Evidence-informed policymaking in practice: country-level examples of use of evidence for iCCM policy

Strengthening health service delivery and governance through institutionalizing 'Urban Health Atlas'-A geo-referenced Information Communication and Technology tool: Lessons learned from an implementation research in three cities in Bangladesh

INTRODUCTION

Urban health governance in Bangladesh is complex as multiple actors are involved and no comprehensive data are currently available on infrastructure, services, or performance either in public and private sectors of the healthcare system. The Urban Health Atlas (UHA)-a novel and interactive geo-referenced, web-based visualization tool was developed in Bangladesh to provide geospatial and service information to decision makers involved in urban health service planning and governance. Our objective was to study the opportunities for institutionalization of the UHA into government health systems responsible for urban healthcare delivery and document the facilitators and barriers to its uptake.

METHODS

This implementation research was carried out during 2017-2019 in three cities in Bangladesh: Dhaka, Dinajpur and Jashore. During the intervention period, six hands-on trainings on UHA were provided to 67 urban health managers across three study sites. Thirty in-depth and twelve key informant interviews were conducted to understand user experience and document stakeholder perceptions of institutionalizing UHA.

RESULTS

Capacity building on UHA enhanced understanding of health managers around its utility for service delivery planning, decision making and oversight. Findings from the IDIs and KIIs suggest that UHA uptake was challenged by inadequate ICT infrastructure, shortage of human resources and lack of ICT skill among managers. Motivating key decision makers and stakeholders about the potential of UHA and engaging them from its inception helped the institutionalization process.

CONCLUSION

While uptake of UHA by government health managers appears possible with dedicated capacity building initiatives, its use and regular update are challenged by multiple factors at the implementation level. A clear understanding of context, actors and system readiness is foundational in determining whether the institutionalization of health ICTs is timely, realistic or relevant.

From knowledge production to knowledge translation: Waterpipe tobacco control research in the Eastern Mediterranean Region

Waterpipe tobacco smoking (WTS) rates in the Eastern Mediterranean Region (EMR) are the highest worldwide, particularly among young people. Although fiscal policies to curb tobacco use have been recommended by the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), implementation has been suboptimal. The Eastern Mediterranean Consortium on the Economics of Waterpipe Tobacco Smoking (ECON-WTS) was formed in response to this need to produce knowledge on the economics of WTS in the EMR and apply a comprehensive Knowledge translation (KT) framework. The KT framework comprised priority setting, evidence synthesis, knowledge translation, and knowledge uptake. In this article, we discuss the approaches followed in applying the KT framework to WTS control, providing examples and noting challenges and lessons learned where possible.

Evidence synthesis to policy: development and implementation of an impact-oriented approach from the Eastern Mediterranean Region

BACKGROUND

Despite the importance of evidence syntheses in informing policymaking, their production and use remain limited in the Eastern Mediterranean region (EMR). There is a lack of empirical research on approaches to promote and use policy-relevant evidence syntheses to inform policymaking processes in the EMR.

OBJECTIVE

This study sought to describe the development of an impact-oriented approach to link evidence synthesis to policy, and its implementation through selected case studies in Lebanon, a middle-income country in the EMR.

METHODS

This study followed a multifaceted and iterative process that included (i) a review of the literature, (ii) input from international experts in evidence synthesis and evidence-informed health policymaking, and (iii) application in a real-world setting (implementation). We describe four selected case studies of implementation. Surveys were used to assess policy briefs, deliberative dialogues, and post-dialogue activities. Additionally, Kingdon's stream theory was adopted to further explain how and why the selected policy issues rose to the decision agenda.

