Why do policies change? Institutions, interests, ideas and networks in three cases of policy reform

Form and functioning: contextualising the start of the global financing facility policy processes in Burkina Faso

BACKGROUND

Burkina Faso joined the Global Financing Facility for Women, Children and Adolescents (GFF) in 2017 to address persistent gaps in funding for reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N). Few empirical papers deal with how global funding mechanisms, and specifically GFF, support resource mobilisation for health nationally.

OBJECTIVE

This study describes the policy processes of developing the GFF planning documents (the Investment Case and Project Appraisal Document) in Burkina Faso.

METHODS

We conducted an exploratory qualitative policy analysis. Data collection included document review (N = 74) and in-depth semi-structured interviews (N = 23). Data were analysed based on the components of the health policy triangle.

RESULTS

There was strong national political support to RMNCAH-N interventions, and the process of drawing up the investment case (IC) and the project appraisal document was inclusive and multi-sectoral. Despite high-level policy commitments, subsequent implementation of the World Bank project, including the GFF contribution, was perceived by respondents as challenging, even after the project restructuring process occurred. These challenges were due to ongoing policy fragmentation for RMNCAH-N, navigation of differing procedures and perspectives between stakeholders in the setting up of the work, overcoming misunderstandings about the nature of the GFF, and weak institutional anchoring of the IC. Insecurity and political instability also contributed to observed delays and difficulties in implementing the commitments agreed upon. To tackle these issues, transformational and distributive leaderships should be promoted and made effective.

CONCLUSIONS

Few studies have examined national policy processes linked to the GFF or other global health initiatives. This kind of research is needed to better understand the range of challenges in aligning donor and national priorities encountered across diverse health systems contexts. This study may stimulate others to ensure that the GFF and other global health initiatives respond to local needs and policy environments for better implementation.

Shifting patterns and competing explanations for infectious disease priority in global health agenda setting arenas

The highly decentralized nature of global health governance presents significant challenges to conceptualizing and systematically measuring the agenda status of diseases, injuries, risks and other conditions contributing to the collective disease burden. An arenas model for global health agenda setting was recently proposed to help address these challenges. Further developing the model, this study aims to advance more robust inquiry into how and why priority levels may vary among the array of stakeholder arenas in which global health agenda setting occurs. We analyse order and the magnitude of changes in priority for eight infectious diseases in four arenas (international aid, scientific research, pharmaceutical industry and news media) over a period of more than two decades in relation to five propositions from scholarship. The diseases vary on burden and prominence in United Nations Sustainable Development Goal 3 for health and well-being, including four with specific indicators for monitoring and evaluation (HIV/AIDS, tuberculosis, malaria, hepatitis) and four without (dengue, diarrhoeal diseases, measles, meningitis). The order of priority did not consistently align with the disease burden or international development goals in any arena. Additionally, using new methods to measure the scale of annual change in resource allocations that are indicative of priority reveals volatility at the disease level in all arenas amidst broader patterns of stability. Insights around long-term patterns of priority within and among arenas are integral to strengthening analyses that aim to identify pivotal causal mechanisms, to clarify how arenas interact, and to measure the effects they produce.

How can advocates leverage power to advance comprehensive regulation on ultra-processed foods? learning from advocate experience in Argentina

BACKGROUND

The use of corporate power to undermine public health policy processes is increasingly well understood; however, relatively little scholarship examines how advocates can leverage power to promote the successful adoption of public health policies. The objective of this paper is to explore how advocates leveraged three forms of power - structural, instrumental and discursive - to promote the passage of the Promotion of Healthy Eating Law (Ley 27,642) in Argentina, one of the most comprehensive policies to introduce mandatory front-of-package (FOP) warning labels and regulate the marketing and sales of ultra-processed foods (UPFs) adopted to date.

METHODS

We conducted seventeen semi-structured interviews with advocates from different sectors, including civil society, international agencies, and government. Both data collection and analysis were guided by Milsom's conceptual framework for analyzing power in public health policymaking, and the data was analyzed using hybrid deductive and inductive thematic analysis.

RESULTS

Advocates harnessed structural power through the leveraging of revolving doors, informal alliances, and formal coalitions, enabling them to convene discussion spaces with decision-makers, make strategic use of limited resources, and cultivate the diverse expertise (e.g., research, nutrition science, advocacy, law, political science, activism and communications) needed to support the law through different phases of the policy process. Advocates wielded instrumental power by amassing an armada of localized evidence to promote robust policy design, building technical literacy amongst themselves and decision-makers, and exposing conflicts of interest to harness public pressure. Advocates exercised discursive power by adopting a rights-based discourse, including of children and adolescents and of consumers to transparent information, which enabled advocates to foster a favorable perception of the law amongst both decision-makers and the public. Key contextual enablers include a political window of opportunity, the COVID-19 pandemic, and the ability to learn from the regional precedent of similar policies.

CONCLUSIONS

Public health policymaking, particularly when encroaching upon corporate interests, is characterized by stark imbalances of power that hinder policy decisions. The strategies identified in the case of Argentina provide important insights as to how advocates might harness and exercise structural, instrumental, and discursive power to counter corporate influence and promote the successful adoption of comprehensive UPF regulation.

Comparing priority received by global health issues: a measurement framework applied to tuberculosis, malaria, diarrhoeal diseases and dengue fever

INTRODUCTION

The relative priority received by issues in global health agendas is subjected to impressionistic claims in the absence of objective methods of assessment of priority. To build an approach for conducting structured assessments of comparative priority health issues receive, we expand the public arenas model (2021) and offer a framework for future assessments of health issue priority in global and national health agendas.

METHODS

We aimed to develop a more comprehensive set of measures for conducting multiyear priority comparisons of health issues in six agenda-setting arenas by identifying possible measures and data sources, selecting indicators based on feasibility and comparability of measures and gathering the data on selected indicators. We applied these measures to four communicable diseases-tuberculosis (TB), malaria, diarrhoeal diseases and dengue fever-given their differing impressionistic claims of priority. Where possible, we analysed the annual and/or 5-year trends from 2000 through 2022.

RESULTS

We observed that TB and malaria received the highest priority for most periods in the past two decades in most arenas. However, a stagnation in development funding for these two conditions over the last 8-10 years may have fuelled the neglect claims. Despite having a higher disease burden, diarrhoea has been slipping in global priority with reduced spending, fewer clinical trials and stagnating publications. Dengue remains a low-priority condition but has witnessed a sharp rise in attention from the pharmaceutical industry.

DISCUSSIONS

We expanded the arenas model by including a transnational arena (international representation) and additional measurements for various arenas. This analysis presents an approach to enable comparative trend analysis of the markers of agenda status over a multiyear period. More such analyses can bring much-desired objectivity in understanding how attention to global or national health issues changes over time in different arenas, potentiating a more equitable allocation of resources.

Evidence uptake is only part of the process: Stakeholders' insights on WHO treatment guideline recommendation processes for radical cure of P. vivax malaria

Health policy processes should be evidence-informed, transparent and timely, but these processes are often unclear to stakeholders outside the immediate policymaking environment. We spoke to 36 international malaria stakeholders to gain insights on the processes involved in the World Health Organization's Global Malaria Programme's recommendations for their treatment guidelines of P. vivax malaria. Four key themes which drew on the 3i policy framework and Shiffman's four factors that influence global and national policymaking were identified to understand these processes. Triggers for policy change and change prioritisation, evidence types that inform policy, effects of funding on decision-making processes, and transparency and communication of these processes to external stakeholders. Results indicate that more clarity is needed on what triggers global malaria policy change processes, a clearer justification of evidence types used to inform policymaking, better understanding of the impact of the WHO's funding model on policymaking and further transparency and improved communication of these processes to external stakeholders is also needed. We suggest that global malaria policymaking could be improved by using the following strategies: ensuring that identified triggers actually initiate the policy change process, expediting decision-making timelines by developing a priority framework for assessing new evidence, adopting suitable frameworks to assess contextual evidence, and increasing the transparency of the role of non-state funders in policy decision-making processes and when publishing new recommendations.

