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Contrastingly, Peru moved from standalone to integrated RMNCH programme implementation, combined with multi-sectoral, anti-poverty strategies. The HSP Tracer Indicators Dashboards show that Peru has adopted nine of 11 policy tracer indicators and Tanzania has adopted seven. Peru costed national RMNCH plans pre-2000, whereas Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. Both countries included all lifesaving RMNCH commodities on their essential medicines lists. Peru has twice the health worker density of Tanzania (15.4 vs. 7.1/10,000 population, respectively), although both are below the 22.8 WHO minimum threshold.

CONCLUSIONS

These are the first HSP tools using mixed methods to systematically analyse and describe RMNCH changes within and across countries, important in informing accelerated progress for ending preventable maternal, newborn and child mortality in the post-2015 era.

Patterns of public participation

Purpose

– The paper summarizes data from 12 countries, chosen to exhibit wide variation, on the role and place of public participation in the setting of priorities. The purpose of this paper is to exhibit cross-national patterns in respect of public participation, linking those differences to institutional features of the countries concerned.

Design/methodology/approach

– The approach is an example of case-orientated qualitative assessment of participation practices. It derives its data from the presentation of country case studies by experts on each system. The country cases are located within the historical development of democracy in each country.

Findings

– Patterns of participation are widely variable. Participation that is effective through routinized institutional processes appears to be inversely related to contestatory participation that uses political mobilization to challenge the legitimacy of the priority setting process. No system has resolved the conceptual ambiguities that are implicit in the idea of public participation.

Originality/value

– The paper draws on a unique collection of country case studies in participatory practice in prioritization, supplementing existing published sources. In showing that contestatory participation plays an important role in a sub-set of these countries it makes an important contribution to the field because it broadens the debate about public participation in priority setting beyond the use of minipublics and the observation of public representatives on decision-making bodies.

The bit in the middle: a synthesis of global health literature on policy formulation and adoption

Policy formulation and adoption are poorly understood phases of the health policy process. We conducted a narrative synthesis of 28 articles on health policy in low- and middle-income countries to provide insight on what kinds of activities take place in these phases, the actors crafting policies and the institutions in which policy making occurs. The narrative synthesis involved an inductive process to identify relevant articles, extract relevant data from text and reach new understandings. We find that actors exercising decision-making power include not just various governmental entities, but also civil society, commissioners, nongovernmental organizations and even clergy. We also find that most articles identified two or more distinct institutions in which policy formulation and adoption occurred. Finally, we identify seven distinct activities inherent in policy formulation and adoption: generation of policy alternatives, deliberation and/or consultation, advocacy of specific policy alternatives, lobbying for specific alternatives, negotiation of policy decisions, drafting or enacting policy and guidance/influence on implementation development. Health policy researchers can draw on these categories to deepen their understanding of how policy formulation and adoption unfolds.

Can frameworks inform knowledge about health policy processes? Reviewing health policy papers on agenda setting and testing them against a specific priority-setting framework

This article systematically reviews a set of health policy papers on agenda setting and tests them against a specific priority-setting framework. The article applies the Shiffman and Smith framework in extracting and synthesizing data from an existing set of papers, purposively identified for their relevance and systematically reviewed. Its primary aim is to assess how far the component parts of the framework help to identify the factors that influence the agenda setting stage of the policy process at global and national levels. It seeks to advance the field and inform the development of theory in health policy by examining the extent to which the framework offers a useful approach for organizing and analysing data. Applying the framework retrospectively to the selected set of papers, it aims to explore influences on priority setting and to assess how far the framework might gain from further refinement or adaptation, if used prospectively. In pursuing its primary aim, the article also demonstrates how the approach of framework synthesis can be used in health policy analysis research.

Nutrition policy process challenges in Iran

Introduction

Nutrition transition is occurring rapidly in the world, especially in developing countries. The nutrition transition occurred in Iran very fast due to urbanization and changes in the lifestyle of people, leading to overweight and obesity. However, nutritional deficiencies are still detected due to economic factors and low nutritional knowledge. Nutrition policies do not adequately respond to the nutrition challenges in Iran. This study was conducted to evaluate and analyze the nutrition policy process challenges in Iran.

Methods

A qualitative study using semi-structured interviews was conducted with 59 policy makers and nutrition experts of medical universities across Iran. Interviews were continued until data saturation was achieved. Data were supplemented with surveys and documentary analysis. Thematic analysis was guided by the propositions of the stages heuristic framework.

