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Ramponi F, Ssennyonjo A, Banda S, Aliti T, Nkhoma D, Kaonga O, Griffin S, Revill P, Kataika E, Nabyonga-Orem J. Demands for Intersectoral Actions to Meet Health Challenges in East and Southern Africa and Methods for Their Evaluation. Value Health Reg Issues 2024; 39:74-83. [PMID: 38007854 DOI: 10.1016/j.vhri.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVES Focusing on the East, Central, and Southern African region, this study examines both regional and country-level initiatives aimed at promoting multisectoral collaboration to improve population health and the methods for their economic evaluation. METHODS We explored the interventions that necessitate cooperation among policymakers from diverse sectors and the mechanisms that facilitate effective collaboration and coordination across these sectors. To gain insights into the demand for multisectoral collaboration in the East, Central, and Southern African region, we presented 3 country briefs, highlighting policy areas and initiatives that have successfully incorporated health-promoting actions from outside the health sector in Zimbabwe, Uganda, and Malawi. Additionally, we showcased initiatives undertaken by the Ministry of Health in each country to foster coordination with national and international stakeholders, along with existing coordination mechanisms established for intersectoral collaboration. Drawing on these examples, we identified the primary challenges in the economic evaluation of multisectoral programs aimed at improving health in the region. RESULTS We illustrated how decision making in reality differs from the traditional single-sector and single-decision-maker perspective commonly used in cost-effectiveness analyses. To ensure economic evaluations can inform decision making in diverse settings and facilitate regional collaboration, we highlighted 3 fundamental principles: identifying policy objectives, defining the perspective of the analysis, and considering opportunity costs. We emphasized the importance of adopting a flexible and context-specific approach to economic evaluation. CONCLUSIONS Through this work, we contribute to bridging the gap between theory and practice in the context of intersectoral activities aimed at improving health outcomes.
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Affiliation(s)
- Francesco Ramponi
- Centre for Health Economics, University of York, York, England, UK; ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.
| | - Aloysius Ssennyonjo
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | - Dominic Nkhoma
- Health Economics & Policy Unit (HEPU), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Oliver Kaonga
- Centre for Health Economics, University of York, York, England, UK
| | - Susan Griffin
- Centre for Health Economics, University of York, York, England, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, England, UK
| | - Edward Kataika
- East, Central, and Southern Africa Health Community, Arusha, Tanzania
| | - Juliet Nabyonga-Orem
- WHO Regional Office for Africa, Inter Country Support team for Eastern and Southern Africa, Harare, Zimbabwe; Centre for Health Professions Education, Faculty of Health Sciences, North-West University, Potchefstroom Campus, Potchefstroom, South Africa
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Liwanag HJ, James O, Frahsa A. A review and analysis of accountability in global health funding, research collaborations and training: towards conceptual clarity and better practice. BMJ Glob Health 2023; 8:e012906. [PMID: 38084477 PMCID: PMC10711908 DOI: 10.1136/bmjgh-2023-012906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/21/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Accountability is a complex idea to unpack and involves different processes in global health practice. Calls for accountability in global health would be better translated to action through a better understanding of the concept and practice of accountability in global health. We sought to analyse accountability processes in practice in global health funding, research collaborations and training. METHODS This study is a literature review that systematically searched PubMed and Scopus for articles on formal accountability processes in global health. We charted information on processes based on accountability lines ('who is accountable to whom') and the outcomes the processes were intended for ('accountability for what'). We visualised the representation of accountability in the articles by mapping the processes according to their intended outcomes and the levels where processes were implemented. RESULTS We included 53 articles representing a wide range of contexts and identified 19 specific accountability processes for various outcomes in global health funding, research collaborations and training. Target setting and monitoring were the most common accountability processes. Other processes included interinstitutional networks for peer checking, litigation strategies to enforce health-related rights, special bodies that bring actors to account for commitments, self-accountability through internal organisational processes and multipolar accountability involving different types of institutional actors. Our mapping identified gaps at the institutional, interinstitutional and broader system levels where accountability processes could be enhanced. CONCLUSION To rebalance power in global health, our review has shown that analysing information on existing accountability processes regarding 'who is accountable to whom' and 'accountability for what' would be useful to characterise existing lines of accountability and create lines where there are gaps. However, we also suggest that institutional and systems processes for accountability must be accompanied by political engagement to mobilise collective action and create conditions where a culture of accountability thrives in global health.