RESULTS

The approach incorporates three interrelated phases: (1) priority setting, (2) evidence synthesis, and (3) uptake. Policy-relevant priorities are generated through formal priority setting exercises, direct requests by policymakers and stakeholders, or a focusing event. Identified priorities are translated into focused questions that can be addressed via evidence synthesis (phase 1). Next, a scoping of the literature is conducted to identify existing evidence syntheses addressing the question of interest. Unless the team identifies relevant, up-to-date and high-quality evidence syntheses, it proceeds to conducting SRs addressing the priority questions of interest (phase 2). Next, the team prepares knowledge translation products (e.g., policy briefs) for undertaking knowledge uptake activities, followed by monitoring and evaluation (phase 3). There are two prerequisites to the application of the approach: enhancing contextual awareness and capacity strengthening. The four case studies illustrate how evidence produced from the suites of activities was used to inform health policies and practices.

CONCLUSIONS

To our knowledge, this is the first study to describe both the development and implementation of an approach to link evidence synthesis to policy in the EMR. We believe the approach will be useful for researchers, knowledge translation platforms, governments, and funders seeking to promote evidence-informed policymaking and practice.

Framing and the formation of global health priorities

Health issues vary in the amount of attention and resources they receive from global health organisations and national governments. How issues are framed could shape differences in levels of priority. We reviewed scholarship on global health policy making to examine the role of framing in shaping global health priorities. The review provides evidence of the influence of three framing processes-securitisation, moralisation, and technification. Securitisation refers to an issue's framing as an existential threat, moralisation as an ethical imperative, and technification as a wise investment that science can solve. These framing processes concern more than how issues are portrayed publicly. They are socio-political processes, characterised by contestation among actors in civil society, government, international organisations, foundations, and research institutions. These actors deploy various forms of power to advance particular frames as a means of securing attention and resources for the issues that concern them. The ascription of an issue as a security concern, an ethical imperative, or a wise investment is historically contingent: it is not inevitable that any given issue will be framed in one or more of these ways. A health issue's inherent characteristics-such as the lethality of a pathogen that causes it-also shape these ascriptions, but do not fully determine them. Although commonly facing resistance, global health elites often determine which frames prevail, raising questions about the legitimacy of priority-setting processes. We draw on the review to offer ideas on how to make these processes fairer than they are at present, including a call for democratic representation even as necessary space is preserved for elite expertise.

The role of integrated community case management projects in strengthening health systems: case study analysis in Ethiopia, Malawi and Mozambique

Integrated community case management (iCCM) has now been implemented at scale globally. Literature to-date has focused primarily on the effectiveness of iCCM and the systems conditions required to sustain iCCM. In this study, we sought to explore opportunities taken and lost for strengthening health systems through successive iCCM programmes. We employed a systematic, embedded, multiple case study design for three countries-Ethiopia, Malawi and Mozambique-where Save the Children implemented iCCM programmes between 2009 and 2017. We used textual analysis to code 62 project documents on nine categories of functions of health systems using NVivo 11.0. The document review was supplemented by four key informant interviews. This study makes important contributions to the theoretical understanding of the role of projects in health systems strengthening by not only documenting evidence of systems strengthening in multi-year iCCM projects, but also emphasizing important deficiencies in systems strengthening efforts. Projects operated on a spectrum, ranging from gap-filling interventions, to support, to actual strengthening. While there were natural limits to the influence of a project on the health system, all successive projects found constructive opportunities to try to strengthen systems. Alignment with the Ministry of Health was not always static and simple, and ministries themselves have shown pluralism in their perspectives and orientations. We conclude that systems strengthening remains 'everybody's business' and places demands for realism and transparency on government and the development architecture. While mid-size projects have limited decision space, there is value in better defining where systems strengthening contributions can actually be made. Furthermore, systems strengthening is not solely about macro-level changes, as operational and efficiency gains at meso and micro levels can have value to the system. Claims of 'systems strengthening' are, however, bounded within the quality of evaluation and learning investments.

