ArticlePDF Available

Strengthening Health Policy Development and Management Systems in Low- and Middle- Income Countries: South Africa’s Approach

Authors:

Abstract and Figures

The development and management of health policies, strategies and guidelines (collectively, policies) in many low- and middle-income countries (LMICs) are often ad hoc and fragmented due to resource constraints a variety of other reasons within ministries of health. The ad hoc nature of these policy processes can undermine the quality of health policy analysis, decision-making and ultimately public health program implementation. To identify potential areas for policy system strengthening, we reviewed the literature to identify potential best practices for ministries and departments of health in LMICs regarding the development and management of health policies. This review led us to identify 34 potential best practices for health policy systems categorized across all five stages of the health policy process. While our review focused on best practices for ministries of health in LMICs, many of these proposed best practices may be applicable to policy processes in high income countries. After presenting these 34 potential best practices, we discuss the potential of operationalizing these potential best practices at ministries of health through the adoption of policy development and management manuals and policy information management systems using the South Africa National Department of Health’s experience as an example.
Content may be subject to copyright.
Journal Pre-proof
Strengthening Health Policy Development and Management
Systems in Low- and Middle- Income Countries: South Africa’s
Approach
Jeffrey Lane, Gail Andrews, Erica Orange, Audrey Brezak,
Gaurang Tanna, Lebogang Lebese, Terence Carter, Evasen
Naidoo, Elise Levendal, Aaron Katz
PII: S2590-2296(20)30008-3
DOI: https://doi.org/10.1016/j.hpopen.2020.100010
Reference: HPOPEN 100010
To appear in:
Received date: 29 October 2019
Revised date: 24 June 2020
Accepted date: 17 July 2020
Please cite this article as: J. Lane, G. Andrews, E. Orange, et al., Strengthening Health
Policy Development and Management Systems in Low- and Middle- Income Countries:
South Africa’s Approach, (2020), https://doi.org/10.1016/j.hpopen.2020.100010
This is a PDF file of an article that has undergone enhancements after acceptance, such
as the addition of a cover page and metadata, and formatting for readability, but it is
not yet the definitive version of record. This version will undergo additional copyediting,
typesetting and review before it is published in its final form, but we are providing this
version to give early visibility of the article. Please note that, during the production
process, errors may be discovered which could affect the content, and all legal disclaimers
that apply to the journal pertain.
© 2020 Published by Elsevier.
Journal Pre-proof
Title Page: 15 October, 2019
Title: Strengthening Health Policy Development and Management Systems in Low- and Middle-
Income Countries: South Africa’s Approach
Authors: Jeffrey Lane1, Gail Andrews2, Erica Orange1, Audrey Brezak1, Gaurang Tanna2,
Lebogang Lebese2, Terence Carter3, Evasen Naidoo3, Elise Levendal3, Aaron Katz1
1 University of Washington, School of Public Health, Department of Global Health, International
Training and Education Center for Health (I-TECH)
2 National Department of Health of the Republic of South Africa
3 International Training and Education Center for Health South Africa
Corresponding Author: Jeffrey Lane; University of Washington, International Training and
Education Center for Health (I-TECH), HMC #359932, 325 9th Avenue, Seattle, WA 98104-
2499; lanej3@uw.edu
Acknowledgments: This research is a product of the University of Washington International
Training and Education Center for Health and was supported by the United States President’s
Emergency Plan for Aids Relief (PEPFAR) through the U. S. Health Resources and Services
Administration under Cooperative Agreement number 5 U91HA0680112. The findings and
conclusions in this report are those of the authors.
Declarations of interest: none
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
Abstract
The development and management of health policies, strategies and guidelines (collectively,
policies) in many low- and middle-income countries (LMICs) are often ad hoc and fragmented
due to resource constraints a variety of other reasons within ministries of health. The ad hoc
nature of these policy processes can undermine the quality of health policy analysis, decision-
making and ultimately public health program implementation. To identify potential areas for
policy system strengthening, we reviewed the literature to identify potential best practices for
ministries and departments of health in LMICs regarding the development and management of
health policies. This review led us to identify 34 potential best practices for health policy
systems categorized across all five stages of the health policy process. While our review focused
on best practices for ministries of health in LMICs, many of these proposed best practices may
be applicable to policy processes in high income countries. After presenting these 34 potential
best practices, we discuss the potential of operationalizing these potential best practices at
ministries of health through the adoption of policy development and management manuals and
policy information management systems using the South Africa National Department of Health’s
experience as an example.
