Agenda setting for essential medicines policy in sub-Saharan Africa: a retrospective policy analysis using Kingdon's multiple streams model

Non-government advocacy for health equity: evidence from Australia

The aim of this paper is to identify non-governmental organizations (NGOs) advocating for policy and practices to address rising health inequities in Australia. NGOs can play a critical role in shaping and influencing governance processes including public policy relating to the social and commercial determinants of health inequities. However, scholarship on who the NGOs are that are advocating to address health inequities in Australia and how they operate is sparse. Through desktop analysis in 2022, we searched NGO websites and documents for evidence of advocacy activities related to health inequities between 2017 and 2022. A database of the NGOs was compiled, noting the type of organization, function, advocacy activities and main issues their advocacy covered. A total of 137 NGOs were identified as engaging in activities advocating for change to address health inequities either directly (e.g. advocating directly to address health inequities) or indirectly (e.g. advocating on social determinants of health inequities such as housing and linking to their unequal health impacts). We noted the primary issues they advocated on, including topic categories: risk factor, disease-specific, broader health system, social determinants of health equity, and health workforce and service issues. The results indicate that Australian NGOs from multiple sectors are active in advocacy to address heath inequities on a variety of topics and through a variety of activities. This study provides a template for similar studies in other countries and suggests further research is needed to understand the role and impact of civil society advocacy to address growing health inequities.

Long-term Care in the Agenda: The Case of Chile

The Chilean presidential elections of 2021 included an unprecedented topic in the country's political debate: long-term care (LTC). Although some public policies and programs have been in place for at least 20 years, during this 2021 presidential election LTC was mentioned for the first time in a political campaign. Five out of seven candidates highlighted the importance of LTC in their proposals and designed policies to address it. Why did this topic gain momentum as a campaign topic in 2021? What can explain the sudden inclusion of a new topic on the Chilean political agenda? Using Kingdon's multiple streams framework this article aims to understand the factors explaining the inclusion of LTC in the Chilean political agenda during the past presidential elections. A two-step qualitative research design was performed using a case study approach. As a first step, a documentary analysis of the campaign programs was conducted searching for references to LTC proposals. In a second step, semi-structured interviews were carried out with representatives from three of the seven campaign teams, including the teams that reached the ballotage. Data were analyzed using Kingdon's multiple streams framework. Results showed that the availability of national data on LTC needs helped highlight the problem and acted as a facilitator for advocacy; international organizations and other countries' experiences in implementing LTC systems served as policy entrepreneurs; and four events-the feminist movement, the social outbreak with the constitutional process, and the COVID-19 pandemic-pushed LTC forward on the political agenda. The case of Chile illustrates how Kingdon's framework can be used to identify facilitators for LTC inclusion on the political agenda, serving as an example for other countries facing similar issues and fostering the global debate around the increase in LTC needs.

Adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Adherence to evidence-based standard treatment guidelines (STGs) enable healthcare providers to deliver consistently appropriate diagnosis and treatment. Irrational use of antimicrobials significantly contributes to antimicrobial resistance in sub-Saharan Africa (SSA).  The best available evidence is needed to guide healthcare providers on adherence to evidence-based implementation of STGs. This systematic review and meta-analysis aimed to determine the pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in SSA.

METHODS

The review followed the JBI methodology for systematic reviews of prevalence data. CINAHL, Embase, PubMed, Scopus, and Web of Science databases were searched with no language and publication year limitations. STATA version 17 were used for meta-analysis. The publication bias and heterogeneity were assessed using Egger's test and the I2 statistics. Heterogeneity and publication bias were validated using Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis. The summary prevalence and the corresponding 95% confidence interval (CI) of healthcare professionals' compliance with evidence-based implementation of STG were estimated using random effect model. The review protocol has been registered with PROSPERO code CRD42023389011. The PRISMA flow diagram and checklist were used to report studies included, excluded and their corresponding section in the manuscript.

RESULTS

Twenty-two studies with a total of 17,017 study participants from 14 countries in sub-Saharan Africa were included. The pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines in SSA were 45%. The pooled prevalence of the most common clinical indications were respiratory tract (35%) and gastrointestinal infections (18%). Overall prescriptions per wards were inpatients (14,413) and outpatients (12,845). Only 391 prescribers accessed standard treatment guidelines during prescription of antimicrobials.