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Affiliation(s)
- Harvy Joy Liwanag
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Oria James
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Annika Frahsa
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Knittel B, Coile A, Zou A, Saxena S, Brenzel L, Orobaton N, Bartel D, Williams CA, Kambarami R, Tiwari DP, Husain I, Sikipa G, Achan J, Ajiwohwodoma JO, Banerjee B, Kasungami D. Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance. Gates Open Res 2023; 6:116. [PMID: 36415884 PMCID: PMC9646484 DOI: 10.12688/gatesopenres.13632.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Barbara Knittel
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
| | - Amanda Coile
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
| | - Annette Zou
- Global ChangeLabs, Portola Valley, CA, 94028, USA
| | - Sweta Saxena
- United States Agency for International Development, Washington, DC, 20523, USA
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Nosa Orobaton
- Bill & Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Doris Bartel
- Independent Researcher, Washington, District of Columbia, USA
| | | | | | | | - Ishrat Husain
- United States Agency for International Development, Washington, DC, 20523, USA
| | | | | | | | | | - Dyness Kasungami
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
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Bartel D, Coile A, Zou A, Martinez Valle A, Nyasulu HM, Brenzel L, Orobaton N, Saxena S, Addy P, Strother S, Ogundimu M, Banerjee B, Kasungami D. Exploring system drivers of gender inequity in development assistance for health and opportunities for action. Gates Open Res 2022. [DOI: 10.12688/gatesopenres.13639.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Deep-rooted and widespread gender-based bias and discrimination threaten achievement of the Sustainable Development Goals. Despite evidence that addressing gender inequities contributes to better health and development outcomes, the resources for, and effectiveness of, such efforts in development assistance for health (DAH) have been insufficient. This paper explores systemic challenges in DAH that perpetuate or contribute to gender inequities, with a particular focus on the role of external donors and funders. Methods: We applied a co-creation system design process to map and analyze interactions between donors and recipient countries, and articulate drivers of gender inequities within the landscape of DAH. We conducted qualitative primary data collection and analysis in 2021 via virtual facilitated discussions and visual mapping exercises among a diverse set of 41 stakeholders, including representatives from donor institutions, country governments, academia, and civil society. Results: Six systemic challenges emerged as perpetuating or contributing to gender inequities in DAH: 1) insufficient input and leadership from groups affected by gender bias and discrimination; 2) decision-maker blind spots inhibit capacity to address gender inequities; 3) imbalanced power dynamics contribute to insufficient resources and attention to gender priorities; 4) donor funding structures limit efforts to effectively address gender inequities; 5) fragmented programming impedes coordinated attention to the root causes of gender inequities; and 6) data bias contributes to insufficient understanding of and attention to gender inequities. Conclusions: Many of the drivers impeding progress on gender equity in DAH are embedded in power dynamics that distance and disempower people affected by gender inequities. Overcoming these dynamics will require more than technical solutions. Groups affected by gender inequities must be centered in leadership and decision-making at micro and macro levels, with practices and structures that enable co-creation and mutual accountability in the design, implementation, and evaluation of health programs.
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Knittel B, Coile A, Zou A, Saxena S, Brenzel L, Orobaton N, Bartel D, Williams CA, Kambarami R, Tiwari DP, Husain I, Sikipa G, Achan J, Ajiwohwodoma JO, Banerjee B, Kasungami D. Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance. Gates Open Res 2022; 6:116. [PMID: 36415884 PMCID: PMC9646484 DOI: 10.12688/gatesopenres.13632.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- Barbara Knittel
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
| | - Amanda Coile
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
| | - Annette Zou
- Global ChangeLabs, Portola Valley, CA, 94028, USA
| | - Sweta Saxena
- United States Agency for International Development, Washington, DC, 20523, USA
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Nosa Orobaton
- Bill & Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Doris Bartel
- Independent Researcher, Washington, District of Columbia, USA
| | | | | | | | - Ishrat Husain
- United States Agency for International Development, Washington, DC, 20523, USA
| | | | | | | | | | - Dyness Kasungami
- JSI Research & Training Institute, Inc., Arlington, VA, 22202, USA
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Eusebio C, Bakola M, Stuckler D. How to Achieve Universal Health Coverage: A Case Study of Uganda Using the Political Process Model Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective". Int J Health Policy Manag 2022; 12:7307. [PMID: 35942962 PMCID: PMC10125088 DOI: 10.34172/ijhpm.2022.7307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/30/2022] [Indexed: 11/09/2022] Open
Abstract
How can resource-deprived countries accelerate progress towards universal health coverage (UHC)? Here we extend the analysis of Nanini and colleagues to investigate a case-study of Uganda, where despite high-level commitments, health system priority and funding has shrunk over the past two decades. We draw on the Stuckler-McKee adapted Political Process model to evaluate three forces for effecting change: reframing the debate; acting on political windows of opportunity; and mobilising resources. Our analysis proposes a series of pragmatic steps from academics, non-governmental organisations, and government officials that can help neutralise the forces that oppose UHC and overcome fragmentation of the pro-UHC movement.
