10 best resources on power in health policy and systems in low- and middle-income countries

How to leverage implementation research for equity in global health

Implementation research (IR) is important for addressing equity in global health. However, there is limited knowledge on how to operationalize IR for health equity, and pathways for improving health equity through IR in global health settings. This paper provides an overview of guidance and frameworks for thinking about health equity as part of IR while noting the gaps in how this guidance and frameworks apply to global health. It proposes an approach to guide implementation teams in the application of IR for achieving equity in global health considering these gaps. It describes key equity considerations for different aspects of IR (i.e., implementation contexts, strategies, outcomes, and research designs). These considerations can be applied prospectively and retrospectively, and at different stages of IR. The paper further describes causal pathways, intervention levers, and strategies for achieving health equity in global health settings through IR. Central to these pathways is the power asymmetries among different actors involved in IR in global health and how these contribute to health inequities. The paper suggests recommendations and strategies for shifting the balance of power among these actors while addressing the structural and systemic determinants of health inequities as part of IR. Explicit considerations for health equity as part of implementation research and practice are needed for the achievement of global health goals. Such explicit considerations should look back as much as possible, and entail defining and analyzing health inequities and intervening on the underlying causes and mechanisms of health inequities as part of IR on a routine basis.

Defining equity, its determinants, and the foundations of equity science

Advancing equity as a priority is increasingly declared in response to decades of evidence showing the association between poorer health outcomes and the unfair distribution of resources, power, and wealth across all levels of society. Quandries present, however, through incongruence, vagueness and disparate interpretations of the meaning of equity dilute and fragment efforts across research, policy and practice. Progress on reducing health inequities is, in this context, unsurprisingly irresolute. In this article, we make a case for equity science that reimagines the ways in which we (as researchers, as systems leaders, as teachers and mentors, and as citizens in society) engage in this work. We offer a definition of equity, its determinants, and the paradigmatic foundations of equity science, including the assumptions, values, and processes., and methods of this science. We argue for an equity science that can more meaningfully promote coherent alignment between intention, knowledge and action within and beyond the health sciences to spark a more equitable future.

Network power and mental health policy in post-war Liberia

This article traces the influence of network power on mental health policy in Liberia, a low-income, post-conflict West African country. Based on key informant interviews, focus group discussions and document analysis, the work uses an inductive approach to uncover how a network of civil society groups, government officials, diasporans and international NGOs shaped the passage, implementation and revision of the country's 2009 and 2016 mental health policies. With relations rooted in ties of information, expertise, resources, commitment and personal connections, the network coalesced around a key agent, the Carter Center, which connected members and guided initiatives. Network power was evident when these actors channelled expertise, shared narratives of post-war trauma and mental health as a human right, and financial resources to influence policy. Feedback loops appeared as policy implementation created new associations of mental health clinicians and service users, research entities and training institutes. These beneficiaries offered the network information from lived experiences, while also pressing their own interests in subsequent policy revisions. As the network expanded over time, some network members gained greater autonomy from the key agent. Network power outcomes included the creation of government mental health institutions, workforce development, increased public awareness, civil society mobilization and a line for mental health in the government budget, though concerns about network overstretch and key agent commitment emerged over time. The Liberian case illustrates how networks need not be inimical to development, and how network power may facilitate action on stigmatized, unpopular issues in contexts with low state capacity. A focus on network power in health shows how power can operate not only through discrete resources such as funding but also through the totality of assets that network linkages make possible.

Applying a Power and Gender Lens to Understanding Health Care Provider Experience and Behavior: A Multicountry Qualitative Study

A limited but growing body of literature shows that health care providers (HCPs) in reproductive, maternal, and newborn health face challenges that affect how they provide services. Our study investigates provider perspectives and behaviors using 4 interrelated power domains-beliefs and perceptions; practices and participation; access to assets; and structures-to explore how these constructs are differentially experienced based on one's gender, position, and function within the health system. We conducted a framework-based secondary analysis of qualitative in-depth interview data gathered with different cadres of HCPs across Kenya, Malawi, Madagascar, and Togo (n=123). We find across countries that power dynamics manifest in and are affected by all 4 domains, with some variation by HCP cadre and gender. At the service interface, HCPs' power derives from the nature and quality of their relationships with clients and the community. Providers' power within working relationships stems from unequal decision-making autonomy among HCP cadres. Limited and sometimes gendered access to remuneration, development opportunities, material resources, supervision quality, and emotional support affect HCPs' power to care for clients effectively. Power manifests variably among community and facility-based providers because of differences in prevailing hierarchical norms in routine and acute settings, community linkages, and type of collaboration required in their work. Our findings suggest that applying power-and secondarily, gender lenses-can elucidate consistencies in how providers perceive, internalize, and react to a range of relational and environmental stressors. The findings also have implications on how to improve the design of social behavior change interventions aimed at better supporting HCPs.

A narrative review of challenges related to healthcare worker rights, roles and responsibilities in the provision of sexual and reproductive services in health facilities

INTRODUCTION

This paper identifies and summarises tensions and challenges related to healthcare worker rights and responsibilities and describes how they affect healthcare worker roles in the provision of sexual and reproductive health (SRH) care in health facilities.

METHOD

The review was undertaken in a two-phase process, namely: (1) development of a list of core constructs and concepts relating to healthcare worker rights, roles and responsibilities to guide the review and (2) literature review.

RESULT

A total of 110 papers addressing a variety of SRH areas and geographical locations met our inclusion criteria. These papers addressed challenges to healthcare worker rights, roles and responsibilities, including conflicting laws, policies and guidelines; pressure to achieve coverage and quality; violations of the rights and professionalism of healthcare workers, undercutting their ability and motivation to fulfil their responsibilities; inadequate stewardship of the private sector; competing paradigms for decision-making-such as religious beliefs-that are inconsistent with professional responsibilities; donor conditionalities and fragmentation; and, the persistence of embedded practical norms that are at odds with healthcare worker rights and responsibilities. The tensions lead to a host of undesirable outcomes, ranging from professional frustration to the provision of a narrower range of services or of poor-quality services.

CONCLUSION

Social mores relating to gender and sexuality and other contested domains that relate to social norms, provider religious identity and other deeply held beliefs complicate the terrain for SRH in particular. Despite the particularities of SRH, a whole of systems response may be best suited to address embedded challenges.

Turning the tide on inequity through systematic equity action-analysis

BACKGROUND

Collective agreement about the importance of centering equity in health research, practice, and policy is growing. Yet, responsibility for advancing equity is often situated as belonging to a vague group of 'others', or delegated to the leadership of 'equity-seeking' or 'equity-deserving' groups who are tasked to lead systems transformation while simultaneously navigating the violence and harms of oppression within those same systems. Equity efforts also often overlook the breadth of equity scholarship. Harnessing the potential of current interests in advancing equity requires systematic, evidence-guided, theoretically rigorous ways for people to embrace their own agency and influence over the systems in which they are situated. ln this article, we introduce and describe the Systematic Equity Action-Analysis (SEA) Framework as a tool that translates equity scholarship and evidence into a structured process that leaders, teams, and communities can use to advance equity in their own settings.

METHODS

This framework was derived through a dialogic, critically reflective and scholarly process of integrating methodological insights garnered over years of equity-centred research and practice. Each author, in a variety of ways, brought engaged equity perspectives to the dialogue, bringing practical and lived experience to conversation and writing. Our scholarly dialogue was grounded in critical and relational lenses, and involved synthesis of theory and practice from a broad range of applications and cases.