CONCLUSIONS

Healthcare professionals' adherence to evidence-based implementation of STG for antimicrobial treatment were low in SSA. Healthcare systems in SSA must make concerted efforts to enhance prescribers access to STGs through optimization of mobile clinical decision support applications. Innovative, informative, and interactive strategies must be in place by the healthcare systems in SSA to empower healthcare providers to make evidence-based clinical decisions informed by the best available evidence and patient preferences, to ultimately improving patient outcomes and promoting appropriate antimicrobial use.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Framing access to essential medicines in the context of Universal Health Coverage: a critical analysis of health sector strategic plans from eight countries in the WHO African region

BACKGROUND

Framing affects how issues are understood and portrayed. This profoundly shapes the construction of social problems and how policy options are considered. While access to essential medicines (ATM) in the World Health Organization (WHO) African Region is often framed as a societal problem, there is dominance of medical and technically oriented approaches to analyze and remedy the situation. Hence, the systematic application of social science approaches, such as framing theory, remains under-explored. Through a framing analysis of National Strategic Plans (NSPs) from eight countries, this study explores the applicability and potential usefulness of framing theory to analyze essential medicines policies.

METHODS

We inductively coded the relevant NSP textual fragments using the qualitative content analysis software ATLAS.ti.22. Benford and Snow's conceptualization of framing was used to organize the coded data into three frames: diagnostic (problems), prognostic (solutions) and motivational (values and ideological).

RESULTS

The following five diagnostic frames were dominant or in-frame: medicine unavailability, ineffective regulation, weak supply chain management, proliferation of counterfeit (substandard or falsified) medicines and use of poor quality medicines. Diagnostic frames related to financing, affordability, efficiency and corruption were given limited coverage or out of frame. Prognostic frames corresponded with how these problems were framed. Whilst Universal Health Coverage (UHC) and its guiding principles was the dominant motivational frame, we identified some frame discordance between the global discourse and national level policies.

CONCLUSIONS

Social science approaches such as framing analysis are applicable and useful to systematically analyze essential medicine aspects. By applying framing theory, we revealed that ATM aspects in the eight countries we analyzed are more often characterized in relation to availability at the expense of affordability which undermines UHC. We conclude that whilst UHC is a strong motivational frame to guide ATM aspects, it is insufficient to inform a comprehensive approach to address the problems related to ATM at country level. To effectively advance ATM, concerned actors need to realize such limitation and endeavor to gain a deeper understanding of how problems are framed and agendas are set at country level, the processes through which ideas and knowledge become policies, including the political demands, incentives and trade-offs facing decision-makers in selecting policy priorities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Importance of Prioritising Politics in Good Governance for Medicines Initiative in Zimbabwe: A Qualitative Policy Analysis Study

In 2004 the World Health Organization (WHO) launched the Good Governance for Medicines (GGM) initiative with the aim of fighting corruption in the pharmaceutical sector. In the case of Zimbabwe, implementation of the initiative slowed down after the development phase. Often, lack of funding and technical considerations are cited as major reasons for issue de-prioritization whilst ignoring the influence of politics in mediating policy diffusion. Between June and August 2021, we conducted an in-depth document review and interviewed individuals involved with GGM in Zimbabwe to understand the political determinants of GGM prioritization in Zimbabwe. To guide and direct our analysis, we used the Shiffman and Smith framework. We found that the inception of GGM was facilitated by capable leaders, effective guiding institutions and resonance of the idea with the political environment. Prioritization from inception to implementation was constrained by limited citizen engagement, restriction of the issue to the pharmaceutical domain and a political transition that re-oriented policy priorities and reconfigured individual actor power. The portrayal of corruption as a priority problem requiring policy action has been hampered by the political sensitivity of the issue, lack of credible indicators on the prevalence and severity of the problem and challenges to measure the effectiveness of interventions such as the GGM. Despite the slowdown, from 2018 GGM actors have taken advantage of momentous policy windows to reconstitute their power by opportunistically framing GGM within the broader framework of access to essential medicines leading to the creation of new policy alliances and establishment of strategic political structures. To sustain the political prioritization, actors need to lobby for the institutionalization of GGM within the Ministry of Health strategy, sensitize citizens on the initiative, involve multiple stakeholders and frame the issue as a strategic intervention that underpins pharmaceutical sector performance within the national developmental framework.