Results

The results were categorized into four main themes and eight sub-themes. The main themes were 1) nutrition problem definition, 2) policy formulation, 3) implementation of the policies, and 4) evaluation of the policies. However, the multi-faceted nature of the nutritional problem makes it difficult to deal with, so a multi-sectoral approach is needed.

Conclusion

Nutrition policies have been implemented in Iran with varying degrees of success and with different levels of cross-sectoral collaboration. The nutrition policies sometimes have not been able to respond to the nutritional problems. One of the important reasons is that nutrition is not a priority for policy makers. Many policies suffer from a lack of adequate and appropriate resource allocation. Cooperation mechanisms to resolve nutritional problems are sometimes ineffective and inefficient.

Is 'mainstreaming AYUSH' the right policy for Meghalaya, northeast India?

BACKGROUND

National policy on medical pluralism in India encourages the mainstreaming of AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) systems and the revitalization of local health traditions (LHT). In Meghalaya state in the northeast, the main LHT is its indigenous tribal traditional medicine. This paper presents the perceptions of tribal medicine and of AYUSH systems among various policy actors and locates the tribal medicine of Meghalaya within the policy on medical pluralism currently being implemented in the state, a region that is ethnically and culturally different and predominantly inhabited by indigenous peoples.

METHODS

A stakeholder mapping exercise identified appropriate policy actors and 46 in-depth interviews were conducted with policy makers, doctors, academics, members of healer associations and elders of the community. A further 44 interviews were conducted with 24 Khasi and 20 Garo traditional healers. Interview data were supplemented with document analysis and observations. Qualitative data were analyzed using thematic content analysis that incorporated elements of grounded theory.

RESULTS

In Meghalaya there is high awareness and utilization of tribal medicine, but no visible efforts by the public sector to support or engage with healers. The AYUSH systems in contrast had little local acceptance but promotion of these systems has led to a substantial increase in AYUSH doctors, particularly homeopaths, in rural areas. Policy actors outside the health department saw an important role for tribal medicine due to its popularity, local belief in its efficacy and its cultural resonance. The need to engage with healers to enhance referral, training, documentation and research of tribal medicine was made.

CONCLUSIONS

The wide acceptance of tribal medicine suggests that tribal medicine needs to be supported. The results of the study question the process of the implementation of the 'mainstreaming AYUSH' policy for Meghalaya and highlight the importance of contextualizing health policy within the local culture. A potential role for Health Policy and Systems Research (HPSR) at sub-national levels is also highlighted.

National malaria vector control policy: an analysis of the decision to scale-up larviciding in Nigeria

Background: New vector control tools are needed to combat insecticide resistance and reduce malaria transmission. The World Health Organization (WHO) endorses larviciding as a supplementary vector control intervention using larvicides recommended by the WHO Pesticides Evaluation Scheme (WHOPES). The decision to scale-up larviciding in Nigeria provided an opportunity to investigate the factors influencing policy adoption and assess the role that actors and evidence play in the policymaking process, in order to draw lessons that help accelerate the uptake of new methods for vector control.

Methods: A retrospective policy analysis was carried out using in-depth interviews with national level policy stakeholders to establish normative national vector control policy or strategy decision-making processes and compare these with the process that led to the decision to scale-up larviciding. The interviews were transcribed, then coded and analyzed using NVivo10. Data were coded according to pre-defined themes from an analytical policy framework developed a priori.

Results: Stakeholders reported that the larviciding decision-making process deviated from the normative vector control decision-making process. National malaria policy is normally strongly influenced by WHO recommendations, but the potential of larviciding to contribute to national economic development objectives through larvicide production in Nigeria was cited as a key factor shaping the decision. The larviciding decision involved a restricted range of policy actors, and notably excluded actors that usually play advisory, consultative and evidence generation roles. Powerful actors limited the access of some actors to the policy processes and content. This may have limited the influence of scientific evidence in this policy decision.

Conclusions: This study demonstrates that national vector control policy change can be facilitated by linking malaria control objectives to wider socioeconomic considerations and through engaging powerful policy champions to drive policy change and thereby accelerate access to new vector control tools.