RESULTS

The SEA Framework balances practices of agency, humility, critically reflective dialogue, and systems thinking. The framework guides users through four elements of analysis (worldview, coherence, potential, and accountability) to systematically interrogate how and where equity is integrated in a setting or object of action-analysis. Because equity issues are present in virtually all aspects of society, the kinds of 'things' the framework could be applied to is only limited by the imagination of its users. It can inform retrospective or prospective work, by groups external to a policy or practice setting (e.g., using public documents to assess a research funding policy landscape); or internal to a system, policy, or practice setting (e.g., faculty engaging in a critically reflective examination of equity in the undergraduate program they deliver).

CONCLUSIONS

While not a panacea, this unique contribution to the science of health equity equips people to explicitly recognize and interrupt their own entanglements in the intersecting systems of oppression and injustice that produce and uphold inequities.

Geographic prioritisation in Kenya and Uganda: a power analysis of donor transition

Introduction Donor transition for HIV/AIDS programmes remains sensitive, marking a significant shift away from the traditional investment model of large-scale, vertical investments to control the epidemic and achieve rapid scaling-up of services. In late 2015, the United States President's Emergency Plan for AIDS Relief (PEPFAR) headquarters instructed their country missions to implement 'geographic prioritisation' (GP), whereby PEPFAR investments would target geographic areas with high HIV burden and reduce or cease support in areas with low burden.Methods Using Gaventa's power cube framework, we compare how power is distributed and manifested using qualitative data collected in an evaluation of the GP's impact in Kenya and Uganda.Results We found that the GP was designed with little space for national and local actors to shape either the policy or its implementation. While decision-making processes limited the scope for national-level government actors to shape the GP, the national government in Kenya claimed such a space, proactively pressuring PEPFAR to change particular aspects of its GP plan. Subnational level actors were typically recipients of top-down decision-making with apparently limited scope to resist or change GP. While civil society had the potential to hold both PEPFAR and government actors accountable, the closed-door nature of policy-making and the lack of transparency about decisions made this difficult.Conclusion Donor agencies should exercise power responsibly, especially to ensure that transition processes meaningfully engage governments and others with a mandate for service delivery. Furthermore, subnational actors and civil society are often better positioned to understand the implications and changes arising from transition. Greater transparency and accountability would increase the success of global health programme transitions, especially in the context of greater decentralisation, requiring donors and country counterparts to be more aware and flexible of working within political systems that have implications for programmatic success.

Political Prioritisation for Performance-Based Financing at the County Level in Kenya: 2015 to 2018

BACKGROUND

Performance based financing was introduced to Kilifi county in Kenya in 2015. This study investigates how and why political and bureaucratic actors at the local level in Kilifi county influenced the extent to which PBF was politically prioritised at the sub-national level.

METHODS

The study employed a single-case study design. The Shiffman and Smith political priority setting framework with adaptations proposed by Walt and Gilson was applied. Data was collected through document review (n=19) and in-depth interviews (n=8). Framework analysis was used to analyse data and generate findings.

RESULTS

In the period 2015-2018, the political prioritisation of PBF at the county level in Kilifi was influenced by contextual features including the devolution of power to sub-national actors and rigid public financial management structures. It was further influenced by interpretations of the idea of 'pay-for-performance', its framing as 'additional funding', as well as contestation between actors at the sub national level about key PBF design features. Ultimately PBF ceased at the end of 2018 after donor funding stopped.

CONCLUSION

Health reformers must be cognisant of the power and interests of national and sub national actors in all phases of the policy process, including both bureaucratic and political actors in health and non-health sectors. This is particularly important in devolved public governance contexts where reforms require sustained attention and budgetary commitment at the sub national level. There is also need for early involvement of critical actors to develop shared understandings of the ideas on which interventions are premised, as well as problems and solutions.

A critical interpretive synthesis of power and mistreatment of women in maternity care

Labouring women may be subjected to physical and verbal abuse that reflects dynamics of power, described as Mistreatment of Women (MoW). This Critical Interpretive Synthesis on power and MoW consolidates current research and advances theory and practice through inter-disciplinary literature exploration. The review was undertaken in 3 phases. Phase 1 consisted of topic scoping; phase 2 entailed exploration of key power-related drivers emerging from the topic scoping; and phase 3 entailed data synthesis and analysis, with a particular focus on interventions. We identified 63 papers for inclusion in Phase 1. These papers utilized a variety of methods and approaches and represented a wide range of geographic regions. The power-related drivers of mistreatment in these articles span multiple levels of the social ecological model, including intrapersonal (e.g. lack of knowledge about one's rights), interpersonal (e.g. patient-provider hierarchy), community (e.g. widespread discrimination against indigenous women), organizational (e.g. pressure to achieve performance goals), and law/policy (e.g. lack of accountability for rights violations). Most papers addressed more than one level of the social-ecological model, though a significant minority were focused just on interpersonal factors. During Phase 1, we identified priority themes relating to under-explored power-related drivers of MoW for exploration in Phase 2, including lack of conscientization and normalization of MoW; perceptions of fitness for motherhood; geopolitical and ethnopolitical projects related to fertility; and pressure to achieve quantifiable performance goals. We ultimately included 104 papers in Phase 2. The wide-ranging findings from Phase 3 (synthesis and analysis) coalesce in several key meta-themes, each with their own evidence-base for action. Consistent with the notion that research on power can point us to "drivers of the drivers," the paper includes some intervention-relevant insights for further exploration, including as relating to broader social norms, health systems design, and the utility of multi-level strategies.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

Between Rhetoric and Reality: Learnings From Youth Participation in the Adolescent and Youth Health Policy in South Africa

BACKGROUND

Youth participation makes an essential contribution to the design of policies and with the appropriate structures, and processes, meaningful engagement leads to healthier, more just, and equal societies. There is a substantial gap between rhetoric and reality in terms of youth participation and there is scant research about this gap, both globally and in South Africa. In this paper we examine youth participation in the Adolescent and Youth Health Policy (AYHP) formulation process to further understand how youth can be included in health policy-making.

METHODS

A conceptual framework adapted from the literature encompassing Place, Purpose, People, Process and Partnerships guided the case study analysis of the AYHP. Qualitative data was collected via 30 in-depth, semi-structured interviews with policy actors from 2019-2021.

RESULTS

Youth participation in the AYHP was a 'first' and unique component for health policy in South Africa. It took place in a fragmented policy landscape with multiple actors, where past and present social and structural determinants, as well as contemporary bureaucratic and donor politics, still shape both the health and participation of young people. Youth participation was enabled by leadership from certain government actors and involvement of key academics with a foundation in long standing youth research participatory programmes. However, challenges related to when, how and which youth were involved remained. Youth participation was not consistent throughout the health policy formulation process. This is related to broader contextual challenges including the lack of a representative and active youth citizenry, siloed health programmes and policy processes, segmented donor priorities, and the lack of institutional capability for multi-sectoral engagement required for youth health.

CONCLUSION

Youth participation in the AYHP was a step toward including youth in the development of health policy but more needs to be done to bridge the gap between rhetoric and reality.

Implementation of medicines pricing policies in sub-Saharan Africa: systematic review

BACKGROUND

High medicine prices contribute to increasing cost of healthcare worldwide. Many patients with limited resources in sub-Saharan Africa (SSA) are confronted with out-of-pocket charges, constraining their access to medicines. Different medicine pricing policies are implemented to improve affordability and availability; however, evidence on the experiences of implementations of these policies in SSA settings appears limited. Therefore, to bridge this knowledge gap, we reviewed published evidence and answered the question: what are the key determinants of implementation of medicines pricing policies in SSA countries?

METHODS

We identified policies and examined implementation processes, key actors involved, contextual influences on and impact of these policies. We searched five databases and grey literature; screening was done in two stages following clear inclusion criteria. A structured template guided the data extraction, and data analysis followed thematic narrative synthesis. The review followed best practices and reported using PRISMA guidelines.