Identifying key factors for successful formulation and implementation of healthcare policies on non-communicable diseases: a multinational analysis

Objectives

Non-communicable diseases (NCDs) are a major public health concern that accounts for 74% of global deaths each year. The increasing burden of NCDs exhausts public health resources and threatens the achievement of the 2030 agenda for sustainable development. The purpose of this study is to thematically analyze the contributory factors in the health policy process and reforms to strengthen the prevention of NCDs across borders, as well as the milestones achieved through the process of policy-making, change, and implementation.

Method

This study informs and draws on the findings of contributory factors in the health policy process for preventing NCDs across borders: United States, England, Sweden, Bangladesh, Singapore, South Korea, and Thailand. Ten experts from the seven countries were recruited purposively for a semi-structured interview (e-Interview) on the NCD policy-making process in their countries, either through health ministries or the authors' network. This descriptive qualitative study design is guided by the "Three I's" framework of public policy (institutions, ideas, and interests). In addition to the information obtained from the interviewee, data were also sourced from relevant documents and homepages suggested by the interviewee, as well as health homepages of the countries.

Result

The following themes were generated: (1) environmental policies and social determinants, (2) multistakeholder involvement, (3) interministerial collaboration, (4) independent evidence and review institution, (5) integrated health data, and (6) primary care system. There was a shift from individual-targeted policies to environmental policies and social determinants. Notably, national campaigns were developed through non-governmental organizations (NGOs) for the primary prevention of NCDs.

Conclusion

The shift from behavioral modification and treatment to social determinants is important. NCDs are broad and require a multisector and multilevel approach. Establishing an organization or hierarchical body to overlook NCDs could result in increased awareness, focus, and surveillance and enhance the policy process.

The role of private healthcare sector actors in health service delivery and financing policy processes in low-and middle-income countries: a scoping review

The expansion of the private healthcare sector in some low-income and middle-income countries (LMICs) has raised key questions and debates regarding the governance of this sector, and the role of actors representing the sector in policy processes. Research on the role played by this sector, understood here as private hospitals, pharmacies and insurance companies, remains underdeveloped in the literature. In this paper, we present the results of a scoping review focused on synthesising scholarship on the role of private healthcare sector actors in health policy processes pertaining to health service delivery and financing in LMICs. We explore the role of organisations or groups-for example, individual companies, corporations or interest groups-representing healthcare sector actors, and use a conceptual framework of institutions, ideas, interests and networks to guide our analysis. The screening process resulted in 15 papers identified for data extraction. We found that the literature in this domain is highly interdisciplinary but nascent, with largely descriptive work and undertheorisation of policy process dynamics. Many studies described institutional mechanisms enabling private sector participation in decision-making in generic terms. Some studies reported competing institutional frameworks for particular policy areas (eg, commerce compared with health in the context of medical tourism). Private healthcare actors showed considerable heterogeneity in their organisation. Papers also referred to a range of strategies used by these actors. Finally, policy outcomes described in the cases were highly context specific and dependent on the interaction between institutions, interests, ideas and networks. Overall, our analysis suggests that the role of private healthcare actors in health policy processes in LMICs, particularly emerging industries such as hospitals, holds key insights that will be crucial to understanding and managing their role in expanding health service access.

Barriers and Opportunities for WHO "Best Buys" Non-communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review

BACKGROUND

Improving the adoption and implementation of policies to curb non-communicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policy-makers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation.

METHODS

We conducted a complex systematic review of articles discussing the adoption and implementation of World Health Organization's (WHO's) "best buys" NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria.

RESULTS

Our CLD highlights a central feedback loop encompassing three vital variables: (1) the ability to define, (re)shape, and pass appropriate policy into law; (2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); and (3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies.

CONCLUSION

To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions.

Political Economy of Non-Communicable Disease (NCD) prevention and control in Lebanon: identifying challenges and opportunities for policy change and care provision reforms

INTRODUCTION

Lebanon is a middle-income country facing substantial fragility features. Its health profile shows a high burden of NCD morbidity and mortality. This paper intends to analyse the political economy of NCD prevention and control in Lebanon.

METHODS

This study adopted a literature-based case study research design using a problem-driven political economy analysis framework. A total of 94 peer-reviewed articles and documents from the grey literature published before June 2019 were retrieved and analysed.

RESULTS

Lebanon's political instability and fragile governance negatively affect its capacity to adapt a Health-in-All-Policies approach to NCD prevention and enable the blocking of NCD prevention policies by opposed stakeholders. Recent economic crises limit the fiscal capacity to address health financing issues and resulting health inequities. NCD care provision is twisted by powerful stakeholders towards a hospital-centred model with a powerful private sector. Stakeholders like the MOPH, UN agencies, and NGOs have been pushing towards changing the existing care model towards a primary care model. An incremental reform has been adopted to strengthen a network of primary care centres, support them with health technologies and improve the quality of primary care services. Nevertheless, outpatient services that are covered by other public funds remain specialist-led without much institutional regulation.

CONCLUSION

Our study revealed a locked equilibrium in NCD prevention policymaking in Lebanon, but with an incremental progress in service delivery reforms towards a primary care model. Advocacy and close monitoring by policy entrepreneurs (such as civil society) could initiate and sustain the implementation of policy change and care model reforms.

A sweet deal for domestic industry: the political economy and framing of Vanuatu's sugar-sweetened beverage tax

INTRODUCTION

The Government of Vanuatu introduced an excise tax on sugar-sweetened beverages (SSBs) in 2015. While lauded for its alignment with the WHO's Best Buys recommendations for addressing non-communicable diseases (NCDs), little is known about the tax's adoption process or whose interests it serves.

METHODS

Using case study methodology, this study examined how and why Vanuatu's SSB tax was introduced. Policy documents, key informant interviews (n=33) and direct observations were analysed using theories of policy analysis, power analysis and postcolonial theory to map the policy's adoption, surrounding political economy and the ideas, interests and institutions that shaped the tax and its framing.

RESULTS

The SSB tax emerged during a politically and economically unstable time in Vanuatu's history. The tax's links to the national health agenda were tenuous despite its ostensible framing as a way to combat NCDs. Rather, the tax was designed to respond to tightening economic and trade conditions. Spearheaded by several finance-focused bureaucrats, and with limited input from health personnel, the tax targeted less frequently consumed carbonated SSBs (which are mostly imported) without any revenue reinvestments into health. Driven by the desire to generate much-needed government revenue and instal domestic protections via selective implementation and carve-outs for local producers, the Vanuatu SSB tax did meet national objectives, just not the dual health and economic 'win-win' projected by the NCD Best Buys.

CONCLUSION

Vanuatu's SSB tax adoption process reveals the limitations of decontextualised policy recommendations, such as the NCD Best Buys, whose framing may be overcome by local political realities. This research highlights the need for further political economy considerations in global health recommendations, since contextual forces and power dynamics are key to shaping both how and why policies are enacted and also whose interest they serve.