Development of oral health policy in Nigeria: an analysis of the role of context, actors and policy process

Background

In Nigeria, there is a high burden of oral health diseases, poor coordination of health services and human resources for delivery of oral health services. Previous attempts to develop an Oral Health Policy (OHP) to decrease the oral disease burden failed. However, a policy was eventually developed in November 2012. This paper explores the role of contextual factors, actors and the policy process in the development of the OHP and possible reasons why the current approved OHP succeeded.

Methods

The study was undertaken across Nigeria; information gathered through document reviews and in-depth interviews with five groups of purposively selected respondents. Analysis of the policy development process was guided by the policy triangle framework, examining context, policy process and actors involved in the policy development.

Results

The foremost enabling factor was the yearning among policy actors for a policy, having had four failed attempts. Other factors were the presence of a democratically elected government, a framework for health sector reform instituted by the Federal Ministry of Health (FMOH). The approved OHP went through all stages required for policy development unlike the previous attempts. Three groups of actors played crucial roles in the process, namely academics/researchers, development partners and policy makers. They either had decision making powers or influenced policy through funding or technical ability to generate credible research evidence, all sharing a common interest in developing the OHP. Although evidence was used to inform the development of the policy, the complex interactions between the context and actors facilitated its approval.

Conclusions

The OHP development succeeded through a complex inter-relationship of context, process and actors, clearly illustrating that none of these factors could have, in isolation, catalyzed the policy development. Availability of evidence is necessary but not sufficient for developing policies in this area. Wider socio-political contexts in which actors develop policy can facilitate and/or constrain actors’ roles and interests as well as policy process. These must be taken into consideration at stages of policy development in order to produce policies that will strengthen the health system, especially in low and middle-income countries, where policy processes and influences can be often less than transparent.

What is needed for taking emergency obstetric and neonatal programmes to scale?

Scaling up an emergency obstetric and neonatal care (EmONC) programme entails reaching a larger number of people in a potentially broader geographical area. Multiple strategies requiring simultaneous attention should be deployed. This paper provides a framework for understanding the implementation, scale-up and sustainability of such programmes. We reviewed the existing literature and drew on our experience in scaling up the Essential Steps in the Management of Obstetric Emergencies (ESMOE) programme in South Africa. We explore the non-linear change process and conditions to be met for taking an existing EmONC programme to scale. Important concepts cutting across all components of a programme are equity, quality and leadership. Conditions to be met include appropriate awareness across the board and a policy environment that leads to the following: commitment, health systems-strengthening actions, allocation of resources (human, financial and capital/material), dissemination and training, supportive supervision and monitoring and evaluation.

What can volunteer co-providers contribute to health systems? The role of people living with HIV in the Thai paediatric HIV programme

In Thailand people living with HIV (PLHIV) have played a major role in shaping policy and practice. They have acted as volunteer co-providers, although their potential in terms of paediatric service provision has seldom been explored from a health systems perspective. We describe the Thai paediatric HIV care system and use both demand- and supply-side perspectives to explore the impact, opportunities and challenges of PLHIV acting as volunteer co-providers. We employed qualitative methods to assess experiences and perceptions and triangulate stakeholder perspectives. Data were collected in Khon Kaen province, in the poorest Northeastern region of Thailand: three focus group discussions and two workshops (total participants n = 31) with co-providers and hospital staff; interviews with ART service-users (n = 35). Nationally, key informant interviews were conducted with policy actors (n = 20). Volunteer co-providers were found to be ideally placed to broker the link between clinic and communities for HIV infected children and played an important part in the vital psychosocial support component of HIV care. As co-providers they were recognized as having multiple roles linking and delivering services in clinics and communities. Clear emerging needs include strengthened coordination and training as well as strategies to support funding. Using motivated volunteers with a shared HIV status as co-providers for specific clinical services can contribute to strengthening health systems in Asia; they are critical players in delivering care (supply side) and being responsive to service-users needs (demand side). Co-providers blur the boundaries between these two spheres. Sustaining and optimising co-providers' contribution to health systems strengthening requires a health systems approach. Our findings help to guide policy makers and service providers on how to balance clinical priorities with psycho-social responsiveness and on how best to integrate the views and experience of volunteers into a holistic model of care.