RESULTS

Of the 5595 studies identified, 31 met the inclusion criteria. The results showed thirteen pricing policies were implemented across SSA between 2003 and 2020. These were in four domains: targeted public subsides, regulatory frameworks and direct price control, generic medicine policies and purchasing policies. Main actors involved were government, wholesalers, manufacturers, retailers, professional bodies, community members and private and public health facilities. Key contextual barriers to implementation were limited awareness about policies, lack of regulatory capacity and lack of price transparency in external reference pricing process. Key facilitators were favourable policy environment on essential medicines, strong political will and international support. Evidence on effectiveness of these policies on reducing prices of, and improving access to, medicines was mixed. Reductions in prices were reported occasionally, and implementation of medicine pricing policy sometimes led to improved availability and affordability to essential medicines.

CONCLUSIONS

Implementation of medicine pricing policies in SSA shows some mixed evidence of improved availability and affordability to essential medicines. It is important to understand country-specific experiences, diversity of policy actors and contextual barriers and facilitators to policy implementation. Our study suggests three policy implications, for SSA and potentially other low-resource settings: avoiding a 'one-size-fits-all' approach, engaging both private and public sector policy actors in policy implementation and continuously monitoring implementation and effects of policies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020178166.

Power sources among district health managers in Ghana: a qualitative study

Background

In Ghana district directors of health services and district hospital medical superintendents provide leadership and management within district health systems. A healthy relationship among these managers is dependent on the clarity of formal and informal rules governing their routine duties. These rules translate into the power structures within which district health managers operate. However, detailed nuanced studies of power sources among district health managers are scarce. This paper explores how, why and from where district health directors and medical superintendents derive power in their routine functions.

Methods

A multiple case study was conducted in three districts; Bongo, Kintampo North and Juaboso. In each case study site, a cross-sectional design was used to explore the research question. Purposive sampling technique was used to select study sites and 61 participants for interview and focus group discussion. A total of 11 interviews (3 in each district and 2 with deputy regional directors), and 9 focus group discussions (3 in each district) were conducted. Transcriptions of the voice-recordings were done verbatim, cleaned and imported into the Nvivo version 11 software for analysis using the inductive content analysis approach.

Results

The findings revealed that legitimacy provides formal power source for district health managers since they are formally appointed by the Director General of the Ghana Health Service after going through the appointment processes. These appointments serve as the primary power source for district health managers based on the existing legal and policy framework of the Ghana Health Service. Additionally, resource control especially finances and medical dominance are major informal sources of power that district health managers often employ for the management and administration of their functional areas in the health districts.

Conclusions

The study concludes that district health managers derive powers primarily from their positions within the hierarchical structure (legitimacy) of the district health system. Secondary sources of power stems from resource control (medical dominance and financial dominance), and these power sources inform the way district health managers relate to each other. This paper recommends that district health managers are oriented to understand the power dynamics in the district health system.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

Conceptual framework for systemic capacity strengthening for health policy and systems research

Health policy and systems research (HPSR) is critical in developing health systems to better meet the health needs of their populations. The highly contextualised nature of health systems point to the value of local knowledge and the need for context-embedded HPSR. Despite such need, relatively few individuals, groups or organisations carry out HPSR, particularly in low-income and middle-income countries. Greater effort is required to strengthen capacity for, and build the field of, HPSR by capturing the multilevel and nuanced representation of HPSR across contexts. No comprehensive frameworks were found that inform systemic HPSR capacity strengthening. Existing literature on capacity strengthening for health research and development tends to focus on individual-level capacity with less attention to collective, organisational and network levels. This paper proposes a comprehensive framework for systemic capacity strengthening for HPSR, uniquely drawing attention to the blurred boundaries and amplification potential for synergistic capacity strengthening efforts across the individual, organisational and network levels. Further, it identifies guiding values and principles that consciously acknowledge and manage the power dynamics inherent to capacity strengthening work. The framework was developed drawing on available literature and was peer-reviewed by the Board and Thematic Working Groups of Health Systems Global. While the framework focuses on HPSR, it may provide a useful heuristic for systemic approaches to capacity strengthening more generally; facilitate its mainstreaming within organisations and networks and help maintain a focused approach to, and structure repositories of resources on, capacity strengthening.

The missing bit in the middle: Implementation of the Nationals Health Services Standards for Papua New Guinea

OBJECTIVE

This case study examined implementation of the National Health Services Standards (NHSSs) as a continuous quality improvement (CQI) process at three church-based health facilities in Papua New Guinea. This process was designed to improve quality of care and accredit the level three health centers to level four as district hospitals to provide a higher level of care. The aims of the paper are to critically examine driving and restraining forces in CQI implementation and analyses how power influences agenda setting for change.

METHODS

Semi-structured interviews were conducted with nine managers and eight health workers as well as three focus group discussions with health workers from three rural church-based health facilities in Morobe and Madang provinces. They included senior, mid-level and frontline managers and medical doctors, health extension officers, nursing officers and community health workers. Thematic analysis was used as an inductive and deductive process in which applied force field analysis, leadership-member exchange (LMX) theory and agenda setting was applied.

RESULTS

Qualitative analysis showed how internal and external factors created urgency for change. The CQI process was designed as a collective process. Power relations operated at and between various levels: the facilities, which supported or undermined the change process; between management whereby the national management supported the quality improvement agenda, but the regional management exercised positional power in form of inaction. Theoretical analysis identified the 'missing bit in the middle' shaped by policy actors who exercise power over policy formulation and constrained financial and technical resources. Analysis revealed how to reduce restraining forces and build on driving forces to establish a new equilibrium.

CONCLUSION

Multiple theories contributed to the analysis showing how to resolve problematic power relations by building high-quality, effective communication of senior leadership with mid-level management and reactivated broad collaborative processes at the health facilities. Addressing the 'missing bit in the middle' by agenda setting can improve implementation of the NHSSs as a quality improvement process. The paper concludes with learning for policy makers, managers and health workers by highlighting to pay close attention to institutional power dynamics and practices.

Powers, engagements and resultant influences over the design and implementation of medicine pricing policies in Ghana

Introduction

Universal availability and affordability of essential medicines are determined by effective design and implementation of relevant policies, typically involving multiple stakeholders. This paper examined stakeholder engagements, powers and resultant influences over design and implementation of four medicines pricing policies in Ghana: Health Commodity Supply Chain Master Plan, framework contracting for high demand medicines, Value Added Tax (VAT) exemptions for selected essential medicines, and ring-fencing medicines for local manufacturing.

Methods

Data were collected using reviews of policy documentation (n=16), consultative meetings with key policy actors (n=5) and in-depth interviews (n=29) with purposefully identified national-level policymakers, public and private health professionals including members of the National Medicine Pricing Committee, pharmaceutical wholesalers and importers. Data were analysed using thematic framework.

Results

A total of 46 stakeholders were identified, including representatives from the Ministry of Health, other government agencies, development partners, pharmaceutical industry and professional bodies. The Ministry of Health coordinated policy processes, utilising its bureaucratic mandate and exerted high influences over each policy. Most stakeholders were highly engaged in policy processes. Whereas some led or coproduced the policies in the design stage and participated in policy implementation, others were consulted for their inputs, views and opinions. Stakeholder powers reflected their expertise, bureaucratic mandates and through participation in national level consultation meetings, influences policy contents and implementation. A wider range of stakeholders were involved in the VAT exemption policies, reflecting their multisectoral nature. A minority of stakeholders, such as service providers were not engaged despite their interest in medicines pricing, and consequently did not influence policies.