Nutrition policy reforms to address the double burden of malnutrition in Zambia: a prospective policy analysis

The evolution of nutrition patterns in Zambia has resulted in the coexistence of undernutrition and overnutrition in the same population, the double burden of malnutrition. While Zambia has strong policies addressing undernutrition and stunting, these do not adequately address food environment drivers of the double burden of malnutrition and the adolescent age group and hence the need for nutrition policy reforms. We conducted a theory-based qualitative prospective policy analysis involving in-depth interviews with nutrition policy stakeholders and policy document review to examine the feasibility of introducing nutrition policy options that address the double burden of malnutrition among adolescents to identify barriers and facilitators to such policy reforms. Using the multiple streams theory, we categorized the barriers and facilitators to prospective policy reforms into those related to the problem, policy solutions and politics stream. The use of a life-course approach in nutrition programming could facilitate policy reforms, as adolescence is one of the critical invention points in a person's lifecycle. Another key facilitator of policy reform was the availability of institutional infrastructure that could be leveraged to deliver adolescent-focused policies. However, the lack of evidence on the burden and long-term impacts of adolescent nutrition problems, the food industry's strong influence over governments' policy agenda setting and the lack of public awareness to demand better nutrition were perceived as critical barriers to policy reforms. In addition, the use of the individual responsibility framing for nutrition problems was dominant among stakeholders. As a result, stakeholders did not perceive legislative nutrition policy options that effectively address food environment drivers of the double burden of malnutrition to be feasible for the Zambian context. Policy entrepreneurs are required to broker policy reforms that will get legislative policy options on the government's agenda as they can help raise public support and re-engineer the framing of nutrition problems and their solutions in Zambia.

How gender is socially constructed in policy making processes: a case study of the Adolescent and Youth Health Policy in South Africa

BACKGROUND

Gender equality remains an outstanding global priority, more than 25 years after the landmark Beijing Platform for Action. The disconnect between global health policy intentions and implementation is shaped by several conceptual, pragmatic and political factors, both globally and in South Africa. Actor narratives and different framings of gender and gender equality are one part of the contested nature of gender policy processes and their implementation challenges. The main aim of this paper is to foreground the range of policy actors, describe their narratives and different framings of gender, as part exploring the social construction of gender in policy processes, using the Adolescent Youth Health Policy (AYHP) as a case study.

METHODS

A case study design was undertaken, with conceptual underpinnings combined from gender studies, sociology and health policy analysis. Through purposive sampling, a range of actors were selected, including AYHP authors from government and academia, members of the AYHP Advisory Panel, youth representatives from the National Department of Health Adolescent and Youth Advisory Panel, as well as adolescent and youth health and gender policy actors, in government, academia and civil society. Qualitative data was collected via in-depth, semi-structured interviews with 30 policy actors between 2019 and 2021. Thematic data analysis was used, as well as triangulation across both respondents, and the document analysis of the AYHP.

RESULTS

Despite gender power relations and more gender-transformative approaches being discussed during the policy making process, these were not reflected in the final policy. Interviews revealed an interrelated constellation of diverse and juxtaposed actor gender narratives, ranging from framing gender as equating girls and women, gender as inclusion, gender as instrumental, gender as women's rights and empowerment and gender as power relations. Some of these narrative framings were dominant in the policy making process and were consequently included in the final policy document, unlike other narratives. The way gender is framed in policy processes is shaped by actor narratives, and these diverse and contested discursive constructions were shaped by the dynamic interactions with the South Africa context, and processes of the Adolescent Youth Health Policy. These varied actor narratives were further contextualised in terms of reflections of what is needed going forward to advance gender equality in adolescent and youth health policy and programming. This includes prioritising gender and intersectionality on the national agenda, implementing more gender-transformative programmes, as well as having the commitments and capabilities to take the work forward.

CONCLUSIONS

The constellation of actors' gender narratives reveals overlapping and contested framings of gender and what is required to advance gender equality. Understanding actor narratives in policy processes contributes to bridging the disconnect between policy commitments and reality in advancing the gender equality agenda.

Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa

BACKGROUND

Lack of political will is frequently invoked as a rhetorical tool to explain the gap between commitment and action for health reforms in sub-Saharan Africa (SSA). However, the concept remains vague, ill defined and risks being used as a scapegoat to actually examine what shapes reforms in a given context, and what to do about it. This study sought to go beyond the rhetoric of political will to gain a deeper understanding of what drives health reforms in SSA.

METHODS

We conducted a scoping review using Arksey and O'Malley (2005) to understand the drivers of health reforms in SSA.

RESULTS

We reviewed 84 published papers that focused on the politics of health reforms in SSA covering the period 2002-2022. Out of these, more than half of the papers covered aspects related to health financing, HIV/AIDS and maternal health with a dominant focus on policy agenda setting and formulation. We found that health reforms in SSA are influenced by six; often interconnected drivers namely (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) policy diffusion.

CONCLUSION

Political will is relevant but insufficient to drive health reform in SSA. A framework of differential reform politics that considers how the power and beliefs of policy elites is likely to shape policies within a given context can be useful in guiding future policy analysis.

Can the Framing of Climate Mitigation Actions into Government Policies Lead to Delivering Them? - Insights from Nepal's Experience

Many low-income countries (LICs), including Nepal, endeavour to deliver climate mitigation by reducing greenhouse gas (GHG) emissions and achieving more sustainable resource consumption. However, their prospects of delivering on such goals alongside the rapid structural changes in the economy prevalent in the LICs are not clear. This research aims to better understand the underlying complexity in the linkage between the framing of climate mitigation actions into government policies and the prospects for their delivery. We use critical discourse analysis, post-structural discourse analysis, and thematic analysis of textual data corpus generated from government policies (n = 12) and semi-structured interviews (n = 12) with policy actors, such as government policymakers and private sector and non-government organisations' representatives. We also develop energy and material consumption and GHG emissions models to predict their values up to 2050 via the R tools and machine learning algorithms that validate the accuracy of models. Our findings suggest that the social context of policymaking creates a knowledge structure on climate mitigation which is reflected in government policies. The policy actors and their institutions exchange their ideas and interests in a deliberative and collaborative environment to prioritise policies for the energy, forest, and transport sectors to deliver climate mitigation actions in Nepal. However, the energy sector, together with the agriculture sector, has insufficient climate mitigation actions. Reflecting on the high proportion of biomass in the energy mix and the rapid rise in fossil fuel and energy consumption per capita-both of which are driven by the remittance inflows-this research suggests measures to reduce these in an absolute sense.

Considerations for developing regulations for direct-to-consumer genetic testing: a scoping review using the 3-I framework

Direct-to-consumer (DTC) genetic testing exists largely outside of any regulatory schemes, and studies providing a comprehensive overview of the ethical, social, legal, and technological considerations for regulating these types of technologies are lacking. This paper uses the 3-I framework for policy analysis to analyze the ideas, interests, and institutions relevant to policy development for DTC genetic testing in North America and internationally. A scoping review was conducted. Citation databases were searched for papers addressing the ethical, social, legal, and technological implications of DTC genetic testing; stakeholder perspectives on and experiences with DTC genetic testing; or the effect of such testing on the healthcare system. Ninety-nine publications, organizational reports, governmental documents, or pieces of legislation were included. The ideas included are autonomy, informed decision making, privacy, and clinical validity and utility. The interests discussed are those of the public and healthcare providers. The institutions included are regulatory organizations such as the Food and Drug Administration in the United States, laws governing the implementation or delivery of genetic testing in general, and legislation created to protect against genetic discrimination. This analysis clarifies the ethical, social, legal, and technological issues of DTC genetic testing regulation. This information can be used by policy makers to develop or strengthen regulations for DTC genetic testing such as requiring an assessment of the clinical validity of tests before they become publicly available, controlling how tests are marketed, and stipulating requirements for healthcare provider involvement and informed consent.