Using health technology assessment for informing coverage decisions in Thailand

This article aims to illustrate and critically analyze the results from the 1-year experience of using health technology assessment (HTA) in the development of the Thai Universal Coverage health benefit package. We review the relevant documents and give a descriptive analysis of outcomes resulting from the development process in 2009-2010. Out of 30 topics nominated by stakeholders for prioritization, 12 were selected for further assessment. A total of five new interventions were recommended for inclusion in the benefit package based on value for money, budget impact, feasibility and equity reasons. Different stakeholders have diverse interests and capabilities to participate in the process. In conclusion, HTA is helpful for informing coverage decisions for health benefit packages because it enhances the legitimacy of policy decisions by increasing the transparency, inclusiveness and accountability of the process. There is room for improvement of the current use of HTA, including providing technical support for patient representatives and civic groups, better communication between health professionals, and focusing more on health promotion and disease prevention.

Framework for assessing the capacity of a health ministry to conduct health policy processes--a case study from Tajikistan

An adequate capacity of ministries of health (MOH) to develop and implement policies is essential. However, no frameworks were found assessing MOH capacity to conduct health policy processes within developing countries. This paper presents a conceptual framework for assessing MOH capacity to conduct policy processes based on a study from Tajikistan, a former Soviet republic where independence highlighted capacity challenges. The data collection for this qualitative study included in-depth interviews, document reviews and observations of policy events. Framework approach for analysis was used. The conceptual framework was informed by existing literature, guided the data collection and analysis, and was subsequently refined following insights from the study. The Tajik MOH capacity, while gradually improving, remains weak. There is poor recognition of wider contextual influences, ineffective leadership and governance as reflected in centralised decision-making, limited use of evidence, inadequate actors' participation and ineffective use of resources to conduct policy processes. However, the question is whether this is a reflection of lack of MOH ability or evidence of constraining environment or both. The conceptual framework identifies five determinants of robust policy processes, each with specific capacity needs: policy context, MOH leadership and governance, involvement of policy actors, the role of evidence and effective resource use for policy processes. Three underlying considerations are important for applying the capacity to policy processes: the need for clear focus, recognition of capacity levels and elements, and both ability and enabling environment. The proposed framework can be used in assessing and strengthening of the capacity of different policy actors.

Thailand's HIV/AIDS program after weaning-off the global fund's support

Background Although the number of smokers has declined in the last decade, smoking is still a major health problem among youngsters and adolescents. For this reason, there is a need for effective smoking prevention programmes targeting primary school children. A web-based computer-tailored feedback programme may be an effective intervention to stimulate youngsters not to start smoking, and increase their knowledge about the adverse effects of smoking and their attitudes and self-efficacy regarding non-smoking. Methods & Design This paper describes the development and evaluation protocol of a web-based out-of-school smoking prevention programme for primary school children (age 10-13 years) entitled 'Fun without Smokes'. It is a transformation of a postal mailed intervention to a web-based intervention. Besides this transformation the effects of prompts will be examined. This web-based intervention will be evaluated in a 2-year cluster randomised controlled trial (c-RCT) with three study arms. An intervention and intervention + prompt condition will be evaluated for effects on smoking behaviour, compared with a no information control condition. Information about pupils' smoking status and other factors related to smoking will be obtained using a web-based questionnaire. After completing the questionnaire pupils in both intervention conditions will receive three computer-tailored feedback letters in their personal e-mail box. Attitudes, social influences and self-efficacy expectations will be the content of these personalised feedback letters. Pupils in the intervention + prompt condition will - in addition to the personalised feedback letters - receive e-mail and SMS messages prompting them to revisit the 'Fun without Smokes' website. The main outcome measures will be ever smoking and the utilisation of the 'Fun without Smokes' website. Measurements will be carried out at baseline, 12 months and 24 months of follow-up. Discussion The present study protocol describes the purpose, intervention design and study protocol of 'Fun without Smokes'. Expectations are that pupils receiving tailored advice will be less likely to smoke after 24 months in contrast to pupils in the control condition. Furthermore, tailored feedback letters and prompting is expected to be more effective than providing tailored feedback letters only. Trial Registration Dutch Trial Register NTR3116

Securing support for eye health policy in low- and middle-income countries: identifying stakeholders through a multi-level analysis

This article empirically evaluates advocacy in low- and middle-income countries as a key tool for raising policy priority and securing high-level decision maker support in eye health. We used a unique data set based on a survey conducted by World Health Organization in 2011 on eye care and prevention of blindness in 82 low- and middle-income countries. The theoretical framework derives from the idea that a plethora of stakeholders at local and global level pressure national governments, acting in economic and the political spheres. Previously, eye care has not been investigated in such a framework. We found structural differences across countries with different income levels and proposed policy recommendations to secure high-level decision makers' support for promoting eye health. Three case studies suggest that, in order to secure more support and resources for eye health, domestic and international stakeholders must strengthen their engagement with ministries of health at political and above all economic levels.