Conclusions

Stakeholder powers were central to their engagements in, and resultant influences over medicine pricing policy processes. Effective leadership is important for inclusive and participatory policymaking, and one should be cognisant of the nature of policy issues and approaches to policy design and implementation.

A summative content analysis of how programmes to improve the right to sexual and reproductive health address power

INTRODUCTION

Power shapes all aspects of global health. The concept of power is not only useful in understanding the current situation, but it is also regularly mobilised in programmatic efforts that seek to change power relations. This paper uses summative content analysis to describe how sexual and reproductive health (SRH) programmes in low-income and middle-income countries explicitly and implicitly aim to alter relations of power.

METHODS

Content analysis is a qualitative approach to analysing textual data; in our analysis, peer-reviewed articles that describe programmes aiming to alter power relations to improve SRH constituted the data. We searched three databases, ultimately including 108 articles. We extracted the articles into a spreadsheet that included basic details about the paper and the programme, including what level of the social ecological model programme activities addressed.

RESULTS

The programmes reviewed reflect a diversity of priorities and approaches to addressing power, though most papers were largely based in a biomedical framework. Most programmes intervened at multiple levels simultaneously; some of these were 'structural' programmes that explicitly aimed to shift power relations, others addressed multiple levels using a more typical programme theory that sought to change individual behaviours and proximate drivers. This prevailing focus on proximate behaviours is somewhat mismatched with the broader literature on the power-related drivers of SRH health inequities, which explores the role of embedded norms and structures.

CONCLUSION

This paper adds value by summarising what the academic public health community has chosen to test and research in terms of power relations and SRH, and by raising questions about how this corresponds to the significant task of effecting change in power relations to improve the right to SRH.

Power Across the Global Health Landscape: A Network Analysis of Development Assistance 1990-2015

Power distribution across the global health landscape has undergone a fundamental shift over the past three decades. What was once a system comprised largely of bilateral and multilateral institutional arrangements between nation-states evolved into a varied landscape where these traditional actors were joined by a vast assemblage of private firms, philanthropies, non-governmental organizations, public-private partnerships. Financial resources are an explicit power source within global health which direct how, where, and to whom health interventions are delivered, which health issues are (de)prioritised, how and by whom evidence to support policies and interventions is developed, and how we account for progress. Financial resource allocations are not isolated decisions, but rather outputs of negotiation processes and dynamics between actors who derive power from a multiplicity of sources. The aims of this paper are to examine the changes in the global health actor landscape and the shifts in power using data on disbursements of development assistance for health (DAH). A typology of actors was developed from previous literature and refined through an empirical analysis of DAH. The emergent network structure of DAH flows between global health actors and positionality of actors within the network were analysed between 1990 and 2015. The results reflect the dramatic shift in the numbers of actors, relationships between actors, and funding dispersal over this time period. Through a combination of the massive influx of new funding sources and a decrease in public spending, the majority control of financial resources in the DAH network receded from public entities to a vast array of civil society organisations (CSOs) and public-private partnerships (PPPs). The most prominent of these were the Bill and Melinda Gates Foundation (BMGF) and the Global Fund for AIDS, TB, and Malaria (GFATM), which rose to the third and fourth most central positions within the DAH network by 2015.

"We are nurses - what can we say?": power asymmetries and Auxiliary Nurse Midwives in an Indian state

In India, nurses and midwives are key to the provision of public sexual and reproductive health services. Research on impediments to their performance has primarily focused on their individual capability and systemic resource constraints. Despite emerging evidence on gender-based discrimination and low professional acceptance faced by these cadres, little has been done to link these constraints to power asymmetries within the health system. We analysed data from an ethnography conducted in two primary healthcare facilities in an eastern state in India, using Veneklasen and Miller's expressions of power framework, to explore how power and gender asymmetries constrain performance and quality of care provided by Auxiliary Nurse Midwives (ANMs). We find that ANMs' low position within the official hierarchy allows managers and doctors to exercise "power over" them, severely curtailing their expression of all other forms of power. Disempowerment of ANMs occurs at multiple levels in interlinked and interdependent ways. Our findings contribute to the empirical evidence, advancing the understanding of gender as a structurally embedded dimension of power. We illustrate how the weak positioning of ANMs reflects their lack of representation in policymaking positions, a virtual absence of gender-sensitive policies, and ultimately organisational power structures embedded in patriarchy. By deepening the understanding of empowerment, the paper suggests implementable pathways to empower ANMs for improved performance. This requires addressing entrenched gender inequities through structural and organisational changes that realign power relations, facilitate more collaborative ways of exercising power, and create the antecedents to individual empowerment.

Expressions of actor power in implementation: a qualitative case study of a health service intervention in South Africa

Background

Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how interventions at the front line of health systems confront or shape existing power relations. This paper reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal and child health care quality and outcomes in a rural district of South Africa.

Methods

A retrospective qualitative case study based on interviews with 34 actors in three ‘implementation units’ – a district hospital and surrounding primary health care services – of the district, selected as purposefully representing full, moderate and low implementation of the intervention, some three years after it was first introduced. Data are analysed using Veneklasen and Miller’s typology of the forms of power – namely ‘power over’, ‘power to’, ‘power within’ and ‘power with’.

Results

Multiple expressions of actor power were evident during implementation and played a plausible role in shaping variable implementation, while the intervention itself acted to change power relations. As expected, a degree of buy-in of managers (with power over) in implementation units was necessary for the intervention to proceed. Beyond this, the ability to mobilise collective action (power with), combined with support from champions with agency (power within) were key to successful implementation. However, local empowerment may pose a threat to hierarchical power (power over) at higher levels (district and provincial) of the system, potentially affecting sustainability.

Conclusions

A systematic approach to the analysis of power in implementation research may provide insights into the fate of interventions. Intervention designs need to consider how they shape power relations, especially where interventions seek to widen participation and responsiveness in local health systems.

Integrating citizen engagement into evidence-informed health policy-making in eastern Europe and central Asia: scoping study and future research priorities

BACKGROUND

The perspectives of citizens are an important and often overlooked source of evidence for informing health policy. Despite growing encouragement for its adoption, little is known regarding how citizen engagement may be integrated into evidence-informed health policy-making in low- and middle-income counties (LMICs) and newly democratic states (NDSs). We aimed to identify the factors and variables affecting the potential integration of citizen engagement into evidence-informed health policy-making in LMICs and NDSs and understand whether its implementation may require a different approach outside of high-income western democracies. Further, we assessed the context-specific considerations for the practical implementation of citizen engagement in one focus region-eastern Europe and central Asia.

METHODS

First, adopting a scoping review methodology, we conducted and updated searches of six electronic databases, as well as a comprehensive grey literature search, on citizen engagement in LMICs and NDSs, published before December 2019. We extracted insights about the approaches to citizen engagement, as well as implementation considerations (facilitators and barriers) and additional political factors, in developing an analysis framework. Second, we undertook exploratory methods to identify relevant literature on the socio-political environment of the focus region, before subjecting these sources to the same analysis framework.

RESULTS

Our searches identified 479 unique sources, of which 28 were adjudged to be relevant. The effective integration of citizen engagement within policy-making processes in LMICs and NDSs was found to be predominantly dependent upon the willingness and capacity of citizens and policy-makers. In the focus region, the implementation of citizen engagement within evidence-informed health policy-making is constrained by a lack of mutual trust between citizens and policy-makers. This is exacerbated by inadequate incentives and capacity for either side to engage.

CONCLUSIONS

This research found no reason why citizen engagement could not adopt the same form in LMICs and NDSs as it does in high-income western democracies. However, it is recognized that certain political contexts may require additional support in developing and implementing citizen engagement, such as through trialling mechanisms at subnational scales. While specifically outlining the potential for citizen engagement, this study highlights the need for further research on its practical implementation.