The political economy of health financing reforms in Zimbabwe: a scoping review

Background

Implementation of health financing reforms for Universal Health Coverage (UHC) is inherently political. Despite the political determinants of UHC, health financing reform in Zimbabwe is often portrayed as a technical exercise with a familiar path of a thorough diagnosis of technical gaps followed by detailed prescriptions of reform priorities. In this study, we sought to understand the interaction between political and economic aspects of health financing reforms since the country got its independence in 1980.

Methods

We conducted a scoping review of health financing reforms in Zimbabwe and reviewed 84 relevant sources of information. We then conducted a thematic analysis using an adapted Fox and Reich’s framework of ideas and ideologies, interests and institutions.

Results

We found that ideas, institutions and interests significantly influence health financing reforms in Zimbabwe with implications on health system performance. Reform priorities of the 1980s were influenced by socialist ideologies with an interest to address pervasive health inequities inherited from the colonial racial system. The progress in equity realized in the 1980s was severely disrupted from the 1990s partly due to neo-liberal ideologies which steered interests towards market-oriented reforms. The period from the 2000s is characterized by increasing donor influence on health financing and a cumulative socio-economic collapse that resulted in a sharp and protracted decline in health spending and widening of health inequities.

Conclusion

Health financing reform process in Zimbabwe is heavily influenced by political economy characteristics which favor certain financing arrangements over others with profound implications on health system performance. We concluded that the political economy factors that slow down UHC reforms are not rooted in the ambiguities of ideas on what needs to be done. Instead, the missing link is how to move from intention to action by aligning espoused ideas with interests and institutions which is an inherently political and redistributive process. International and domestic actors involved in UHC in Zimbabwe  need to explicitly consider the politics of health financing reforms to improve the implementation feasibility of desired reforms.

Non-communicable disease policy implementation in Libya: A mixed methods assessment

The Libyan Ministry of Health is keen to understand how it can introduce policies to protect its population from non-communicable diseases (NCDs). We aimed to perform an implementation research assessment of the current situation, including challenges and opportunities. We used an explanatory sequential mixed methods design. We started with a quantitative assessment of NCD policy performance based on review of the WHO NCD Progress Monitor Reports. Once we had identified Libya's NCD policy gaps we performed a systematic review to identify international lessons around barriers and successful strategies for the policies Libya has not yet implemented. Finally, we performed a series of key stakeholder interviews with senior policymakers to explore their perspectives around promising policy actions. We used a realist paradigm, methods triangulation, and a joint display to synthesise the interpretation of our findings and develop recommendations. Libya has not fully implemented any of the recommended policies for diet, physical activity, primary care guidelines & therapeutics, or data collection, targets & surveillance. It does not have robust tobacco policies in place. Evidence from the international literature and policymaker interviews emphasised the centrality of according strong political leadership, governance structures, multisectoral engagement, and adequate financing to policy development activities. Libya's complex political and security situation are major barriers for policy implementation. Whilst some policies will be very challenging to develop and deploy, there are a number of simple policy actions that could be implemented with minimum effort; from inviting WHO to conduct a second STEPS survey, to signing the international code on breast-milk substitutes. Like many other fragile and conflict-affected states, Libya has not accorded NCDs the policy attention they demand. Whilst strong high-level leadership is the ultimate key to providing adequate protections, there are a range of simple measures that can be implemented with relative ease.

Political economy analysis of universal health coverage and health financing reforms in low- and middle-income countries: the role of stakeholder engagement in the research process

Background

Progress towards universal health coverage (UHC) is an inherently political process. Political economy analysis (PEA) is gaining momentum as a tool to better understand the role of the political and economic dimensions in shaping and achieving UHC in different contexts. Despite the acknowledged importance of actors and stakeholders in political economy considerations, their role in the PEA research process beyond “study subjects” as potential cocreators of knowledge and knowledge users has been overlooked so far. We therefore aimed to review the approaches with reference to stakeholder engagement during the research process adopted in the current published research on the political economy of UHC and health financing reforms, and the factors favouring (or hindering) uptake and usability of PEA work.

Methods

We reviewed the literature to describe whether, when and how stakeholders were involved in the research process of studies looking at the political economy of UHC and health financing reforms, and to identify challenges and lessons learned on effective stakeholder engagement and research uptake. We used a standardized search strategy with key terms across several databases; we screened and included articles that focused on PEA and UHC. Additionally, we conducted a short survey of the authors of the included studies to complement the information retrieved.

Results

Fifty articles met the inclusion criteria and were included in the analysis. We found overall little evidence of systematic engagement of stakeholders in the research process, which focused mostly on the data collection phase of the research (i.e., key informant interviews). Our study identifies some reasons for the varying stakeholder engagement. Challenges include PEA requiring specific skills, a focus on sensitive issues, and the blurriness in researchers’ and stakeholders’ roles and the multiple roles of stakeholders as research participants, study subjects and research users. Among the approaches that might favour usability of PEA work, we identified early engagement, coproduction of research questions, local partners and personal contact, political willingness, and trust and use of prospective analysis.

Conclusions

Stakeholder engagement and research uptake are multifaceted concepts and complex processes, particularly when applied to PEA. As such, stakeholder engagement in the research process of PEA of UHC and health financing reforms is limited and underreported. Despite the challenges, however, stakeholder engagement remains key to ensuring relevance, usability and research uptake of PEA studies. More efforts are required to ensure engagement at different stages of the research process and better reporting in published articles.

Understanding the Political Challenge of Red and Processed Meat Reduction for Healthy and Sustainable Food Systems: A Narrative Review of the Literature

BACKGROUND

Diets high in red and processed meat (RPM) contribute substantially to environmental degradation, greenhouse gas (GHG) emissions, and the global burden of chronic disease. Recent high-profile reports from international expert bodies have called for a significant reduction in global dietary meat intake, particularly RPM, especially in high-income settings, while acknowledging the importance of animal-sourced foods to population nutrition in many lower-income countries. However, this presents a major yet under-investigated political challenge given strong cultural preferences for meat and the economic importance and power of the meat industry.

METHODS

A theoretically-guided narrative review was undertaken. The theoretical framework used to guide the review considered the interests, ideas and institutions that constitute food systems in relation to meat reduction; and the instrumental, discursive and structural forms of power that actors deploy in relation to others within the food system.

RESULTS

High production and consumption levels of RPM are promoted and sustained by a number of factors. Actors with an interest in RPM included business and industry groups, governments, intergovernmental organisations, and civil society. Asymmetries of power between these actors exist, with institutional barriers recognised in the form of government-industry dependence, trade agreement conflicts, and policy incoherence. Industry lobbying, shaping of evidence and knowledge, and highly concentrated markets are key issues. Furthermore, prevailing ideologies like carnism and neoliberalism present embedded difficulties for RPM reduction. The literature noted the power of actors to resist meat reduction efforts exists in varying forms, including the use of lobbying, shaping of evidence and knowledge, and highly concentrated markets.

CONCLUSION

There are a number of political challenges related to RPM reduction that contribute to policy inertia, and hence are likely to impede the transformation of food systems. Research on policy efforts to reduce RPM production and consumption should incorporate the role of power and political feasibility.

District health network policy in Iran: the role of ideas, interests, and institutions (3i framework) in a nutshell

Background

District Health Network (DHN), one of Iran’s most successful health reforms, was launched in 1985 to provide primary health care (PHC), in response to health inequities in Iran. The present study aims to use interrelated elements of the 3i framework: ideas (e.g., beliefs and values, culture, knowledge, research evidence and solutions), interests (e.g., civil servants, pressure groups, elected parties, academians and researchers, and policy entrepreneurs), and institutions (e.g., rules, precedents, and organizational, government structures, policy network, and policy legacies) to explain retrospectively how (DHN) policy in Iran, as a developing country, was initiated and formed.