The role of governance in implementing sustainable global health interventions: review of health system integration for integrated community case management (iCCM) of childhood illnesses

Improving health outcomes in countries with the greatest burden of under-5 child mortality requires implementing innovative approaches like integrated community case management (iCCM) to improve coverage and access for hard-to-reach populations. ICCM improves access for hard-to-reach populations by deploying community health workers to manage malaria, diarrhoea and pneumonia. Despite documented impact, challenges remain in programme implementation and sustainability. An analytical review was conducted using evidence from published and grey literature from 2010 to 2019. The goal was to understand the link between governance, policy development and programme sustainability for iCCM. A Governance Analytical Framework revealed thematic challenges and successes for iCCM adaptation to national health systems. Governance in iCCM included the collective problems, actors in coordination and policy-setting, contextual norms and programmatic interactions. Key challenges were country leadership, contextual evidence and information-sharing, dependence on external funding, and disease-specific stovepipes that impede funding and coordination. Countries that tailor and adapt programmes to suit their governance processes and meet their specific needs and capacities are better able to achieve sustainability and impact in iCCM.

Lessons Learned from Strategies for Promotion of Evidence-to-Policy Process in Health Interventions in the ECOWAS Region: A Rapid Review

Context:

The West African Health Organization (WAHO) is vigorously supporting evidence-informed policymaking (EIPM) in the countries of West Africa. EIPM is increasingly recognized as one of the key strategies that can contribute to health systems strengthening and the improvement of health outcomes. The purpose of this rapid review is to examine two key examples of evidence-based strategies used to successfully implement health interventions in each of the West African countries and to highlight the lessons learned.

Methods:

A rapid review technique, defined as a type of knowledge synthesis in which systematic review processes are accelerated and methods are streamlined to complete the review more quickly, was used. A PubMed search was conducted using the combination of the following keywords: Health, policy making, evidence, plus name of each of the 15 countries to identify studies that described the process of use of evidence in policymaking in health interventions. Two examples of the publications that fulfilled the study inclusion criteria were selected.

Results:

Among the key processes used by the countries to promote EIPM in health interventions include policy cycle mechanism and political prioritization, rapid response services, technical advisory group and steering committees (SCs), policy dialog, capacity-strengthening mechanisms, local context evidence and operational guidelines, multisectoral action and consultative process.

Conclusion:

Various degrees of success have been achieved in by West African countries in the promotion of EIPM. As the science of EIPM continues to evolve and better understanding of the process is gained among policymakers, more studies on effective strategies to improve the evidence-to-policy process are advocated.

Public health policy-making for hearing loss: stakeholders' evaluation of a novel eHealth tool

Background

Hearing loss (HL) affects 466 million people of all ages worldwide, with a rapidly increasing prevalence, and therefore requires appropriate public health policies. Multi-disciplinary approaches that make use of eHealth services can build the evidence to influence public policy. The European Union-funded project EVOTION developed a platform that is fed with real-time data from hearing aids, a smartphone, and additional clinical data and makes public health policy recommendations based on hypothetical public health policy-making models, a big data engine and decision support system. The present study aimed to evaluate this platform as a new tool to support policy-making for HL.

Methods

A total of 23 key stakeholders in the United Kingdom, Croatia, Bulgaria and Poland evaluated the platform according to the Strengths, Weaknesses, Opportunities and Threats methodology.

Results

There was consensus that the platform, with its advanced technology as well as the amount and variety of data that it can collect, has huge potential to inform commissioning decisions, public health regulations and affect healthcare as a whole. To achieve this, several limitations and external risks need to be addressed and mitigated. Differences between countries highlighted that the EVOTION tool should be used and managed according to local constraints to maximise success.

Conclusion

Overall, the EVOTION platform can equip HL policy-makers with a novel data-driven tool that can support public health policy-making for HL in the future.

Thematic areas and complexity of integrated community case management (iCCM) design, implementation, and evaluation: protocol for a scoping review

BACKGROUND

Integrated community case management (iCCM) is a community-based child health strategy designed to reduce deaths due to pneumonia, malaria, and diarrhea in low-income countries. Due to the integrated nature of the intervention and the diversity of its stakeholders and activities, iCCM is complex and comprises many systems elements. However, the extent to which studies examine these different elements is unknown. The purpose of this scoping review is to summarize the key areas of emphasis of the iCCM literature and assess the extent to which this takes into account systems complexity.