Embedding health policy and systems research into decision-making processes in low- and middle-income countries

Attention is increasingly directed to bridging the gap between the production of knowledge and its use for health decision-making in low- and middle-income countries (LMICs). An important and underdeveloped area of health policy and systems research (HPSR) is the organization of this process. Drawing from an interdisciplinary conception of embeddedness, a literature review was conducted to identify examples of embedded HPSR used to inform decision-making in LMICs. The results of the literature review were organized according to the World Health Organization’s Building Blocks Framework. Next, a conceptual model was created to illustrate the arrangement of organizations that produce embedded HPSR and the characteristics that facilitate its uptake into the arena of decision-making. We found that multiple forces converge to create context-specific pathways through which evidence enters into decision-making. Depending on the decision under consideration, the literature indicates that decision-makers may call upon an intricate combination of actors for sourcing HPSR. While proximity to decision-making does have advantages, it is not the position of the organization within the network, but rather the qualities the organization possesses, that enable it to be embedded. Our findings suggest that four qualities influence embeddedness: reputation, capacity, quality of connections to decision-makers, and quantity of connections to decision-makers and others. In addition to this, the policy environment (e.g. the presence of legislation governing the use of HPSR, presence of strong civil society, etc.) strongly influences uptake. Through this conceptual model, we can understand which conditions are likely to enhance uptake of HPSR in LMIC health systems. This raises several important considerations for decision-makers and researchers about the arrangement and interaction of evidence-generating organizations in health systems.

The provincial health office as performance manager: change in the local healthcare system after Thailand's universal coverage reforms

This paper examines the implementation of Thailand's universal coverage healthcare reforms in a rural province, using data from field studies undertaken in 2003-2005 and 2008-2011. We focus on the strand of policy that aimed to develop primary care by allocating funds to contracting units for primary care (CUPs) responsible for managing local service networks. The two studies document a striking change in the balance of power in the local healthcare system over the 8-year period. Initially, the newly formed CUPs gained influence as 'power followed the money', and the provincial health offices (PHOs), which had commanded the service units, were left with a weaker co-ordination role. However, the situation changed as a new insurance purchaser, the National Health Security Office, took financial control and established regional outposts. National Health Security Office outposts worked with PHOs to develop rationalised management tools-strategic plans, targets, KPIs and benchmarking-that installed the PHOs as performance managers of local healthcare systems. New lines of accountability and changed budgetary systems reduced the power of the CUPs to control resource allocation and patterns of services within CUP networks. Whereas some CUPs fought to retain limited autonomy, the PHO has been able to regain much of its former control. We suggest that implementation theory needs to take a long view to capture the complexity of a major reform initiative and argue for an analysis that recognises the key role of policy networks and advocacy coalitions that span national and local levels and realign over time.

Core Concepts of Human Rights and Inclusion of Vulnerable Groups in the Disability and Rehabilitation Policies of Malawi, Namibia, Sudan, and South Africa

In recent decades, there has been a push to incorporate the World Health Organization “Health for All” principles in national, regional, and local health policy documents. However, there is still no methodology guiding the appraisal of such policies with regard to the extent that they address social inclusion. In this article, the authors report on the development of EquiFrame, a novel policy analysis framework that was used to evaluate the disability and rehabilitation policies of Malawi, Namibia, Sudan, and South Africa. The policies were assessed in terms of their commitment to 21 predefined core concepts of human rights and inclusion of 12 vulnerable groups. Substantial variability was identified in the degree to which the core concepts and vulnerable groups were featured in these policy documents. The overall summary rankings for the disability policies of the countries studied were as follows: Namibia–High, Malawi–Low, and Sudan–Low. The rehabilitation policy of South Africa was ranked as Low. The results support the idea that adequate disability and rehabilitation policies remain mostly undefined. EquiFrame may offer a useful methodology for evaluating and comparing human rights and social inclusion across policy documents.