Methods

A historical narrative approach with a case study perspective was employed to focus on the formation and framing process of DHN. For this purpose, the 3i framework was used as a guideline for data analysis. This study mainly searched and extracted secondary sources, including online news, reports, books, dissertations, and published articles in the scientific databases. Primary interviews as a supplementary source were also carried out to meet cross-validation of the data. Data were analyzed using a deductive and inductive approach.

Results

According to the 3i framework, the following factors contributed to the formation of DHN policy in Iran: previous national efforts (for instance Rezaieh plan) and international events aiming to provide public health services for peripheral regions; dominant social discourses and values at the beginning of the Iranian revolution such as addressing the needs of disadvantaged and marginalized groups, which were embedded in the goals of DHN policy aiming to provide basic health services for deprived people especially living in rural and remote areas. Besides, the remarkable social cohesion and solidarity among people reinforced by the Iran-Iraq war were among other factors which contributed to the formation of participatory plans such as DHN (ideas). Main policy entrepreneurs including Minister of Health, his public health deputy and two planners of DHN with similar and rich background in the public health field and sharing the same beliefs (interests) which subsequently led to creation of tight-knit policy community network between them (institutions) also accelerated the creation of DHN in Iran to great extent. Political support of parliamentary representatives (interests), and formal laws such as principles of Iran Constitution (institutions) were also influential in passing the DHN in Iran.

Conclusions

The 3i framework constituents would be insightful in explaining the creation of public health policies. This framework showed that the alignment of laws, structures, and interests of the main actors of the policy with the dominant ideas and beliefs in the society, opened the opportunity to form DHN in Iran.

Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review

Transnational tobacco, alcohol and ultra-processed food corporations use the international trade regime to prevent policy action on non-communicable diseases (NCDs); i.e. to promote policy 'non-decisions'. Understanding policy non-decisions can be assisted by identifying power operating in relevant decision-making spaces, but trade and health research rarely explicitly engages with theories of power. This realist review aimed to synthesize evidence of different forms and mechanisms of power active in trade and health decision-making spaces to understand better why NCD policy non-decisions persist and the implications for future transformative action. We iteratively developed power-based theories explaining how transnational health-harmful commodity corporations (THCCs) utilize the international trade regime to encourage NCD policy non-decisions. To support theory development, we also developed a conceptual framework for analysing power in public health policymaking. We searched six databases and relevant grey literature and extracted, synthesized and mapped the evidence against the proposed theories. One hundred and four studies were included. Findings were presented for three key forms of power. Evidence indicates THCCs attempt to exercise instrumental power by extensive lobbying often via privileged access to trade and health decision-making spaces. When their legitimacy declines, THCCs have attempted to shift decision-making to more favourable international trade legal venues. THCCs benefit from structural power through the institutionalization of their involvement in health and trade agenda-setting processes. In terms of discursive power, THCCs effectively frame trade and health issues in ways that echo and amplify dominant neoliberal ideas. These processes may further entrench the individualization of NCDs, restrict conceivable policy solutions and perpetuate policymaking norms that privilege economic/trade interests over health. This review identifies different forms and mechanisms of power active in trade and health policy spaces that enable THCCs to prevent progressive action on NCDs. It also points to potential strategies for challenging these power dynamics and relations.

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.

A scoping review of theories and conceptual frameworks used to analyse health financing policy processes in sub-Saharan Africa

Health financing policies are critical policy instruments to achieve Universal Health Coverage, and they constitute a key area in policy analysis literature for the health policy and systems research (HPSR) field. Previous reviews have shown that analyses of policy change in low- and middle-income countries are under-theorised. This study aims to explore which theories and conceptual frameworks have been used in research on policy processes of health financing policy in sub-Saharan Africa and to identify challenges and lessons learned from their use. We conducted a scoping review of literature published in English and French between 2000 and 2017. We analysed 23 papers selected as studies of health financing policies in sub-Saharan African countries using policy process or health policy-related theory or conceptual framework ex ante. Theories and frameworks used alone were from political science (35%), economics (9%) and HPSR field (17%). Thirty-five per cent of authors adopted a 'do-it-yourself' (bricolage) approach combining theories and frameworks from within political science or between political science and HPSR. Kingdon's multiple streams theory (22%), Grindle and Thomas' arenas of conflict (26%) and Walt and Gilson's policy triangle (30%) were the most used. Authors select theories for their empirical relevance, methodological rational (e.g. comparison), availability of examples in literature, accessibility and consensus. Authors cite few operational and analytical challenges in using theory. The hybridisation, diversification and expansion of mid-range policy theories and conceptual frameworks used deductively in health financing policy reform research are issues for HPSR to consider. We make three recommendations for researchers in the HPSR field. Future research on health financing policy change processes in sub-Saharan Africa should include reflection on learning and challenges for using policy theories and frameworks in the context of HPSR.

A network analysis of patient referrals in two district health systems in Tanzania

Patient referral systems are fragile and overlooked components of the health system in Tanzania. Our study aims at exploring patient referral networks in two rural districts in Tanzania, Kilolo and Msalala. Firstly, we ask whether secondary-level facilities act as gatekeepers, mediating referrals from primary- to tertiary-level facilities. Secondly, we explore the facility and network-level determinants of patient referrals focusing on treatment of childhood illnesses and non-communicable diseases. We use data collected across all public health facilities in the districts in 2018. To study gatekeeping, we employ descriptive network analysis tools. To explore the determinants of referrals, we use exponential random graph models. In Kilolo, we find a disproportionate share of patients referred directly to the largest hospital due to geographical proximity. In Msalala, small and specialized secondary-level facilities seem to attract more patients. Overall, the results call for policies to increase referrals to secondary facilities avoiding expensive referrals to hospitals, improving timeliness of care and reducing travel-related financial burden for households.

Understanding the implementation of evidence-informed policies and practices from a policy perspective: a critical interpretive synthesis

BACKGROUND

The fields of implementation science and knowledge translation have evolved somewhat independently from the field of policy implementation research, despite calls for better integration. As a result, implementation theory and empirical work do not often reflect the implementation experience from a policy lens nor benefit from the scholarship in all three fields. This means policymakers, researchers, and practitioners may find it challenging to draw from theory that adequately reflects their implementation efforts.

METHODS

We developed an integrated theoretical framework of the implementation process from a policy perspective by combining findings from these fields using the critical interpretive synthesis method. We began with the compass question: How is policy currently described in implementation theory and processes and what aspects of policy are important for implementation success? We then searched 12 databases as well as gray literature and supplemented these documents with other sources to fill conceptual gaps. Using a grounded and interpretive approach to analysis, we built the framework constructs, drawing largely from the theoretical literature and then tested and refined the framework using empirical literature.

RESULTS

A total of 11,434 documents were retrieved and assessed for eligibility and 35 additional documents were identified through other sources. Eighty-six unique documents were ultimately included in the analysis. Our findings indicate that policy is described as (1) the context, (2) a focusing lens, (3) the innovation itself, (4) a lever of influence, (5) an enabler/facilitator or barrier, or (6) an outcome. Policy actors were also identified as important participants or leaders of implementation. Our analysis led to the development of a two-part conceptual framework, including process and determinant components.

CONCLUSIONS

This framework begins to bridge the divide between disciplines and provides a new perspective about implementation processes at the systems level. It offers researchers, policymakers, and implementers a new way of thinking about implementation that better integrates policy considerations and can be used for planning or evaluating implementation efforts.

Understanding the implementation of evidence-informed policies and practices from a policy perspective: a critical interpretive synthesis

BACKGROUND

The fields of implementation science and knowledge translation have evolved somewhat independently from the field of policy implementation research, despite calls for better integration. As a result, implementation theory and empirical work do not often reflect the implementation experience from a policy lens nor benefit from the scholarship in all three fields. This means policymakers, researchers, and practitioners may find it challenging to draw from theory that adequately reflects their implementation efforts.