Introduction
The development and management of health policies, strategies and guidelines (collectively,
policies) in many low and middle income countries (LMICs) are often ad hoc and fragmented
due to a variety of reasons, undermining the quality of policy analysis, decision-making, and
ultimately public health program implementation.(1) Poor health policy management practices
can unnecessarily lengthen policy development and adoption processes, which can delay scale up
of programmatic best practices and scientific breakthroughs. These challenges can be especially
pronounced in LMICs where ministries of health often face severe budget constraints that may
restrict spending on policy administrative, coordination, and management functions.(2) Once
policies are adopted, many LMICs also struggle to effectively implement policies for a variety
of reasons, including a lack of financial and human resources, poor policy dissemination, or lack
of implementer buy-in. (3) Poor policy practices and weak processes can make it challenging for
ministry of health staff to effectively monitor and manage policy processes and performance.
Ministry of health investment in policy management will vary by country, as illustrated by
variable public health spending rates across LMICs.(4) To avoid confusion of terms, the term
“policy” is used to refer to all types of instruments adopted by a health ministry to guide the
functioning of the health sector, including policies, strategies and guidelines.
The National Department of Health of the Republic of South Africa (NDoH) partnered with
[name of institution redacted for peer review purposes] from 2016-2019 on a project to
strengthen its policy development and management systems with the goal of improving the
quality of NDoH policy processes and strengthening policy implementation. We determined that
existing NDoH policies varied in structure, content, and process, and that the NDoH currently
lacks a comprehensive database of its existing policies, and inconsistent policy development and
management processes, with resultant risks such as conflicts between some policies, insufficient
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
funding for implementation, untended policy consequences which could have been averted
through consistent policy analyses. This project attempt to respond to these concerns.
In an effort to identify potential best practices to strengthen NDoHs policy development and
management processes, we reviewed the literature but determined that the literature does not
offer consolidated guidance on best practices for policy development and management practices
in LMICs. To address this gap, we conducted a literature review to identify potential best
practices for ministries and departments of health in LMICs regarding the development and
management of health policies that could be used to develop greater standardization in various
stages of the policy management process. This comprehensive review led us to identify and
consolidate 34 potential best practices that are described in this manuscript. After presenting
these potential best practices, we discuss NDoH’s plans to translate these findings into practice
by creating a Manual for the Development and Management for National Health Sector Policies
and designing a policy information management system to manage information regarding health
policy development and implementation at NDoH.
Methods
We conducted an inductive scope review of the literature to identify potential best practices for
policy development and management in LMICs. The literature review search parameters are
summarized in Table 1.
The initial inclusion criteria identified 642 responsive articles. We then conducted an abstract
review of the 642 articles applying a secondary inclusion criterion to limit the scope to articles
that appear to address how and why policies are analyzed, developed and/or adopted, including
influential actors, processes, and context. This secondary inclusion criterion reduced the number
of responsive articles to 190. Two co-authors ([co-author initials redacted]) reviewed the 190
responsive articles using inductive grounded theory to identify potential policy process best
practices. Articles were coded using Excel and codes were updated throughout the review
process in consultation with two additional co-authors ([co-author initials redacted]). We then
organized the potential best practices using a 5-stage policy process heuristic adopted by
Howlett, Ramesh, and Perl (2009), consisting of the following stages: agenda setting, policy
formulation, decision-making, policy implementation, and policy evaluation (see Figure 1: 5-
Stage Policy Cycle). (5) Agenda setting was defined as identifying and describing a public
health problem as a priority for governmental action. Policy formulation was defined as
identifying and evaluating possible policy options and detailing and drafting a specific policy
proposal. Decision-making was defined as the formal process of review and approval of a policy
proposal by governmental decision-makers and/or structures. Implementation was defined as the
process of carrying out the plan established in the adopted policy, including the development and
adoption of related implementation policies, such as regulations, standard operating procedures,
or budgets. Evaluation was defined as the process of verifying whether the policy’s
implementation, and its effects, align with its objectives. A number of potential best practices
were coded as applicable to more than one stage.
Results
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
Our literature review identified 34 potential best practices for policy development and
management processes in LMICs that, if adopted, could strengthen the quality of policies
developed by ministries and departments of health in LMICs and ultimately increase the
likelihood of successful implementation of these policies. Table 2 lists each of the 34 proposed
best practices organized by the stage or stages of the policy process where the potential best
practice is most applicable.
STAGE 1 AGENDA SETTING. Our review identified five potential best practices in the agenda
setting stage.
Conduct robust situational analysis. The literature identified the importance of conducting a
robust situational analysis to understand the contextual factors contributing to specific public
health problems.(3, 6) The goal of a situational analysis is to develop a common understanding
of contextual factors affecting a public health problem. These contextual factors can include
economic, social, racial, historical, cultural, political, gender, technological, and institutional
considerations. Situational analyses can include both qualitative and quantitative data. The time
frame for the situation analysis should examine the current context and sufficient historical
context to identify relevant trends.