Inclusion and human rights in health policies: comparative and benchmarking analysis of 51 policies from Malawi, Sudan, South Africa and Namibia

While many health services strive to be equitable, accessible and inclusive, peoples' right to health often goes unrealized, particularly among vulnerable groups. The extent to which health policies explicitly seek to achieve such goals sets the policy context in which services are delivered and evaluated. An analytical framework was developed--EquiFrame--to evaluate 1) the extent to which 21 Core Concepts of human rights were addressed in policy documents, and 2) coverage of 12 Vulnerable Groups who might benefit from such policies. Using this framework, analysis of 51 policies across Malawi, Namibia, South Africa and Sudan, confirmed the relevance of all Core Concepts and Vulnerable Groups. Further, our analysis highlighted some very strong policies, serious shortcomings in others as well as country-specific patterns. If social inclusion and human rights do not underpin policy formation, it is unlikely they will be inculcated in service delivery. EquiFrame facilitates policy analysis and benchmarking, and provides a means for evaluating policy revision and development.

National ICT Policies and Development

While there is a fairly robust literature on information and communications technology (ICT) national policy, there are missing elements in the existing research. First, nation states at different stages of development are generally not considered in terms of what kind of ICT national policy is optimal. Second, a stakeholder perspective on the creation and implementation of the policy is typically absent. This theoretical paper attempts to fill these gaps by combining the idea of nations at different stages of development with stakeholder theory. The authors also integrate past thinking and research about information technology transfer, i.e., ICT outcomes, into a Stage-Stakeholder Model of ICT Policy. Directions for future research are proposed.

What shapes research impact on policy? Understanding research uptake in sexual and reproductive health policy processes in resource poor contexts

Assessing the impact that research evidence has on policy is complex. It involves consideration of conceptual issues of what determines research impact and policy change. There are also a range of methodological issues relating to the question of attribution and the counter-factual. The dynamics of SRH, HIV and AIDS, like many policy arenas, are partly generic and partly issue- and context-specific. Against this background, this article reviews some of the main conceptualisations of research impact on policy, including generic determinants of research impact identified across a range of settings, as well as the specificities of SRH in particular. We find that there is scope for greater cross-fertilisation of concepts, models and experiences between public health researchers and political scientists working in international development and research impact evaluation. We identify aspects of the policy landscape and drivers of policy change commonly occurring across multiple sectors and studies to create a framework that researchers can use to examine the influences on research uptake in specific settings, in order to guide attempts to ensure uptake of their findings. This framework has the advantage that distinguishes between pre-existing factors influencing uptake and the ways in which researchers can actively influence the policy landscape and promote research uptake through their policy engagement actions and strategies. We apply this framework to examples from the case study papers in this supplement, with specific discussion about the dynamics of SRH policy processes in resource poor contexts. We conclude by highlighting the need for continued multi-sectoral work on understanding and measuring research uptake and for prospective approaches to receive greater attention from policy analysts.

Health policy processes in maternal health: a comparison of Vietnam, India and China

This article reports on a comparative analysis to assess and explain the strengths and weaknesses of policy processes based on 9 case-studies of maternal health in Vietnam, India and China. Policy processes are often slow, inadequately coordinated and opaque to outsiders. Use of evidence is variable and, in particular, could be more actively used to assess different policy options. Whilst an increasing range of actors are involved, there is scope for further opening up of the policy processes. This is likely, if appropriately managed with due regard to issues such as accountability of advocacy organisations, to lead to stronger policy development and greater subsequent ownership; it may however be a more messy process to co-ordinate. Coordination is critical where policy issues span conventional sectoral boundaries, but is also essential to ensure development of policy considers critical health system and resource issues. This, and other features related to the nature of a specific policy issue, suggests the need both to adapt processes for each particular policy issue and to monitor the progress of the policy processes themselves. The article concludes with specific questions to be considered by actors keen to enhance policy processes.

The evolution of HIV policy in Vietnam: from punitive control measures to a more rights-based approach

Aim

Policymaking in Vietnam has traditionally been the preserve of the political elite, not open to the scrutiny of those outside the Communist Party. This paper aims to analyse Vietnam's HIV policy development in order to describe and understand the policy content, policy-making processes, actors and obstacles to policy implementation.

Methods

Nine policy documents on HIV were analysed and 17 key informant interviews were conducted in Hanoi and Quang Ninh Province, based on a predesigned interview guide. Framework analysis, a type of qualitative content analysis, was applied for data analysis.