Understanding the role of power and its relationship to the implementation of the polio eradication initiative in india

Background

Power is exercised everywhere in global health, although its presence may be more apparent in some instances than others. Studying power is thus a core concern of researchers and practitioners working in health policy and systems research (HPSR), an interdisciplinary, problem-driven field focused on understanding and strengthening multilevel systems and policies. This paper aims to conduct a power analysis as mobilized by the actors involved in implementation of the polio program. It will also reflect how different power categories are exerted by actors and embedded in strategies to combat program implementation challenges while planning and executing the Global Polio Eradication Initiative.

Methods

We collected quantitative and qualitative data from stakeholders who were part of the Polio universe as a part of Synthesis and Translation of Research and Innovations from the Polio Eradication Project. Key informants were main actors of the polio eradication program, both at the national and sub-national levels. Research tools were designed to explore the challenges, strategies and unintended consequences in implementing the polio eradication program in India. We utilized Moon's expanded typology of power in global governance to analyze the implementation of the polio eradication programme in India.

Results

We collected 517 survey responses and conducted 25 key informant interviews. Understanding power is increasingly recognized as an essential parameter to understand global governance and health. Stakeholders involved during polio program implementation have exerted different kinds of power from structural to discursive, moral power wielded by religious leaders to institutional power, expert power used by professional doctors to commoners like female vaccinators, and network power exercised by community influencers. Hidden power was also demonstrated by powerless actors like children bringing mothers to polio booths.

Conclusion

Power is not a finite resource, and it can be used, shared, or created by stakeholders and networks in multiple ways. Those people who seem to be powerless possess invisible power that can influence decision making. Moreover, these power categories are not mutually exclusive and may be deeply interconnected with each other; one type of power can be transformed into another. Power and relations play an important role in influencing the decision-making of the community and individuals. Mid-range theories of core implementation science like PARIHAS and CFIR can also add an important variable of power in their construct necessary for implementation success of any health program.

Understanding global health policy engagements with qualitative research: Qualitative evidence syntheses and the OptimizeMNH guidelines

Systematic reviews of qualitative evidence-or 'qualitative evidence syntheses' (QES)-have recently become an important form of knowledge production within the broader projects of 'evidence-based medicine' (EBM) and 'evidence-informed policymaking' in global health. Proponents of QES argue that these reviews offer a way to promote 'health systems thinking' and build a better understanding of local process and context in global health policy- and decision-making. EBM's detailed technical procedures for evidence synthesis, however, do not necessarily fit well with conventional qualitative research paradigms and there are concerns that subjecting qualitative research to EBM's logics and practices might fatally compromise both its epistemological integrity and political impact. This article addresses these concerns via a reflective case study of the use of qualitative evidence in the World Health Organization's (WHO) OptimizeMNH guidelines for task shifting in maternal and newborn health programs. When I first joined the team developing the evidence base for these health systems-oriented guidelines, I wondered whether the inclusion of qualitative research would result in a broadening of the forms of reason, experience and judgment that informed global health policy, or instead, be another disheartening example of how modern bureaucratic systems coopt, standardize, and complexity-reduce the alternative logics they encounter. While the integration of qualitative evidence did come at some cost to the depth and critical insights of the evidence we were reviewing, there were also important ways in which the technical procedures of evidence-based medicine were open to adaptation and transformation. The formal inclusion of qualitative evidence syntheses in these global guidelines did not represent-or produce-a dramatic about-turn in global health policy's hegemonic discourses and practices. It did reveal, however, that powerful systems of health governance like the WHO and evidence-based medicine are not inevitably closed, but in fact open to change, in often unpredictable ways.

Organizational structure and human agency within the South African health system: a qualitative case study of health promotion

Despite international recognition of health promotion (HP) as a cost-effective way to improve population health, it is not highly regarded nor is it sufficiently institutionalized in many health systems. This diminishes its ability to deliver on its public health promises. This paper examined the role of organizational structure and human agency within the South African health system (drawing on Giddens's structuration theory) in determining the extent of, and barriers to, the institutionalization of HP. We conducted a qualitative case study using a combination of in-depth interviews (n = 37), key informant interviews (n = 8) and one-day workshops (n = 5) with Department of Health (DoH) staff (HP and non-HP personnel) from national, provincial and district levels as well as external HP stakeholders. Within the South African health system, there are dedicated HP staffs, with no specified professional competencies or a coherent hierarchy of job titles. Allocated HP resources were frequently shifted to other programmes. This resulted in a disconnect between national and provincial levels, which impeded communication and opportunity to develop a shared vision and coherent programme. We found some examples of successful HP organization and implementation practices, such as the tobacco control legislation. Overall, HP staff had limited agency and were often unable to articulate the vision for HP. Uncertainty about the role of HP has led to powerlessness, and feelings of resentment have generated demotivation and moral distress. HP voices were seldom heard and were repressed by dominant curative-focused structures. If leaders of HP continue to be embedded in such an institution, there is little chance of driving an effective HP agenda. Therefore, there is a need to engage policy-makers to integrate HP into the health system fabric. Establishment of an independent HP foundation could be one mechanism to drive multi-sectoral collaboration, contribute to evidence-based HP research and further develop health in all policies through advocacy.

Systems on the Edge: Developing Organizational Theory for the Persistence of Mistreatment in Childbirth

Mistreatment in childbirth is institutionalized in many healthcare settings globally, causing widespread harm. Rising concern has elicited research on its prevalence and characteristics, with limited attention to developing explanatory theory. Mistreatment, a complex systemic and behavioral phenomenon, requires social science theory to explain its persistence despite official norms that promote respectful care. Diane Vaughan's normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. Its multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance. To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan's theory and additional organizational theories. Analysis revealed that normalized scarcity at the macro-level combined with production pressures for biomedical care and imbalanced power-dependence altered values, structures, and processes in the health system. Meso-level actors struggled to achieve production goals with limited autonomy and resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. Analogical comparison with another case of organizational deviance based on literature enabled a novel approach to elaborate theory. The emergent theory sheds light on opportunities to transform systems and routinize respectful care. Theory application in additional settings and exploration of other social theories is needed for further understanding of this complex problem.

Power analysis in health policy and systems research: a guide to research conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

How performance targets can ingrain a culture of 'performing out': An ethnography of two Indian primary healthcare facilities

Low- and middle-income country health systems often apply decontextualised and unrealistic performance targets to facilities. This can lead to empty compliance and 'performing out', whereby managers and providers manipulate or inflate data to create the false impression of a functional system. While this is a well-recognised pitfall of audit-style performance accountability processes, the social processes by which these practices emerge has not been well described in the literature. In this paper, with a focus on maternal and newborn care, we seek to better understand how and why the practices of 'performing out' occur, and their implications for health system functioning, organisational culture, and quality of care. We do this through a focused facility ethnography undertaken in two primary healthcare facilities in an eastern Indian state, anonymised as Esma, where practices of 'performing out' are prevalent. We draw on the understanding that health systems are complex adaptive systems encompassing both hardware and software elements, where individual behavioural practices are an outcome of the system as a whole. To unpack how the dynamic interactions between system elements and agents influence individual behaviours, we draw upon the sociological theories of practice of Bourdieu, encompassing the concepts of field, habitus, and capital. This lens helps illustrate how resource scarcity, unyielding application of unrealistic targets with punitive sanctions for non-achievement, and complex power dynamics lead system actors to manipulate data and create documentation to show the achievement of targets that were not actually met. The practices of 'performing out' are shaped by, and in turn shape, the organisational culture of the facilities, with perverse behaviour becoming part of an entrenched habitus - the 'dispositions' of agents that guide behaviour and thinking. In the longer term, the habituation of 'performing out' contributes to a systemic orientation toward sub-par performance, undermining quality of care.

