Policy entrepreneurs and structural influence in integrated community case management policymaking in Burkina Faso

Health Policy and Systems Research Capacities in Ethiopia and Ghana: Findings From a Self-Assessment

Government investment in strengthening health policy and systems research capacities is needed to enhance the generation of evidence for effective policy making. Researchers’ engagement in the policy-making process helps shape policy-relevant research and support policy-relevant decisions.

Introduction:

Health systems are complex. Policies targeted at health system development may be informed by health policy and systems research (HPSR). This study assesses HPSR capacity to generate evidence and inform policy in Ethiopia and Ghana.

Methods:

We used a mixed-methods approach including a self-administered survey at selected HPSR institutes and in-depth interviews of policy makers.

Results:

Both countries have limited capacity to generate HPSR evidence, especially in terms of mobilizing adequate funding and retaining a critical number of competent researchers who understand complex policy processes, have the skills to influence policy, and know policy makers’ demands for evidence. Common challenges are limited government research funding, rigidity in executing the research budget, and reliance on donor funding that might not respond to national health priorities. There are no large research programs in either country. The annual number of HPSR projects per research institute in Ethiopia (10 projects) was higher than in Ghana (2.5 projects), Ethiopia has a significantly smaller annual budget for health research. Policy makers in the 2 countries increasingly recognize the importance of evidence-informed policy making, but various challenges remain in building effective interactions with HPSR institutes.

Conclusion:

We propose 3 synergistic recommendations to strengthen HPSR capacity in Ethiopia and Ghana. First, strengthen researchers’ capacity and enhance their opportunities to know policy actors; engage with the policy community; and identify and work with policy entrepreneurs, who have attributes, skills, and strategies to achieve a successful policy. Second, deliver policy-relevant research findings in a timely way and embed research into key health programs to guide effective implementation. Third, mobilize local and international funding to strengthen HPSR capacities as well as address challenges with recruiting and retaining a critical number of talented researchers. These recommendations may be applied to other low- and middle-income countries to strengthen HPSR capacities.

The effects of the global health crisis on U. S. immigration policies: shifting political agenda-setting and the mobility crisis of immigrants

The continuing health crisis (COVID-19) reinforces a historical pattern in which partisan-elected officials engage as legislative policy entrepreneurs (LPE) and use the health crisis time as a policy window to advance specifically restricted agendas by (re)introducing immigration bills on the House and Senate. The current exploratory qualitative study utilizes the theoretical underpinning of Kingdon’s Multiple Streams Framework (MSF) to analyze the US House immigration bills from 2013 to 2021. The qualitative method of content relational analysis was applied in this research to capture the shifts and changes in (re)introduced immigration bills (n = 904) in the US House of Representatives for the 113th, 114th, 115th, and 116th sessions. Capturing and examining the underlying tone, word choices, and proposed measures in these immigration bills during health and non-health crisis periods received special attention. The qualitative relational content analysis revealed three major themes: (1) During public health crises (Ebola, Zika, and the first two years of COVID-19), restrictive House immigration bills tend to rise sharply; (2) Elected representatives from the Southern States are more likely to introduce restrictive immigration bills during health crises; and (3) Restrictive immigration bills are more likely to receive partisan support (bill co-sponsors) during health crises. The findings emphasize the need for inclusive agenda-setting during health crises and provide light on adaptive measures for supporting underprivileged immigrant communities with increased access to healthcare and public support.

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.

How actors, processes, context and evidence influenced the development of Malawi's Health Sector Strategic Plan II

Health sector strategic plans are health policies outlining health service delivery in low- and middle- income countries, guiding health sectors to meet health needs while maximizing resources. However, little research has explored the formulation of these plans. This study utilized qualitative methods to explore the formulation of Malawi's Health Sector Strategic Plan II, including processes utilized, actors involved, important contextual factors and the use of evidence-based decision-making. Thirteen semi-structured key informant interviews with health policy actors were conducted to explore perceptions and experiences of formulating the policy. Data analysis used an inductive-deductive approach and interpretation of the data was guided by an adapted version of the Walt and Gilson Health Policy Triangle. Our results indicate that HSSP II formulation was complex and inclusive but that the Ministry of Health may have given up ownership of the formulation process to development partners to ensure their continued involvement. Disagreements between actors centered around inclusion of critical services in the Essential Health Package and selection of performance-based financing as purchasing strategy. Resource constraints and the Cashgate Scandal are critical contextual elements influencing the formulation and content of the policy. Evidence-based decision-making contributed to the plan's development despite respondents' divergent opinions regarding evidence availability, quality and the weight that evidence carried. The study raises questions regarding the roles of policy actors during health policy formulation, the inclusivity of health policy processes and their potential influence on government ownership of health policy, as well as the use of evidence in developing health sector strategic plans.