Results

Our main finding was that during the last two decades, developments in HIV policy in Vietnam were driven in a top-down way by the state organs, with support and resources coming from international agencies. Four major themes were identified: HIV policy content, the policy-making processes, the actors involved and human resources for policy implementation. Vietnam's HIV policy has evolved from one focused on punitive control measures to a more rights-based approach, encompassing harm reduction and payment of health insurance for medical costs of patients with HIV-related illness. Low salaries and staff reluctance to work with patients, many of whom are drug users and female sex workers, were described as the main barriers to low health staff motivation.

Conclusion

Health policy analysis approaches can be applied in a traditional one party state and can demonstrate how similar policy changes take place, as those found in pluralistic societies, but through more top-down and somewhat hidden processes. Enhanced participation of other actors, like civil society in the policy process, is likely to contribute to policy formulation and implementation that meets the diverse needs and concerns of its population.

Mental health policy process: a comparative study of Ghana, South Africa, Uganda and Zambia

BACKGROUND

Mental illnesses are increasingly recognised as a leading cause of disability worldwide, yet many countries lack a mental health policy or have an outdated, inappropriate policy. This paper explores the development of appropriate mental health policies and their effective implementation. It reports comparative findings on the processes for developing and implementing mental health policies in Ghana, South Africa, Uganda and Zambia as part of the Mental Health and Poverty Project.

METHODS

The study countries and respondents were purposively selected to represent different levels of mental health policy and system development to allow comparative analysis of the factors underlying the different forms of mental health policy development and implementation. Data were collected using semi-structured interviews and document analysis. Data analysis was guided by conceptual framework that was developed for this purpose. A framework approach to analysis was used, incorporating themes that emerged from the data and from the conceptual framework.

RESULTS

Mental health policies in Ghana, South Africa, Uganda and Zambia are weak, in draft form or non-existent. Mental health remained low on the policy agenda due to stigma and a lack of information, as well as low prioritisation by donors, low political priority and grassroots demand. Progress with mental health policy development varied and respondents noted a lack of consultation and insufficient evidence to inform policy development. Furthermore, policies were poorly implemented, due to factors including insufficient dissemination and operationalisation of policies and a lack of resources.

CONCLUSIONS

Mental health policy processes in all four countries were inadequate, leading to either weak or non-existent policies, with an impact on mental health services. Recommendations are provided to strengthen mental health policy processes in these and other African countries.

Costing the scaling-up of human resources for health: lessons from Mozambique and Guinea Bissau

INTRODUCTION

In the context of the current human resources for health (HRH) crisis, the need for comprehensive Human Resources Development Plans (HRDP) is acute, especially in resource-scarce sub-Saharan African countries. However, the financial implications of such plans rarely receive due consideration, despite the availability of much advice and examples in the literature on how to conduct HRDP costing. Global initiatives have also been launched recently to standardise costing methodologies and respective tools.

METHODS

This paper reports on two separate experiences of HRDP costing in Mozambique and Guinea Bissau, with the objective to provide an insight into the practice of costing exercises in information-poor settings, as well as to contribute to the existing debate on HRH costing methodologies. The study adopts a case-study approach to analyse the methodologies developed in the two countries, their contexts, policy processes and actors involved.

RESULTS

From the analysis of the two cases, it emerged that the costing exercises represented an important driver of the HRDP elaboration, which lent credibility to the process, and provided a financial framework within which HRH policies could be discussed. In both cases, bottom-up and country-specific methods were designed to overcome the countries' lack of cost and financing data, as well as to interpret their financial systems. Such an approach also allowed the costing exercises to feed directly into the national planning and budgeting process.

CONCLUSIONS

The authors conclude that bottom-up and country-specific costing methodologies have the potential to serve adequately the multi-faceted purpose of the exercise. It is recognised that standardised tools and methodologies may help reduce local governments' dependency on foreign expertise to conduct the HRDP costing and facilitate regional and international comparisons. However, adopting pre-defined and insufficiently flexible tools may undermine the credibility of the costing exercise, and reduce the space for policy negotiation opportunities within the HRDP elaboration process.

Prospective policy analysis: how an epistemic community informed policymaking on intentional self poisoning in Sri Lanka

Background

Policy analysis is often retrospective and not well suited to helping policy makers decide what to do; in contrast prospective policy analysis seeks to assist in formulating responses to challenging public policy questions. Suicide in Sri Lanka is a major public health problem, with ingestion of pesticides being the primary method. Previous policy interventions have been associated with reduced mortality through restricting access to the most toxic pesticides. Additional means of reducing access are still needed.