METHODS

We developed an integrated theoretical framework of the implementation process from a policy perspective by combining findings from these fields using the critical interpretive synthesis method. We began with the compass question: How is policy currently described in implementation theory and processes and what aspects of policy are important for implementation success? We then searched 12 databases as well as gray literature and supplemented these documents with other sources to fill conceptual gaps. Using a grounded and interpretive approach to analysis, we built the framework constructs, drawing largely from the theoretical literature and then tested and refined the framework using empirical literature.

RESULTS

A total of 11,434 documents were retrieved and assessed for eligibility and 35 additional documents were identified through other sources. Eighty-six unique documents were ultimately included in the analysis. Our findings indicate that policy is described as (1) the context, (2) a focusing lens, (3) the innovation itself, (4) a lever of influence, (5) an enabler/facilitator or barrier, or (6) an outcome. Policy actors were also identified as important participants or leaders of implementation. Our analysis led to the development of a two-part conceptual framework, including process and determinant components.

CONCLUSIONS

This framework begins to bridge the divide between disciplines and provides a new perspective about implementation processes at the systems level. It offers researchers, policymakers, and implementers a new way of thinking about implementation that better integrates policy considerations and can be used for planning or evaluating implementation efforts.

Mixed method evaluation of the CEBHA+ integrated knowledge translation approach: a protocol

Background

The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA+) is a research consortium concerned with the prevention, diagnosis and treatment of non-communicable diseases. CEBHA+ seeks to engage policymakers and practitioners throughout the research process in order to build lasting relationships, enhance evidence uptake, and create long-term capacity among partner institutions in Ethiopia, Malawi, Rwanda, South Africa and Uganda in collaboration with two German universities. This integrated knowledge translation (IKT) approach includes the formal development, implementation and evaluation of country specific IKT strategies.

Methods

We have conceptualised the CEBHA+ IKT approach as a complex intervention in a complex system. We will employ a comparative case study (CCS) design and mixed methods to facilitate an in-depth evaluation. We will use quantitative surveys, qualitative interviews, quarterly updates, and a policy document analysis to capture the process and outcomes of IKT across the African CEBHA+ partner sites. We will conduct an early stage (early 2020) and a late-stage evaluation (early 2022), triangulate the data collected with various methods at each site and subsequently compare our findings across the five sites.

Discussion

Evaluating a complex intervention such as the CEBHA+ IKT approach is complicated, even more so when undertaken across five diverse countries. Despite conceptual, methodological and practical challenges, our comparative case study addresses important evidence gaps: While involving decision-makers in the research process is gaining traction worldwide, we still know very little regarding (i) whether this approach really makes a difference to evidence uptake, (ii) the mechanisms that make IKT successful, and (iii) relevant differences across socio-cultural contexts. The evaluation described here is intended to provide relevant insights on all of these aspects, notably in countries in Sub-Saharan Africa, and is expected to contribute to the science of IKT overall.

Risk factors affecting maternal health outcomes in Rivers State of Nigeria: Towards the PRISMA model

Existing research suggests that Nigeria accounts for about 23% of the world's maternal mortality ratio, with negative impacts on women's wellbeing and the country's socio-economic development. The underlying risk factors can be categorized into political influences, poor access to healthcare, inadequate utilization of health facilities, poor family planning support and complex pregnancy-related illness. Yet, the complex interrelations amongst the factors makes it difficult to ascertain the riskiest ones that affect women's reproduction and child death, with the existing intervening strategies failing to address the problem. This study identifies maternal health risk factors and prioritizes their management in Rivers State of Nigeria, using the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA) model. Taking a quantitative turn, we applied exploratory factor analysis to analyze 174 returned questionnaires from healthcare professionals working in Rivers State and used the results to establish relationships between maternal health risk factors, prioritizing the riskiest factors. The outcomes indicate that the PRISMA model provides an effective framework for identifying and managing maternal mortality risks that can enable healthcare experts and managers to address the avoidable risk factors and mitigate the unavoidable patient-related risk factors in Nigeria. The implications for theory, practice and policy are discussed.

Advancing a health equity agenda across multiple policy domains: a qualitative policy analysis of social, trade and welfare policy

OBJECTIVE

While there is urgent need for policymaking that prioritises health equity, successful strategies for advancing such an agenda across multiple policy sectors are not well known. This study aims to address this gap by identifying successful strategies to advance a health equity agenda across multiple policy domains.

DESIGN

We conducted in-depth qualitative case studies in three important social determinants of health equity in Australia: employment and social policy (Paid Parental Leave); macroeconomics and trade policy (the Trans Pacific Partnership agreement); and welfare reform (the Northern Territory Emergency Response). The analysis triangulated multiple data sources included 71 semistructured interviews, document analysis and drew on political science theories related to interests, ideas and institutions.

RESULTS

Within and across case studies we observed three key strategies used by policy actors to advance a health equity agenda, with differing levels of success. The first was the use of multiple policy frames to appeal to a wide range of actors beyond health. The second was the formation of broad coalitions beyond the health sector, in particular networking with non-traditional policy allies. The third was the use of strategic forum shopping by policy actors to move the debate into more popular policy forums that were not health focused.

CONCLUSIONS

This analysis provides nuanced strategies for agenda-setting for health equity and points to the need for multiple persuasive issue frames, coalitions with unusual bedfellows, and shopping around for supportive institutions outside the traditional health domain. Use of these nuanced strategies could generate greater ideational, actor and institutional support for prioritising health equity and thus could lead to improved health outcomes.

Lessons learned from descriptions and evaluations of knowledge translation platforms supporting evidence-informed policy-making in low- and middle-income countries: a systematic review

BACKGROUND

Knowledge translation (KT) platforms are organisations, initiatives and networks that focus on supporting evidence-informed policy-making at least in part about the health-system arrangements that determine whether the right programmes, services and products get to those who need them. Many descriptions and evaluations of KT platforms in low- and middle-income countries have been produced but, to date, they have not been systematically reviewed.

METHODS

We identified potentially relevant studies through a search of five electronic databases and a variety of approaches to identify grey literature. We used four criteria to select eligible empirical studies. We extracted data about seven characteristics of included studies and about key findings. We used explicit criteria to assess study quality. In synthesising the findings, we gave greater attention to themes that emerged from multiple studies, higher-quality studies and different contexts.

RESULTS

Country was the most common jurisdictional focus of KT platforms, EVIPNet the most common name and high turnover among staff a common infrastructural feature. Evidence briefs and deliberative dialogues were the activities/outputs that were the most extensively studied and viewed as helpful, while rapid evidence services were the next most studied but only in a single jurisdiction. None of the summative evaluations used a pre-post design or a control group and, with the exception of the evaluations of the influence of briefs and dialogues on intentions to act, none of the evaluations achieved a high quality score.

CONCLUSIONS

A large and growing volume of research evidence suggests that KT platforms offer promise in supporting evidence-informed policy-making in low- and middle-income countries. KT platforms should consider as next steps expanding their current, relatively limited portfolio of activities and outputs, building bridges to complementary groups, and planning for evaluations that examine 'what works' for 'what types of issues' in 'what types of contexts'.

Measuring nurses' perceptions of their work environment and linking with behaviour change theories and implementation strategies to support evidence based practice change

PURPOSE

Survey tools, such as the Alberta Context Tool, reliably measure context but researchers have no process to map context to clinician behaviour and develop strategies to support practice change. Therefore, we aimed to map the Alberta Context Tool to the Theoretical Domains Framework and the Behaviour Change Wheel.