The dynamics of TCAM integration in the Indian public health system: Medical dominance, countervailing power and co-optation

Hierarchies of power among healthcare professionals are well documented, nonetheless, power remains neglected, understudied and under-theorised in health systems analysis and policy discussions, especially in the domain of Traditional, Complementary and Alternative Medicine (TCAM). Sociological and public health scholarship has documented the persistence of medical dominance in the health system, theorised as the limitation, subordination, exclusion and incorporation of other professions. This paper explores how interprofessional power dynamics shape the integration of TCAM into Indian primary healthcare centres, as part of a nationwide policy of TCAM integration and medical pluralism implemented since 2005. We conducted interviews (n = 37) with health system administrators, nurses, pharmacists, TCAM and biomedicine doctors, and observed day-to-day activities of primary healthcare centres for six months in Odisha state, India. Thematic analysis enabled the identification of themes and exploration of sub-themes. The analysis revealed multilayered forms of medical dominance within the primary healthcare system and identified multiple sites where everyday power is mobilised. Biomedicine practitioners exercised authoritative power and restricted TCAM doctors' access to facility-level resources, i.e. financial and workforce support, which inhibited the integration policy implementation. Significantly, TCAM doctors were 'ordered' to practice biomedicine at primary healthcare centres, which was beyond the scope of the integration policy. However, TCAM doctors were also able to exercise countervailing power in their day-to-day activities in the primary healthcare centres and sought to assist patients' health behaviour change through their authoritative knowledge about 'how to live a healthy life'. The health system actors involved in policy implementation hold a range of forms of power specific to the circumstances, influencing the integration processes. We explain these dynamics in relation to existing theories of medical dominance and countervailing power, while introducing a previously unreported dimension of dominance: 'co-optation', which enrols TCAM practitioners in the practice of biomedicine.

What is considered as global health scholarship? A meta-knowledge analysis of global health journals and definitions

Despite the rapid growth of the global health field over the past few decades, consensus on what qualifies as global health scholarship or practice remains elusive. We conducted a meta-knowledge analysis of the titles and abstracts of articles published in 25 journals labelled as global health journals between 2001 and 2019. We identified the major topics in these journals by creating clusters based on terms co-occurrence over time. We also conducted a review of global health definitions during the same period.

The analysis included 16 413 articles. The number of journals, labelled as global health, and articles published in these journals, increased dramatically during the study period. The majority of global health publications focused on topics prevalent in low-resource settings. Governance, infectious diseases, and maternal and child health were major topics throughout the analysis period. Surveillance and disease outcomes appeared during the 2006–2010 epoch and continued, with increasing complexity, until the 2016–2019 epoch. Malaria, sexual and reproductive health, and research methodology appeared for only one epoch as major topics. We included 11 relevant definitions in this analysis. Definitions of global health were not aligned with the major topics identified in the analysis of articles published in global health journals.

These results highlight a lack of alignment between what is published as global health scholarship and global health definitions, which often advocate taking a global perspective to population health. Our analysis suggests that global health has not truly moved beyond its predecessor, international health. There is a need to define the parameters of the discipline and investigate the disconnect between what is published in global health versus how the field is defined.

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.

Adoption of evidence-based global policies at the national level: intermittent preventive treatment for malaria in pregnancy and first trimester treatment in Kenya, Malawi, Mali and The Gambia

In 2012, the World Health Organization (WHO) updated its policy on intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP). A global recommendation to revise the WHO policy on the treatment of malaria in the first trimester is under review. We conducted a retrospective study of the national policy adoption process for revised IPTp-SP dosing in four sub-Saharan African countries. Alongside this retrospective study, we conducted a prospective policy adoption study of treatment of first trimester malaria with artemisinin combination therapies (ACTs). A document review informed development and interpretation of stakeholder interviews. An analytical framework was used to analyse data exploring stakeholder perceptions of the policies from 47 in-depth interviews with a purposively selected range of national level stakeholders. National policy adoption processes were categorized into four stages: (1) identify policy need; (2) review the evidence; (3) consult stakeholders and (4) endorse and draft policy. Actors at each stage were identified with the roles of evidence generation; technical advice; consultative and statutory endorsement. Adoption of the revised IPTp-SP policy was perceived to be based on strong evidence, support from WHO, consensus from stakeholders; and followed these stages. Poor tolerability of quinine was highlighted as a strong reason for a potential change in treatment policy. However, the evidence on safety of ACTs in the first trimester was considered weak. For some, trust in WHO was such that the anticipated announcement on the change in policy would allay these fears. For others, local evidence would first need to be generated to support a change in treatment policy. A national policy change from quinine to ACTs for the treatment of first trimester malaria will be less straightforward than experienced with increasing the IPTp dosing regimen despite following the same policy processes. Strong leadership will be needed for consultation and consensus building at national level.

Unpacking power dynamics in research and evaluation on social accountability for sexual and reproductive health and rights

Over the past decade, social accountability for health has coalesced into a distinct field of research and practice. Whether explicitly stated or not, changed power relations are at the heart of what social accountability practitioners seek, particularly in the context of sexual and reproductive health. Yet, evaluations of social accountability programs frequently fail to assess important power dynamics. In this commentary, we argue that we must include an examination of power in research and evaluation of social accountability in sexual and reproductive health, and suggest ways to do this. The authors are part of a community of practice on measuring social accountability and health outcomes. We share key lessons from our efforts to conduct power sensitive research using different approaches and methods.First, participatory research and evaluation approaches create space for program participants to engage actively in evaluations by defining success. Participation is also one of the key elements of feminist evaluation, which centers power relations rooted in gender. Participatory approaches can strengthen 'traditional' health evaluation approaches by ensuring that the changes assessed are meaningful to communities.Fields from outside health offer approaches that help to describe and assess changes in power dynamics. For example, realist evaluation analyses the causal processes, or mechanisms, grounded in the interactions between social, political and other structures and human agency; programs try to influence these structures and/or human agency. Process tracing requires describing the mechanisms underlying change in power dymanics in a very detailed way, promoting insight into how changes in power relationships are related to the broader program.Finally, case aggregation and comparison entail the aggregation of data from multiple cases to refine theories about when and how programs work. Case aggregation can allow for nuanced attention to context while still producing lessons that are applicable to inform programming more broadly.We hope this brief discussion encourages other researchers and evaluators to share experiences of analysing power relations as part of evaluation of social accountability interventions for sexual and reproductive health so that together, we improve methodology in this crucial area.

A Stakeholder Analysis of Schistosomiasis Diagnostic Landscape in South-West Nigeria: Insights for Diagnostics Co-creation

Background: Schistosomiasis, one of the neglected tropical diseases, is a water-based parasitic disease of public health importance. Currently, tests for Schistosoma haematobium infection either demonstrate poor specificity, are expensive or too laborious for use in endemic countries, creating a need for more sensitive, cheaper, and easy to use devices for the diagnosis of schistosomiasis. To ensure engagement during the process of device development; and effective acceptance and use after the introduction of diagnostics devices for S. haematobium, there is a need to involve stakeholders with varying power, interest, and stakes in device co-creation, as well as those relevant for later use situation in the diagnostic landscape. The main goal of this study is to identify and analyze relevant stakeholders for co-creation using a power-interest matrix.

Materials and Methods: The study was based on an action research methodology using a case study approach. A contextual inquiry approach consisting of 2 stages: stakeholder identification and interview; and stakeholder analysis was used. The field part of the study was carried out in Oyo State, Nigeria using a multistage cluster purposive sampling technique based on the category of stakeholders to be interviewed predicated on the organizational structure within the state and communities. A mix of qualitative research techniques was used. Identified themes related to power and interest were mapped and analyzed.