Methods

The prospective policy analysis comprised two stages. The first used a consensus activity within a well defined policy community to generate and frame policy options. The second broadened the analysis to include other stakeholders. We report the consensus activity with seven actors from agriculture, health, and academia. Policy options were identified through two rounds of discussion along with ratings by each participant on their degree of support for each option. Data were analysed quantitatively and discussions analysed with Nvivo 8 to code prominent and recurrent themes.

Results

The main finding was the strong support and consensus for two proposals: further regulation of pesticides and the novel idea of repackaging pesticides into non-lethal doses. Participants identified several factors that were supportive of future policy change including a strong legislative framework, good links between agriculture, health and academia, and a collaborative relationship with industry. Identified barriers and potential threats to policy change included political interference, difficulties of intersectoral collaboration, acceptability of options to the community, difficulty of implementation in rural communities and the challenge of reducing mortality.

Conclusions

The development and consideration of policy options within this epistemic community reflected an appreciation and understanding of many of the factors that can facilitate or thwart policy change. The understanding of context, evidence and ideas, implementation and impact influenced how the participants considered and rated the options. Use of epistemic community actors identified the level of support for each option, helped elaborate the particularities of context, as well as the power and influence of ideas. Further examination of the potential barriers and opportunities for these options will determine if broader consensus, involving a wider range of stakeholders, can be achieved and policy change promoted.

Historical development of health technology assessment in Thailand

OBJECTIVES

This study aims to review the development of health technology assessment (HTA), including the socioeconomic context, outputs, and policy utilization in the Thai setting.

METHODS

This study was conducted through extensive document reviews including these published in both domestic and international literature.

RESULTS

Evidence suggests that contextual elements of the health system, especially the country's economic status and health financing reforms, as well as their effects on government budgeting for medical and public health services, played an important role in the increasing needs and demands for HTA information among policy makers. In the midst of substantial economic growth during the years 1982 to 1996, several studies reported the rapid diffusion and poor distribution of health technologies, and inequitable access to high-cost technology in public and private hospitals. At the same time, economic analysis and its underpinning concept of efficiency were suggested by groups of scholars and health officials to guide national policy on the investment in health technology equipment. Related research and training programs were subsequently launched. However, none of these HTA units could be institutionalized into national bodies. From 1997 to 2005, an economic recession, followed by the introduction of a universal health coverage plan, triggered the demands for effective measures for cost containment and prioritization of health interventions. This made policy makers and researchers at the Ministry of Public Health (MOPH) pay increasing attention to economic appraisals, and several HTA programs were established in the Ministry. Despite the rising number of Thai health economic publications, a major problem at that period involved the poor quality of studies. Since 2006, economic recovery and demands from different interests to include expensive technologies in the public health benefit package have been crucial factors promoting the role of HTA in national policy decisions. Meanwhile, HTA capacity has been strengthened through the establishment of many health economic and HTA initiatives. An illustration of the work and contributions of the Health Intervention and Technology Assessment Program (HITAP) is provided. In this phase, HTA policy integration has been enhanced through different mechanisms and organizations.

CONCLUSION

Over the past two decades a notable progression has been made in relation to the capacity building of HTA research and its policy utility in Thailand. Such development has been shaped by multiple factors. It is anticipated that experience gained among academics, health officials, and civil society organizations will be helpful not only in sustaining the momentum but also in improving formal HTA systems in the future.

Challenge and co-operation: civil society activism for access to HIV treatment in Thailand

Civil society has been a driving force behind efforts to increase access to treatment in Thailand. A focus on HIV medicines brought civil society and non-governmental and government actors together to fight for a single cause, creating a platform for joint action on practical issues to improve care for people with HIV/AIDS (PHA) within the public health system. The Thai Network of People with HIV/AIDS, in partnership with other actors, has provided concrete support for patients and for the health system as a whole; its efforts have contributed significantly to the availability of affordable generic medicines, early treatment for opportunistic infections, and an informed and responsible approach towards antiretroviral treatment that is critical to good adherence and treatment success. This change in perception of PHA from 'passive receiver' to 'co-provider' of health care has led to improved acceptance and support within the healthcare system. Today, most PHA in Thailand can access treatment, and efforts have shifted to supporting care for excluded populations.