METHOD

The multi-centre study used the Alberta Context Tool to collect data from a convenience sample of nurses working in two emergency departments. These findings were categorised as barriers and enablers, and then mapped to the Theoretical Domains Framework to examine for behavioural domains. Using the Behaviour Change Wheel functions, strategies were developed to target clinician behaviour change.

RESULTS

Survey response rate was 42% (n = 68). Nurses perceived a positive work environment in the dimensions of Social Capital (median 4.00, IQR 0.33), Culture (median 3.83, IQR 1.16) and Leadership (median 3.60, IQR 1.1). Low scoring dimensions included Formal Interactions (median 2.75, IQR 1.00); Time (median 2.60, IQR 1.00) Staffing (median 3.0, IQR 2.00) and Space (median 3.0, IQR 2.00). Enablers (n = 77) and barriers (n = 25) were identified in both sites. The Theoretical Domains Framework was mapped to Alberta Context Tool barriers and enablers. The behaviour change strengths included: social and professional role; beliefs about capability; goals; and emotions. Using the Behaviour Change Wheel functions, 67 strategies were developed to address barriers and enablers.

CONCLUSIONS

The Alberta Context Tool successfully measured two emergency environments identifying barriers and enablers. This approach enabled environment dimensions to be targeted with practical solutions to support evidence-based practice implementation.

Institutional Engagement Practices as Barriers to Public Health Capacity in Climate Change Policy Discourse: Lessons from the Canadian Province of Ontario

Public health engagement in the communication, discussion, and development of climate change policies is essential for climate change policy decisions and discourse. This study examines how the existing governance approaches impact, enable, or constrain the inclusion, participation, and deliberation of public health stakeholders in the climate change policy discourse. Using the case study of the Canadian Province of Ontario, we conducted semi-structured, key informant interviews of public health (11) and non-public health (13) participants engaged in climate change policies in the province. The study results reveal that engagement and partnerships on climate change policies occurred within and across public health and non-public health organizations in Ontario. These engagements impacted public health's roles, decisions, mandate, and capacities beyond the climate change discourse; enabled access to funds, expertise, and new stakeholders; built relationships for future engagements; supported knowledge sharing, generation, and creation; and advanced public health interests in political platforms and decision making. However, public health's participation and deliberation were constrained by a fragmented sectoral approach, a lack of holistic inter-organizational structures and process, political and bureaucratic influences, irregular and unestablished communication channels for public health integration, and identities and culture focused on functions, mandates, biased ideologies, and a lack of clear commitment to engage public health. We conclude by providing practical approaches for integrating public health into climate change discourse and policymaking processes and advancing public health partnerships and collaborative opportunities.

The Political Economy of Tobacco in Mozambique and Zimbabwe: A Triangulation Mixed Methods Protocol

Changing global markets have generated a dramatic shift in tobacco consumption from high-income countries (HICs) to low- and middle-income countries (LMICs); by 2030, more than 80% of the disease burden from tobacco use will fall on LMICs. Propelling this shift, opponents of tobacco control have successfully asserted that tobacco is essential to the economic livelihoods of smallholder tobacco farmers and the economy of tobacco-growing countries. This nexus of economic, agricultural and public health policymaking is one of the greatest challenges facing tobacco control efforts, especially in LMICs. To date, there is a lack of comparative, individual level evidence about the actual livelihoods of tobacco-growing farmers and the political economic context driving tobacco production. This comparative evidence is critically important to identify similarities and differences across contexts and to provide local evidence to inform policies and institutional engagement. Our proposed four-year project will examine the economic situation of smallholder farmers in two major tobacco-growing LMICs-Mozambique and Zimbabwe-and the political economy shaping farmers' livelihoods and tobacco control efforts. We will collect and analyze the existing data and policy literature on the political economy of tobacco in these two countries. We will also implement household-level economic surveys of nationally representative samples of farmers. The surveys will be complimented with focus group discussions with farmers across the major tobacco-growing regions. Finally, we will interview key informants in these countries in order to illuminate the policy context in which tobacco production is perpetuated. The team will develop country-level reports and policy briefs that will inform two sets of dissemination workshops in each country with relevant stakeholders. We will also conduct workshops to present our findings to the survey and focus group participants, and other members of these tobacco-growing communities, so they can directly benefit from the research to which they are contributing.

Reconceptualising the study of alcohol policy decision-making: the contribution of political science

In this article, we demonstrate the applicability of a 3-I (interests, institutions, and ideas) framework to alcohol policy research. The analysis uses literature from political science research to provide a core theoretical framework. To help illustrate the argument, we draw on relevant examples from alcohol policy in the UK as well as initial findings from an ongoing research study on minimum-unit pricing in Wales. The Welsh case study provides an opportunity to examine the value of the framework in generating testable hypotheses in alcohol policy research. We find that several interrelated factors promoted policy change in Wales, including the government's power to legislate on matters of public health (institutionally), a relatively weak alcohol industry (a key interest group), and a public health community with specific policy arguments on why and how to tackle alcohol-related harms (ideas). Our analysis has important implications for public health research and evidence-based policymaking. It suggests that the uptake of new ideas depends on the existing configuration of interests, institutions and ideas. This analysis provides alcohol policy researchers with a portable framework for analysing the policy context.

Factoring civil society actors into health policy processes in low- and middle-income countries: a review of research articles, 2007-16

Civil society actors have substantially increased their participation in global and national health policymaking processes since the 1970s. Civil society roles in shaping such significant global health milestones as the Doha Declaration on Intellectual Property Rights, the Framework Convention on Tobacco Control and the recently adopted United Nations Sustainable Development Goals are well documented, but knowledge of civil society actor influence on health policy processes in low- and middle-income countries remains fragmented. This study analyses 24 peer-reviewed research articles published between 2007 and 2016 to identify factors affecting civil society influence in the pre-implementation stages of the policy process. The articles reviewed span 13 health issues and more than 50 countries in four regions of the world. This body of work focuses on civil society as represented by formal groups, primarily domestic and to some extent international non-governmental organizations, but also social movements, professional associations and faith-based organizations, among others. The studies document several actor-centred and contextual factors that affect civil society actor power, commonly across stages of the policy process. Crucially, civil society actors were challenged to impact the process in countries that lacked participative norms and governing structures. When repressive conditions existed, regime changes and donors sometimes helped to open doors to participation. The power of civil society actors was enhanced when they joined strong epistemic networks and broader coalitions of stakeholders, were resourced, and framed issues in ways that resonated with national policies and political priorities. The synthesis offers guidance to practitioners on factors to consider in strategy development and points to several issues for further investigation by health policy analysis scholars, including the implications of issue (non)adoption by civil society actors and contestation dynamics among those with differing perspectives.

The governmental health policy-development process for Syrian refugees: an embedded qualitative case studies in Lebanon and Ontario

BACKGROUND

The unprecedented amount of resources dedicated to humanitarian aid has led many stakeholders to demand the use of reliable evidence in humanitarian aid decisions to ensure that desired impacts are achieved at acceptable costs. However, little is known about the factors that influence the use of research evidence in the policy development in humanitarian crises. We examined how research evidence was used to inform two humanitarian policies made in response to the Syrian refugee crisis.

METHODS

We identified two policies as rich potential case studies to examine the use of evidence in humanitarian aid policy decision-making: Lebanon's 2016 Health Response Strategy and Ontario's 2016 Phase 2: Health System Action Plan, Syrian Refugees. To study each, we used an embedded qualitative case study methodology and recruited senior decision-makers, policy advisors, and healthcare providers who were involved with the development of each policy. We reviewed publicly available documents and media articles that spoke to the factors that influence the process. We used the analytic technique of explanation building to understand the factors that influence the use of research evidence in the policy-development process in crisis zones.