A health knowledge brokering intervention in a district of Burkina Faso: A qualitative retrospective implementation analysis

BACKGROUND

A knowledge brokering (KB) intervention was implemented in Burkina Faso. By creating partnerships with health system actors in one district, the broker was expected to assess their knowledge needs, survey the literature to provide the most recent research evidence, produce various knowledge translation tools, and support them in using research to improve their actions. The purpose of this study was to analyze the key factors that influenced the KB project and to make recommendations for future initiatives.

METHODS

The qualitative design involved a single case study in which the KB intervention implementation was evaluated retrospectively. Data came from interviews with the intervention team (n = 4) and with various actors involved in the intervention (n = 16). Data from formative evaluations conducted during the KB implementation and observation data from a two-month field mission were also used. Two conceptual frameworks were combined to guide the analysis: the Consolidated Framework for Implementation Research (Damschroder et al., 2009) and the Ecological Framework (Durlak & DuPre, 2008).

RESULTS

Various KB activities were conducted during the first two years of implementation at the local level. The project came to an early end following vain efforts to relocate the intervention at the central level in order to further influence the policy process. Certain shortcomings in the implementation team negatively influenced the implementation: inadequate leadership, no shared vision regarding the reorientation of the intervention, challenges related to the KB role, and lack of frank communications internally. Other impediments to the intervention's deployment included local actors' lack of decision-making authority, the unavailability of resources and of organizational incentives for involvement in the KB intervention, and contextual challenges in accessing the central level. However, the KB strategy presented several strengths: collaborative development, support provided to local partners by the broker, and training opportunities and support provided to the broker.

CONCLUSIONS

More attention must be paid to intervention planning, partners' engagement, human, financial and technical resources availability, continuous development of skills and of communications within the KB team, and periodic assessment of potential obstacles related to the complexity of the system within which the intervention has been implemented. Using implementation science frameworks when developing KB strategies in the West African context should be promoted.

Kenya's Health in All Policies strategy: a policy analysis using Kingdon's multiple streams

BACKGROUND

Health in All Policies (HiAP) is an intersectoral approach that facilitates decision-making among policy-makers to maximise positive health impacts of other public policies. Kenya, as a member of WHO, has committed to adopting HiAP, which has been included in the Kenya Health Policy for the period 2014-2030. This study aims to assess the extent to which this commitment is being translated into the process of governmental policy-making and supported by international development partners as well as non-state actors.

METHODS

To examine HiAP in Kenya, a qualitative case study was performed, including a review of relevant policy documents. Furthermore, 40 key informants with diverse backgrounds (government, UN agencies, development agencies, civil society) were interviewed. Analysis was carried out using the main dimensions of Kingdon's Multiple Streams Approach (problems, policy, politics).

RESULTS

Kenya is facing major health challenges that are influenced by various social determinants, but the implementation of intersectoral action focusing on health promotion is still arbitrary. On the policy level, little is known about HiAP in other government ministries. Many health-related collaborations exist under the concept of intersectoral collaboration, which is prominent in the country's development framework - Vision 2030 - but with no specific reference to HiAP. Under the political stream, the study highlights that political commitment from the highest office would facilitate mainstreaming the HiAP strategy, e.g. by setting up a department under the President's Office. The budgeting process and planning for the Sustainable Development Goals were found to be potential windows of opportunity.

CONCLUSION

While HiAP is being adopted as policy in Kenya, it is still perceived by many stakeholders as the business of the health sector, rather than a policy for the whole government and beyond. Kenya's Vision 2030 should use HiAP to foster progress in all sectors with health promotion as an explicit goal.

Boundary-spanning actors in complex adaptive governance systems: The case of multisectoral nutrition

A growing literature highlights complexity of policy implementation and governance in global health and argues that the processes and outcomes of policies could be improved by explicitly taking this complexity into account. Yet there is a paucity of studies exploring how this can be achieved in everyday practice. This study documents the strategies, tactics, and challenges of boundary‐spanning actors working in 4 Sub‐Saharan Africa countries who supported the implementation of multisectoral nutrition as part of the African Nutrition Security Partnership in Burkina Faso, Mali, Ethiopia, and Uganda. Three action researchers were posted to these countries during the final 2 years of the project to help the government and its partners implement multisectoral nutrition and document the lessons. Prospective data were collected through participant observation, end‐line semistructured interviews, and document analysis. All 4 countries made significant progress despite a wide range of challenges at the individual, organizational, and system levels. The boundary‐spanning actors and their collaborators deployed a wide range of strategies but faced significant challenges in playing these unconventional roles. The study concludes that, under the right conditions, intentional boundary spanning can be a feasible and acceptable practice within a multisectoral, complex adaptive system in low‐ and middle‐income countries.

Cost-effectiveness analysis of the national implementation of integrated community case management and community-based health planning and services in Ghana for the treatment of malaria, diarrhoea and pneumonia

BACKGROUND

Ghana has developed two main community-based strategies that aim to increase access to quality treatment for malaria, diarrhoea and suspected pneumonia: the integrated community case management (iCCM) and the community-based health planning and services (CHPS). The aim of the study was to assess the cost-effectiveness of these strategies under programme conditions.