METHODS

This study will be guided by Arksey and O'Malley's scoping review methodology. We will systematically screen MEDLINE, Web of Science, and the specialized platform Community Case Management (CCM) Central Library for published literature in English related to the design, implementation, and evaluation of iCCM. Two investigators will independently screen the full list of titles and abstracts for eligibility, followed by a full-text review of selected titles divided between investigators. Emergent themes will be categorized according to a thematic tool iteratively developed to guide the charting and analysis process. To compare the extent to which the literature assesses systems factors, we will compare our results with the iCCM Interagency Framework. We will use the Intervention Complexity Tool for Systematic Reviews (iCAT_SR) to assess how literature measures complexity. Results will be presented in narrative fashion, supplemented by interactive graphical interfaces.

DISCUSSION

The results of this scoping review will identify the priorities and deficiencies of the analysis and evaluation of iCCM programs and may illustrate the need for systems approaches. Bottom-up emergent iCCM themes can help researchers, policymakers, and implementers target and better emphasize true priorities of iCCM. Understanding how complexity is considered and examined in iCCM may result in greater attention to this critical dimension of iCCM program assessment, resulting in the design and development of more robust and sustainable iCCM programs.

Integrated community case management: planning for sustainability in five African countries

Background

The World Health Organization (WHO) launched an initiative to plan for the sustainability of integrated community case management (iCCM) programmes supported by the Rapid Access Expansion (RAcE) Programme in five African countries in 2016. WHO contracted experts to facilitate sustainability planning among Ministries of Health, WHO, nongovernmental organisation grantees, and other stakeholders.

Methods

We designed an iterative and unique process for each RAcE project area which involved creating a sustainability framework to guide planning; convening meetings to identify and prioritise elements of the framework; forming technical working groups to build country ownership; and, ultimately, creating roadmaps to guide efforts to fully transfer ownership of the iCCM programmes to host countries. For this analysis, we compared priorities identified in roadmaps across RAcE project sites, examined progress against roadmaps via transition plans, and produced recommendations for short-term actions based on roadmap priorities that were unaddressed or needed further attention.

Results

This article describes the sustainability planning process, roadmap priorities, progress against roadmaps, and recommendations made for each project area. We found a few patterns among the prioritised roadmap elements. Overall, every project area identified priorities related to policy and coordination of external stakeholders including funders; supply chain management; service delivery and referral system; and communication and social mobilisation, indicating that these factors have persisted despite iCCM programme maturity, and are also of concern to new programmes. We also found that a facilitated process to identify and document programme priorities in roadmaps, along with deliberately planning for transition from an external implementer to a national system could support the sustainability of iCCM programmes by facilitating teams of stakeholders to accomplish explicit tasks related to transitioning the programme.

Conclusions

Certain common elements are of concern for sustaining iCCM programmes across countries, among them political leadership, supply chain management, data processes, human resources, and community engagement. Adapting and using a sustainability planning approach created an inclusive and comprehensive dialogue about systemic factors that influence the sustainability of iCCM services and facilitated changes to health systems in each country.

Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all

Achieving ambitious health goals-from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of 'health for all'-necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers-particularly the well-known WHO 'building blocks' framework-only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.

Evidence map of knowledge translation strategies, outcomes, facilitators and barriers in African health systems

Background

The need for research-based knowledge to inform health policy formulation and implementation is a chronic global concern impacting health systems functioning and impeding the provision of quality healthcare for all. This paper provides a systematic overview of the literature on knowledge translation (KT) strategies employed by health system researchers and policy-makers in African countries.

Methods

Evidence mapping methodology was adapted from the social and health sciences literature and used to generate a schema of KT strategies, outcomes, facilitators and barriers. Four reference databases were searched using defined criteria. Studies were screened and a searchable database containing 62 eligible studies was compiled using Microsoft Access. Frequency and thematic analysis were used to report study characteristics and to establish the final evidence map. Focus was placed on KT in policy formulation processes in order to better manage the diversity of available literature.