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Affiliation(s)
| | - Maria Bakola
- Research Unit for General Medicine and Primary Health Care, Faculty of Medicine, School of Health Science, University of Ioannina, Ioannina, Greece
| | - David Stuckler
- Dondena Centre for Research on Social and Population Dynamics, Milan, Italy
- Cergas Centre for Research on Health and Social Care Management, Milan, Italy
- Department of Social & Political Sciences, Bocconi University, Milan, Italy
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Uneno Y, Iwai M, Morikawa N, Tagami K, Matsumoto Y, Nozato J, Kessoku T, Shimoi T, Yoshida M, Miyoshi A, Sugiyama I, Mantani K, Itagaki M, Yamagishi A, Morita T, Inoue A, Muto M. Development of a national health policy logic model to accelerate the integration of oncology and palliative care: a nationwide Delphi survey in Japan. Int J Clin Oncol 2022; 27:1529-1542. [PMID: 35713754 DOI: 10.1007/s10147-022-02201-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/24/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite recommendations to deliver palliative care to cancer patients and their caregivers, their distress has not been alleviated satisfactorily. National health policies play a pivotal role in achieving a comprehensive range of quality palliative care delivery for the public. However, there is no standardised logic model to appraise the efficacy of these policies. This study aimed to develop a logic model of a national health policy to deliver cancer palliative care and to reach consensus towards specific policy proposals. METHODS A draft version of the logic model and specific policy proposals were formulated by the research team and the internal expert panel, and the independent external expert panel evaluated the policy proposals based on the Delphi survey to reach consensus. RESULTS The logic model was divided into three major conceptual categories: 'care-delivery at cancer hospitals', 'community care coordination', and 'social awareness of palliative care'. There were 18 and 45 major and minor policy proposals, which were categorised into four groups: requirement of government-designated cancer hospitals; financial support; Basic Plan to Promote Cancer Control Programs; and others. These policy proposals were independently evaluated by 64 external experts and the first to third Delphi round response rates were 96.9-98.4%. Finally, 47 policy proposals reached consensus. The priority of each proposal was evaluated within the four policy groups. CONCLUSIONS A national health policy logic model was developed to accelerate the provision of cancer palliative care. Further research is warranted to verify the study design to investigate the efficacy of the logic model.
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Affiliation(s)
- Yu Uneno
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, 606-8507, Japan
| | - Maki Iwai
- Former Non-Profit Organization, Cancer Policy Summit, Tokyo, 155-0032, Japan
| | - Naoto Morikawa
- Department of Clinical Oncology, Tohoku Rosai Hospital, Sendai, 981-8563, Japan
| | - Keita Tagami
- Department of Palliative Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Yoko Matsumoto
- Specified Non-Profit Organization, Ehime Cancer Support Association Orange, Matsuyama, 790-0023, Japan
| | - Junko Nozato
- Department of Internal Medicine, Palliative Care, Tokyo Medical and Dental University Hospital, Tokyo, 113-8519, Japan
| | - Takaomi Kessoku
- Department of Palliative Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.,Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Tatsunori Shimoi
- Department of Medical Oncology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Miyuki Yoshida
- Program for Nursing and Health Sciences, Graduate School of Medicine, Ehime University, Ehime, 791-0295, Japan
| | - Aya Miyoshi
- Specified Non-Profit Organization, Cancer Support Kagoshima, Kagoshima, 890-8511, Japan
| | - Ikuko Sugiyama
- Division of Nursing, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Kazuhiro Mantani
- Cancer Support Centre, National Hospital Organization, Osaka-Minami Medical Center, Osaka, 586-8521, Japan
| | - Mai Itagaki
- Section of Research Administration, National Cancer Center Hospital East, Chiba, 277-8577, Japan
| | - Akemi Yamagishi
- Department of Preventive Medicine and Public Health, School of Medicine, Keio University, Tokyo, 160-8582, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, 433-8558, Japan
| | - Akira Inoue
- Department of Palliative Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan.
| | - Manabu Muto
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, 606-8507, Japan
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