METHODS

A cost-effectiveness analysis was conducted. Appropriate diagnosis and treatment given was the effectiveness measure used. Appropriate diagnosis and treatment data was obtained from a household survey conducted 2 and 8 years after implementation of iCCM in the Volta and Northern Regions of Ghana, respectively. The study population was carers of children under-5 years who had fever, diarrhoea and/or cough in the last 2 weeks prior to the interview. Costs data was obtained mainly from the National Malaria Control Programme (NMCP), the Ministry of Health, CHPS compounds and from a household survey.

RESULTS

Appropriate diagnosis and treatment of malaria, diarrhoea and suspected pneumonia was more cost-effective under the iCCM than under CHPS in the Volta Region, even after adjusting for different discount rates, facility costs and iCCM and CHPS utilization, but not when iCCM appropriate treatment was reduced by 50%. Due to low numbers of carers visiting a CBA in the Northern Region it was not possible to conduct a cost-effectiveness analysis in this region. However, the cost analysis showed that iCCM in the Northern Region had higher cost per malaria, diarrhoea and suspected pneumonia case diagnosed and treated when compared to the Volta Region and to the CHPS strategy in the Northern Region.

CONCLUSIONS

Integrated community case management was more cost-effective than CHPS for the treatment of malaria, diarrhoea and suspected pneumonia when utilized by carers of children under-5 years in the Volta Region. A revision of the iCCM strategy in the Northern Region is needed to improve its cost-effectiveness. Long-term financing strategies should be explored including potential inclusion in the National Health Insurance Scheme (NHIS) benefit package. An acceptability study of including iCCM in the NHIS should be conducted.

Research dissemination workshops: observations and implications based on an experience in Burkina Faso

Background

In Burkina Faso, malaria remains the primary cause of healthcare use, morbidity and child mortality. Therefore, efforts are needed to support the knowledge transfer and application of the results of numerous studies to better formulate and implement programs in the fight against the malaria pandemic. To this end, a 2-day dissemination workshop was held to share the most recent results produced by a multidisciplinary research team. The objective of the present study was to evaluate the workshop and the policy briefs distributed there, the effects these produced on research results use and the processes that facilitated, or not, the application of the knowledge transmitted.

Methods

A mixed-methods design was used. The data were drawn from a quantitative evaluation questionnaire completed after the workshop (n = 25/31) and qualitative interviews conducted with the researchers and various actors who attended the workshop (n = 11) and with participants in working groups (n = 40) that later analysed the policy briefs distributed at the workshop.

Results

The participants recognised the quality of the research results presented, but felt that more needed to be done to adapt the researchers’ language and improve the functioning of the workshop. The potential effects of the workshop were rather limited. Effects were mainly at two levels: individual (e.g. acquisition of new knowledge, personal awareness raising) and local (e.g. change of practice in a local non-governmental organisation). Most participants perceived the utility of the research results, but several reported that their narrow decisional power limited their ability to apply this knowledge.

Conclusions

This study showed the importance of workshops to inform key actors of research results and the need to undertake several different activities to increase the chances that the knowledge will be applied. Several recommendations are proposed to improve knowledge translation approaches in the West African context, including organising working and discussion groups, developing an action plan at the end of the workshop and offering support to participants after the workshop, among others.

Moving the Agenda on Noncommunicable Diseases: Policy Implications of Mobile Phone Surveys in Low and Middle-Income Countries

The growing burden of noncommunicable diseases (NCDs), for example, cardiovascular diseases and chronic respiratory diseases, in low- and middle-income countries (LMICs) presents special challenges for policy makers, due to resource constraints and lack of timely data for decision-making. Concurrently, the increasing ubiquity of mobile phones in LMICs presents possibilities for rapid collection of population-based data to inform the policy process. The objective of this paper is to highlight potential benefits of mobile phone surveys (MPS) for developing, implementing, and evaluating NCD prevention and control policies. To achieve this aim, we first provide a brief overview of major global commitments to NCD prevention and control, and subsequently explore how countries can translate these commitments into policy action at the national level. Using the policy cycle as our frame of reference, we highlight potential benefits of MPS which include (1) potential cost-effectiveness of using MPS to inform NCD policy actions compared with using traditional household surveys; (2) timeliness of assessments to feed into policy and planning cycles; (3) tracking progress of interventions, hence assessment of reach, coverage, and distribution; (4) better targeting of interventions, for example, to high-risk groups; (5) timely course correction for suboptimal or non-effective interventions; (6) assessing fairness in financial contribution and financial risk protection for those affected by NCDs in the spirit of universal health coverage (UHC); and (7) monitoring progress in reducing catastrophic medical expenditure due to chronic health conditions in general, and NCDs in particular. We conclude that MPS have potential to become a powerful data collection tool to inform policies that address public health challenges such as NCDs. Additional forthcoming assessments of MPS in LMICs will inform opportunities to maximize this technology.