Results

The KT literature in African countries is widely distributed, problematically diverse and growing. Significant disparities exist between reports on KT in different countries, and there are many settings without published evidence of local KT characteristics. Commonly reported KT strategies include policy briefs, capacity-building workshops and policy dialogues. Barriers affecting researchers and policy-makers include insufficient skills and capacity to conduct KT activities, time constraints and a lack of resources. Availability of quality locally relevant research was the most reported facilitator. Limited KT outcomes reflect persisting difficulties in outcome identification and reporting.

Conclusion

This study has identified substantial geographical gaps in knowledge and evidenced the need to boost local research capacities on KT practices in low- and middle-income countries. Evidence mapping is also shown to be a useful approach that can assist local decision-making to enhance KT in policy and practice.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0419-0) contains supplementary material, which is available to authorized users.

Implementation research: new imperatives and opportunities in global health

Implementation research is important in global health because it addresses the challenges of the know-do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. This type of research uses multiple disciplines and methods and emphasises partnerships between community members, implementers, researchers, and policy makers. Implementation research focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research and a range of perspectives on its purposes and appropriate methods. However, limited efforts have been made to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this Health Policy paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low-income and middle-income countries. The case studies are organised into four categories related to the purposes of using implementation research, including improving people's health, informing policy design and implementation, strengthening health service delivery, and empowering communities and beneficiaries. Each of the case studies addresses implementation problems, involves partnerships to co-create solutions, uses tacit knowledge and research, and is based on a shared commitment towards improving health outcomes. The case studies reveal the complex adaptive nature of health systems, emphasise the importance of understanding context, and highlight the role of multidisciplinary, rigorous, and adaptive processes that allow for course correction to ensure interventions have an impact. This Health Policy paper is part of a call to action to increase the use of implementation research in global health, build the field of implementation research inclusive of research utilisation efforts, and accelerate efforts to bridge the gap between research, policy, and practice to improve health outcomes.

Knowledge translation for public health in low- and middle- income countries: a critical interpretive synthesis

Background

Effective knowledge translation allows the optimisation of access to and utilisation of research knowledge in order to inform and enhance public health policy and practice. In low- and middle- income countries, there are substantial complexities that affect the way in which research can be utilised for public health action. This review attempts to draw out concepts in the literature that contribute to defining some of the complexities and contextual factors that influence knowledge translation for public health in low- and middle- income countries.

Methods

A Critical Interpretive Synthesis was undertaken, a method of analysis which allows a critical review of a wide range of heterogeneous evidence, through incorporating systematic review methods with qualitative enquiry techniques. A search for peer-reviewed articles published between 2000 and 2016 on the topic of knowledge translation for public health in low- and middle – income countries was carried out, and 85 articles were reviewed and analysed using this method.

Results

Four main concepts were identified: 1) tension between ‘global’ and ‘local’ health research, 2) complexities in creating and accessing evidence, 3) contextualising knowledge translation strategies for low- and middle- income countries, and 4) the unique role of non-government organisations in the knowledge translation process.

Conclusion

This method of review has enabled the identification of key concepts that may inform practice or further research in the field of knowledge translation in low- and middle- income countries.

Electronic supplementary material

The online version of this article (10.1186/s41256-018-0084-9) contains supplementary material, which is available to authorized users.

Hubris, humility and humanity: expanding evidence approaches for improving and sustaining community health programmes