Results: We identified 17 characteristics of stakeholders across 7 categories of stakeholders important for schistosomiasis diagnostics. Most of the stakeholders were important for both the co-creation and adoption phase of the device development for diagnostics. However, not all stakeholders were relevant to co-creation. Key Stakeholders relevant for diagnostics co-creation demonstrated significant social power, organization power, and legitimate power bases. Most of the stakeholders showed significant interest in the device to be created.

Discussion: The power and interest of these stakeholders reveal some insight into how each stakeholder may be engaged for both co-creation and device usage. The involvement of relevant actors who will also be important for co-creation and implementation, will simplify the engagement process for the critical stakeholders, increase the ability to manage the process, and increase diagnostic device acceptability.

Unpacking the implementation blackbox using 'actor interface analysis': how did actor relations and practices of power influence delivery of a free entitlement health policy in India?

Exploring the implementation blackbox from a perspective that considers embedded practices of power is critical to understand the policy process. However, the literature is scarce on this subject. To address the paucity of explicit analyses of everyday politics and power in health policy implementation, this article presents the experience of implementing a flagship health policy in India. Janani Shishu Suraksha Karyakram (JSSK), launched in the year 2011, has not been able to fully deliver its promises of providing free maternal and child health services in public hospitals. To examine how power practices, influence implementation, we undertook a qualitative analysis of JSSK implementation in one state of India. We drew on an actor-oriented perspective of development and used 'actor interface analysis' to guide the study design and analysis. Data collection included in-depth interviews of implementing actors and JSSK service recipients, document review and observations of actor interactions. A framework analysis method was used for analysing data, and the framework used was founded on the constructs of actor lifeworlds, which help understand the often neglected and lived realities of policy actors. The findings illustrate that implementation was both strengthened and constrained by practices of power at various interface encounters. The implementation decisions and actions were influenced by power struggles such as domination, control, resistance, contestation, facilitation and collaboration. Such practices were rooted in: Social and organizational power relationships like organizational hierarchies and social positions; personal concerns or characteristics like interests, attitudes and previous experiences and the worldviews of actors constructed by social and ideological paradigms like their values and beliefs. Application of 'actor interface analysis' and further nuancing of the concept of 'actor lifeworlds' to understand the origin of practices of power can be useful for understanding the influence of everyday power and politics on the policy process.

Enhancing the use of stakeholder analysis for policy implementation research: towards a novel framing and operationalised measures

BACKGROUND

Policy is shaped and influenced by a diverse set of stakeholders at the global, national and local levels. While stakeholder analysis is a recognised practical tool to assess the positions and engagement of actors relevant to policy, few empirical studies provide details of how complex concepts such as power, interest and position are operationalised and assessed in these types of analyses. This study aims to address this gap by reviewing conceptual approaches underlying stakeholder analyses and by developing a framework that can be applied to policy implementation in low-and-middle income countries.

METHODS

The framework was developed through a three-step process: a scoping review, peer review by health policy experts and the conduct of an analysis using key informant interviews and a consensus building exercise. Four characteristics were selected for inclusion: levels of knowledge, interest, power and position of stakeholders related to the policy.

RESULT

The framework development process highlighted the need to revisit how we assess the power of actors, a key issue in stakeholder analyses, and differentiate an actor's potential power, based on resources, and whether they exercise it, based on the actions they take for or against a policy. Exploration of the intersections between characteristics of actors and their level of knowledge can determine interest, which in turn can affect stakeholder position on a policy, showing the importance of analysing these characteristics together. Both top-down and bottom-up approaches in implementation must also be incorporated in the analysis of policy actors, as there are differences in the type of knowledge, interest and sources of power among national, local and frontline stakeholders.

CONCLUSION

The developed framework contributes to health policy research by offering a practical tool for analysing the characteristics of policy actors and tackling the intricacies of assessing complex concepts embedded in the conduct of stakeholder analyses.

Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions

BACKGROUND

Malaria in pregnancy (MiP) is an important public health problem across sub-Saharan Africa. The package of measures for its control in Ghana in the last 20 years include regular use of long-lasting insecticide-treated bed nets (LLINs), directly-observed administration (DOT) of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and prompt and effective case management of MiP. Unfortunately, Ghana like other sub-Saharan African countries did not achieve the reset Abuja targets of 100% of pregnant women having access to IPTp and 100% using LLINs by 2015.

METHODS

This ethnographic study explored how healthcare managers dealt with existing MiP policy implementation challenges and the consequences on IPTp-SP uptake and access to maternal healthcare. The study collected date using non-participant observations, conversations, in-depth interviews and case studies in eight health facilities and 12 communities for 12 months in two Administrative regions in Ghana.

RESULTS

Healthcare managers addressed frequent stock-outs of malaria programme drugs and supplies from the National Malaria Control Programme and delayed reimbursement from the NHIS, by instituting co-payment, rationing and prescribing drugs for women to buy from private pharmacies. This ensured that facilities had funds to pay creditors, purchase drugs and supplies for health service delivery. However, it affected their ability to enforce DOT and to monitor adherence to treatment. Women who could afford maternal healthcare and MiP services and those who had previously benefitted from such services were happy to access uninterrupted services. Women who could not maternal healthcare services resorted to visiting other sources of health care, delaying ANC and skipping scheduled ANC visits. Consequently, some clients did not receive the recommended 5 + doses of SP, others did not obtain LLINs early and some did not obtain treatment for MiP. Healthcare providers felt frustrated whenever they could not provide comprehensive care to women who could not afford comprehensive maternal and MiP care.

CONCLUSION

For Ghana to achieve her goal of controlling MiP, the Ministry of Health and other supporting institutions need to ensure prompt reimbursement of funds, regular supply of programme drugs and medical supplies to public, faith-based and private health facilities.

Communities, universal health coverage and primary health care

Universal health coverage (UHC) depends on a strong primary health-care system. To be successful, primary health care must be expanded at community and household levels as much of the world's population still lacks access to health facilities for basic services. Abundant evidence shows that community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services. Community involvement is the cornerstone of local, equitable and integrated primary health care. Policies and actions to improve primary health care must regard community members as more than passive recipients of health care. Instead, they should be leaders with a substantive role in planning, decision-making, implementation and evaluation. Advancing the science of primary health care requires improved conceptual and analytical frameworks and research questions. Metrics used for evaluating primary health care and UHC largely focus on clinical health outcomes and the inputs and activities for achieving them. Little attention is paid to indicators of equitable coverage or measures of overall well-being, ownership, control or priority-setting, or to the extent to which communities have agency. In the future, communities must become more involved in evaluating the success of efforts to expand primary health care. Much of primary health care has taken place, and will continue to take place, outside health facilities. Involving community members in decisions about health priorities and in community-based service delivery is key to improving systems that promote access to care. Neither UHC nor the Health for All movement will be achieved without the substantial contribution of communities.

When accountability meets power: realizing sexual and reproductive health and rights

This paper addresses a critical concern in realizing sexual and reproductive health and rights through policies and programs - the relationship between power and accountability. We examine accountability strategies for sexual and reproductive health and rights through the lens of power so that we might better understand and assess their actual working. Power often derives from deep structural inequalities, but also seeps into norms and beliefs, into what we 'know' as truth, and what we believe about the world and about ourselves within it. Power legitimizes hierarchy and authority, and manufactures consent. Its capillary action causes it to spread into every corner and social extremity, but also sets up the possibility of challenge and contestation.Using illustrative examples, we show that in some contexts accountability strategies may confront and transform adverse power relationships. In other contexts, power relations may be more resistant to change, giving rise to contestation, accommodation, negotiation or even subversion of the goals of accountability strategies. This raises an important question about measurement. How is one to assess the achievements of accountability strategies, given the shifting sands on which they are implemented?We argue that power-focused realist evaluations are needed that address four sets of questions about: i) the dimensions and sources of power that an accountability strategy confronts; ii) how power is built into the artefacts of the strategy - its objectives, rules, procedures, financing methods inter alia; iii) what incentives, disincentives and norms for behavior are set up by the interplay of the above; and iv) their consequences for the outcomes of the accountability strategy. We illustrate this approach through examples of performance, social and legal accountability strategies.