RESULTS

We interviewed eight informants working in government and six in international agencies in Lebanon, and two informants working in healthcare provider organizations and two in non-governmental organizations in Ontario, for a total of 18 key informants. Based on our interviews and documentary analysis, we identified that there was limited use of research evidence and that four broad categories of factors helped to explain the policy-development process for Syrian refugees - development of health policies without significant chance for derailment from other government bodies (Lebanon) or opposition parties (Ontario) (i.e., facing no veto points), government's engagement with key societal actors to inform the policy-development process, the values underpinning the process, and external factors significantly influencing the policy-development process.

CONCLUSIONS

This study suggests that use of research evidence in the policy-development process for Syrian refugees was subordinate to key political factors, resulting in limited influence of research evidence in the development of both the Lebanese and Ontarian policy.

A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa

BACKGROUND

In 2012 the South African National Department of Health (SA NDoH) set out, using a top down process, to implement several innovations in eleven health districts in order to test reforms to strengthen the district health system. The process of disseminating innovations began in 2012 and senior health managers in districts were expected to drive implementation. The research explored, from a bottom up perspective, how efforts by the National government to disseminate and diffuse innovations were experienced by district level senior managers and why some dissemination efforts were more enabling than others.

METHODS

A multiple case study design comprising three cases was conducted. Data collection in 2012 - early 2014 included 38 interviews with provincial and district level managers as well as non- participant observation of meetings. The Greenhalgh et al. (Milbank Q 82(4):581-629, 2004) diffusion of innovations model was used to interpret dissemination and diffusion in the districts.

RESULTS

Managers valued the national Minister of Health's role as a champion in disseminating innovations via a road show and his personal participation in an induction programme for new hospital managers. The identification of a site coordinator in each pilot site was valued as this coordinator served as a central point of connection between networks up the hierarchy and horizontally in the district. Managers leveraged their own existing social networks in the districts and created synergies between new ideas and existing working practices to enable adoption by their staff. Managers also wanted to be part of processes that decide what should be strengthened in their districts and want clarity on: (1) the benefits of new innovations (2) total funding they will receive (3) their specific role in implementation and (4) the range of stakeholders involved.

CONCLUSION

Those driving reform processes from 'the top' must remember to develop well planned dissemination strategies that give lower-level managers relevant information and, as part of those strategies, provide ongoing opportunities for bottom up input into key decisions and processes. Managers in districts must be recognised as leaders of change, not only as implementers who are at the receiving end of dissemination strategies from those at the top. They are integral intermediaries between those at the at the coal face and national policies, managing long chains of dissemination and natural (often unpredictable) diffusion.

Agenda setting for maternal survival in Ghana and Tanzania against the backdrop of the MDGs

High-level political support for the United Nations Millennium Development Goals (MDGs) drew international attention to included causes at the turn of the century. Influences of this normative framework on national-level health agenda setting remain little investigated. This study investigates the agenda status of maternal survival against the backdrop of the MDGs in two countries in sub-Saharan Africa. Informed by replicative case studies conducted in Ghana and Tanzania, the study finds the MDGs played a significant role in the issue's increasing status in both countries by helping to align several factors that facilitate the agenda setting process, including: ideas concerning the severity of the problem and expectations for its redress; institutions that shape policies, programs and monitoring; and economic and political interests. The agenda setting process was similar in the countries but for two dynamics. HIV/AIDS dominated Tanzania's health policy agenda in the early 2000s, crowding out attention to maternal and other health issues. A network of concerned actors that expanded to form a broad political coalition later facilitated agenda setting in Tanzania, including securing some budgetary commitments. By contrast, Ghana's core maternal health network remained technically oriented and closed to broader political and civil society engagement, limiting its capacity to expand issue attention and budgetary commitments beyond the health sector.

Researcher and policymaker dialogue: the Policy BUDDIES Project in Western Cape Province, South Africa

Dialogue and exchange between researchers and policy personnel may increase the use of research evidence in policy. We piloted and evaluated a programme of formalised dialogue between researchers and provincial health policymakers in South Africa, called the buddying programme. An external evaluation examined implementation and short-term impact, drawing on documents, in-depth interviews with policymakers, a researcher buddies focus group and our own reflection on what we learnt. We set up buddying with seven policymakers and five researchers on six policy questions. Researchers knew little about policymaking or needs of policymakers. Policymakers respected the contact with researchers, respected researchers’ objectivity and appreciated the formalised approach. Having policymaker champions facilitated the dialogue. Scenarios for policy questions and use were different. One topic was at problem identification stage (contraceptives and HIV risk), four at policy formulation stage (healthy lifestyles, chronic illness medication adherence, integrated care of chronic illness and maternal transmission of HIV to infants) and one at implementation stage (task shifting). Research evidence were used to identify or solve a policy problem (two scenarios), to legitimise a predetermined policy position (three scenarios) or the evidence indirectly influenced the policy (one scenario). The formalised dialogue required in this structured buddying programme took time and commitment from both sides. The programme illustrated the importance of researchers listening, and policymakers understanding what research can offer. Both parties recognised that the structured buddying made the dialogue happen. Often the evidence was helpful in supporting provincial policy decisions that were in the roll-out phase from the national government.

How states exerted power to create the Millennium Development Goals and how this shaped the global health agenda: Lessons for the sustainable development goals and the future of global health

Since 2000, the eight Millennium Development Goals (MDGs) provided the framework for global development efforts transforming the field now known as global health. The MDGs both reflected and contributed to shaping a normative global health agenda. In the field of global health, the role of the state is largely considered to have diminished; however, this paper reasserts states as actors in the conceptualisation and institutionalisation of the MDGs, and illustrates how states exerted power and engaged in the MDG process. States not only sanctioned the MDGs through their heads of states endorsing the Millennium Declaration, but also acted more subtly behind the scenes supporting, enabling, and/or leveraging other actors, institutions and processes to conceptualise and legitimize the MDGs. Appreciating the MDGs' role in the conceptualisation of global health is particularly relevant as the world transitions to the MDGs' successor, the Sustainable Development Goals (SDGs). The SDGs' influence, impact and importance remains to be seen; however, to understand the future of global health and how actors, particularly states, can engage to shape the field, a deeper sense of the MDGs' legacy and how actors engaged in the past is helpful.

Harnessing opportunities for good governance of health impacts of mining projects in Mongolia: results of a global partnership

Background

The Sustainable Development Goals call for the effective governance of shared natural resources in ways that support inclusive growth, safeguard the integrity of the natural and physical environment, and promote health and well-being for all. For large-scale resource extraction projects -- e.g. in the mining sector -- environmental regulations and in particular environmental impact assessments (EIA) provide an important but insufficiently developed avenue to ensure that wider sustainable development issues, such as health, have been considered prior to the permitting of projects.

Methods

In recognition of the opportunity provided in EIA to influence the extent to which health issues would be addressed in the design and delivery of mining projects, an international and intersectoral partnership, with the support of WHO and public funds from Canadian sources, engaged over a period of six years in a series of capacity development activities and knowledge translation/dissemination events aimed at influencing policy change in the extractives sector so as to include consideration of human health impacts.

Results

Early efforts significantly increased awareness of the need to include health considerations in EIAs. Coupling effective knowledge translation about health in EIA with the development of networks that fostered good intersectoral partnerships, this awareness supported the development and implementation of key pieces of legislation. These results show that intersectoral collaboration is essential, and must be supported by an effective conceptual understanding about which methods and models of impact assessment, particularly for health, lend themselves to integration within EIA.

Conclusions

The results of our partnership demonstrate that when specific conditions are met, integrating health into the EIA system represents a promising avenue to ensure that mining activities contribute to wider sustainable development goals and objectives.