Community-based approaches are a critical foundation for many health outcomes, including reproductive, maternal, newborn and child health (RMNCH). Evidence is a vital part of strengthening that foundation, but largely focuses on the technical content of what must be done, rather than on how disparate community actors continuously interpret, implement and adapt interventions in dynamic and varied community health systems. We argue that efforts to strengthen evidence for community programmes must guard against the hubris of relying on a single approach or hierarchy of evidence for the range of research questions that arise when sustaining community programmes at scale. Moving forward we need a broader evidence agenda that better addresses the implementation realities influencing the scale and sustainability of community programmes and the partnerships underpinning them if future gains in community RMNCH are to be realised. This will require humility in understanding communities as social systems, the complexity of the interventions they engage with and the heterogeneity of evidence needs that address the implementation challenges faced. It also entails building common ground across epistemological word views to strengthen the robustness of implementation research by improving the use of conceptual frameworks, addressing uncertainty and fostering collaboration. Given the complexity of scaling up and sustaining community RMNCH, ensuring that evidence translates into action will require the ongoing brokering of relationships to support the human creativity, scepticism and scaffolding that together build layers of evidence, critical thinking and collaborative learning to effect change.

Knowledge and power in policy-making for child survival in Niger

Calls to enhance the use of scientific evidence in international health and development policy have increased in recent years; however, analytic frameworks for understanding evidence use focus narrowly on scientific research and were created using data and observations nearly exclusively from Western countries. We examine processes of health policy development in a case study of Niger, a low-income West African country that adopted integrated community case management of childhood illness (iCCM) beginning in 2007, resulting in measurable declines in child mortality. Data collection included in-depth interviews with policy actors in Niger (N = 32), document review (N = 103) and direct observation of policy forums (N = 3). Data analysis used process tracing methodology and applied an Aristotelian definition of "knowledge" as 1) episteme (facts), 2) techne (skills) and 3) phronesis (practical wisdom), while also using a critical perspective to understand issues of power. We found sharp differentials in policy-makers' possession and use of codified forms of knowledge (episteme), with Nigerien policy officers' access highly mediated by actors at international agencies. Government policy-makers possessed skills and capacities (techne) to negotiate with donors and deliberate and weigh conflicting considerations; however they lacked capacity and resources to formally evaluate and document programs and thus reliably draw lessons from them. Practical wisdom (phronesis) emerged as key to the iCCM policy enterprise, particularly among Nigerien government actors, who used logical and ethical arguments to make decisions later found to be critical to iCCM's success. While codified knowledge confers power on members of policy discussions who can access it, this represents only one form of knowledge used in the policy process and perhaps not the most important. Future research on evidence-based policy should use broader definitions of evidence or knowledge, examine on how power conditions the use of knowledge, and examine challenges specific to low-resource policy environments.

Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review

BACKGROUND

Human resource for health crisis has impaired global efforts against malaria in highly endemic countries. To address this, the World Health Organization (WHO) recommended scaling-up of community health workers (CHWs) and related cadres owing to their documented success in malaria and other disease prevention and management. Evidence is inconsistent on the roles and challenges they encounter in malaria interventions. This systematic review aims to summarize evidence on roles and challenges of CHWs and related cadres in integrated community case management for malaria (iCCM).

METHODS

This systematic review retrieved evidence from PubMed, CINAHL, ISI Web of Knowledge, and WHO regional databases. Terms extracted from the Boolean phrase used for PubMed were also used in other databases. The review included studies with Randomized Control Trial, Quasi-experimental, Pre-post interventional, Longitudinal and cohort, Cross-sectional, Case study, and Secondary data analysis. Because of heterogeneity, only narrative synthesis was conducted for this review.

RESULTS

A total of 66 articles were eligible for analysis out of 1380 studies retrieved. CHWs and related cadre roles in malaria interventions included: malaria case management, prevention including health surveillance and health promotion specific to malaria. Despite their documented success, CHWs and related cadres succumb to health system challenges. These are poor and unsustainable finance for iCCM, workforce related challenges, lack of and unsustainable supply of medicines and diagnostics, lack of information and research, service delivery and leadership challenges.

CONCLUSIONS

Community health workers and related cadres had important preventive, case management and promotive roles in malaria interventions. To enable their effective integration into the health systems, the identified challenges should be addressed. They include: introducing sustainable financing on iCCM programmes, tailoring their training to address the identified gaps, improving sustainable supply chain management of malaria drugs and diagnostics, and addressing regulatory challenges in the local contexts.