The role of external actors in shaping migrant health insurance in Thailand

The role of external actors in national health policy in aid-independent countries has received relatively little attention in the literature, despite the fact that influence continues to be exerted once financial support is curtailed as countries graduate from lower income status. Focusing on a specific health policy in an aid-independent country, this qualitative study explores the role of external actors in shaping Thailand’s migrant health insurance. Primary data were collected through in-depth interviews with eighteen key informants from September 2018 to January 2019. The data were analysed using thematic analysis, focusing on three channels of influence, financial resources, technical expertise and inter-sectoral leverage, and their effect on the different stages of the policy process. Given Thailand’s export orientation and the importance of reputational effects, inter-sectoral leverage, mainly through the US TIP Reports and the EU carding decision, emerged as a very powerful channel of influence on priority setting, as it indirectly affected the migrant health insurance through efforts aimed at dealing with problems of human trafficking in the context of labour migration, especially after the 2014 coup d'état. This study helps understand the changed role external actors can play in filling health system gaps in aid-independent countries.

What steps can researchers take to increase research uptake by policymakers? A case study in China

Empirical analysis of the connections between research and health policymaking is scarce in middle-income countries. In this study, we focused on a national multidrug-resistant tuberculosis (TB) healthcare provider training programme in China as a case study to examine the role that research plays in influencing health policy. We specifically focused on the factors that influence research uptake within the complex Chinese policymaking process. Qualitative data were collected from 34 participants working at multilateral organizations, funding agencies, academia, government agencies and hospitals through 14 in-depth interviews and 2 focus group discussions with 10 participants each. Themes were derived inductively from data and grouped based on the 'Research and Policy in Developing countries' framework developed by the Overseas Development Institute. We further classified how actors derive their power to influence policy decisions following the six sources of power identified by Sriram et al. We found that research uptake by policymakers in China is influenced by perceived importance of the health issues addressed in the research, relevance of the research to policymakers' information needs and government's priorities, the research quality and the composition of the research team. Our analysis identified that international donors are influential in the TB policy process through their financial power. Furthermore, the dual roles of two government agencies as both evidence providers and actors who have the power to influence policy decisions through their technical expertise make them natural intermediaries in the TB policy process. We concluded that resolving the conflict of interests between researchers and policymakers, as suggested in the 'two-communities theory', is not enough to improve evidence use by policymakers. Strategies such as framing research to accommodate the fast-changing policy environment and making alliances with key policy actors can be effective to improve the communication of research findings into the policy process, particularly in countries undergoing rapid economic and political development.

Bureaucracies and power: Examining the Medical Council of India and the development of emergency medicine in India

In many countries, professional councils are mandated to oversee the training and conduct of health professionals, including doctors, nurses, pharmacists and allied health workers. The proper functioning of these councils is critical to overall health system performance. Yet, professional councils are sometimes criticized, particularly in the context of low- and middle-income countries, for their misuse of power and overtly bureaucratic nature. The objective of this paper is to understand how professional councils use their bureaucratic power to shape health policy and systems, drawing upon the recent development of emergency medicine in the context of the former Medical Council of India. We undertook a qualitative case study, conducting 87 interviews, observing 6 meetings and conferences, and reviewing approximately 96 documents, and used the Framework method to analyze our data. The passive exercise of bureaucratic power by the Council resulted in three challenges - 1) Opaque policy processes for recognizing new medical specialties; 2) Insular, non-transparent training policy formulation; 3) Unaccountable enforcement for regulating new courses. The Council did not have the requisite technical expertise to manage certain policy processes, and further, did not adequately utilize external expertise. In this time period, the Council applied its bureaucratic power in a manner that negatively impacted emergency medicine training programs and the development of emergency medicine, with implications for availability and quality of emergency care in India. The successor to the Council, the National Medical Commission, should consider new approaches to exercising bureaucratic power in order to meet its objectives of strengthening medical education in India and ensuring access to high-quality services. Future studies should also explore the utilization of bureaucratic power in the health sectors of low- and middle-income countries in order to provider a deeper understanding of institutional barriers to improvements in health.

Re-conceptualising gender and power relations for sexual and reproductive health: contrasting narratives of tradition, unity, and rights

Sexual and reproductive health interventions in sub-Saharan Africa will be most effective if grounded in emic (insider) perspectives of gender and power in intimate relationships. We conducted eight focus group discussions with 62 young adults in Malawi to explore conceptions of gender and power relations and areas of tension between different perspectives. We framed our enquiry according to the three social structures of the Theory of Gender and Power: the sexual division of labour, the sexual division of power, and social norms and affective attachments around femininity and masculinity. Young adults drew on interrelated and competing narratives to describe the state of gender relations, which we named tradition, unity, and rights. Participants used tradition narratives most frequently to describe patriarchal gender roles, norms and ideals. Some participants challenged this predominant discourse using unity and rights narratives. Unity narratives illustrated how love and couple reciprocity were essential sources of 'power with' as opposed to 'power over'. Rights narratives were more contested than other narratives, with some participants acknowledging that women's rights were important to the family's survival and others viewing women's rights as problematic for gender relations. Gender-responsive interventions should consider the tensions and intersections between multiple narratives on gender and power, including unity as a gender-equitable form of power.

Building a transformative agenda for accountability in SRHR: lessons learned from SRHR and accountability literatures

Global strategies and commitments for sexual and reproductive health and rights (SRHR) underscore the need to strengthen rights-based accountability processes. Yet there are gaps between these ambitious SRHR rights frameworks and the constrained socio-political lived realities within which these frameworks are implemented. This paper addresses these gaps by reviewing the evidence on the dynamics and concerns related to operationalising accountability in the context of SRHR. It is based on a secondary analysis of a systematic review that examined the published evidence on SRHR and accountability and also draws on the broader literature on accountability for health. Key themes include the political and ideological context, enhancing community voice and health system responsiveness, and recognising the complexity of health systems. While there is a range of accountability relationships that can be leveraged in the health system, the characteristics specific to SRHR need to be considered as they colour the capabilities and conditions in which accountability efforts occur.

Power in global governance: an expanded typology from global health

The exercise of power permeates global governance processes, making power a critical concept for understanding, explaining, and influencing the intersection of global governance and health. This article briefly presents and discusses three well-established conceptualizations of power-Dahl's, Bourdieu's, and Barnett and Duvall's-from different disciplines, finding that each is important for understanding global governance but none is sufficient. The conceptualization of power itself needs to be expanded to include the multiple ways in which one actor can influence the thinking or actions of others. I further argue that global governance processes exhibit features of complex adaptive systems, the analysis of which requires taking into account multiple types of power. Building on established frameworks, the article then offers an expanded typology of eight kinds of power: physical, economic, structural, institutional, moral, discursive, expert, and network. The typology is derived from and illustrated by examples from global health, but may be applicable to global governance more broadly. Finally, one seemingly contradictory - and cautiously optimistic - conclusion emerges from this typology: multiple types of power can mutually reinforce tremendous power disparities in global health; but at the same time, such disparities are not necessarily absolute or immutable. Further research on the complex interaction of multiple types of power is needed for a better understanding of global governance and health.