Facilitate ideas and feedback from key stakeholders to policymakers. Our review identified
the importance of soliciting ideas and feedback from key stakeholders to policymakers during
the agenda setting and policy formulation stages.(7-16) Stakeholders can and should include a
wide range of perspectives, such as health care providers, public health practitioners, patients,
community members, advocates, and researchers. Methods could include open consultative
forums, surveys, and interviews. This proactive engagement can help improve the diversity of
perspective reflected in the situation analysis and policy formulation.
Develop clearly defined problem statements. We identified the importance of developing
clearly defined problem statements as part of the agenda setting stage.(9-11, 13) Developing
these problem statements helps to adequately describe issues that need to be addressed through
policy action. This is an important step to having a common internal frame of the problems and
their relative importance that need to be addressed in the policy development process.(17)
Facilitate policymaker access to resources with current evidence. The literature showed the
importance of facilitating policymaker access to resources with current evidence, to facilitate
evidence-informed situational analyses and subsequently identifying potential interventions in
the policy formulation stage.(3, 8, 12, 14, 15, 18-22) These resources could include access to
online libraries or systematic linkages to experts (e.g., researchers, think tanks, or policy research
units within ministries or departments of health).
Conduct stakeholder analyses. The literature pointed to the importance of conducting a
stakeholder analysis as part of the agenda setting and policy formulation stages.(21-23) Ongoing
stakeholder analyses are important to identify key interests at stake, their views of the policy
issue and its importance, how optional policy interventions might align or conflict with those
interests, and whether certain groups may be disproportionately burdened or benefited by the
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
policy proposal, which may affect the relative equity of each proposal. As policy proposals
become increasingly detailed and evolve, stakeholder analyses often need to be updated.
STAGE 2 - POLICY FORMULATION. Our review identified fourteen potential best practices that
primarily align with the policy formulation stage.
Brainstorm possible interventions to address problem statement. We identified the
importance of thinking broadly and creatively about possible interventions to address public
health problems identified during the situation analysis.(6, 9, 13, 16, 22-24) This brainstorming
process should include thinking about the various levers of influence available to governments,
including direct service provision, taxation, regulation, insurance mechanisms, and purchasing
power. Often policy proposals are limited to direct service delivery proposals, when
governments have other mechanisms at their disposal that can have a substantial impact on
health systems and health outcomes (e.g. taxes on tobacco products to reduce consumption or
regulations mandating benefits in commercial insurance products to facilitate uptake of
beneficial therapies).
Analyze potential interventions using expressly defined criteria. The literature revealed the
importance of analyzing and comparing possible interventions using expressly defined criteria.
(9, 13, 25) One method for conducting this analysis is multi-criteria decision analysis. Under
this method, specific criteria are selected, and each intervention is scored against each selected
criterion. The total scores for each intervention are then compared to facilitate a prioritization
process. Other forms of intervention analysis can also be used, such as: Program Budgeting and
Marginal Analysis (PBMA); Propriety, Economics, Acceptability, Resources and Legality component (PEARL); Multi-
Voting Technique; and the Delphi technique.(26)
Develop stakeholder engagement plan to ensure input from all relevant stakeholders. To
ensure adequate stakeholder input during the analysis stage, a stakeholder engagement plan
should be developed and followed to ensure input from all relevant stakeholders (e.g.,
geographic, key populations, and implementers). (7, 11, 14, 27) In contrast to ad hoc stakeholder
consultations, developing a thoughtful stakeholder engagement plan can help ensure that a broad
array of key stakeholders are engaged in the policy development process at critical points,
including during policy conceptualization and prioritization processes.
Model implementation to identify potential implementation barriers. The literature revealed
the importance of policy implementation modeling, such as creating an implementation logic
model.(7, 28, 29) Implementation modeling requires that the policy development team develop
its intervention proposals to a relatively detailed stage to facilitate detecting potential barriers to
effective implementation during the policy development phase. If these barriers are identified
during the policy development phase, the team can integrate proactive strategies into their policy
proposal to address and overcome these barriers, instead of waiting to identify and address these
during implementation. An implementation logic model or theory of change framework can be
used to support implementation modeling.
Model policy implementation on work load. The literature supported the importance of
modeling policy implementation on work load burden of implementers.(16, 28, 32-49) Modeling
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
work load burden was primarily discussed in the context of clinical settings. For example, do
nurses in public clinics have the time to conduct an additional screening for a new priority
condition? If the additional screening is added, what effect will that have on the number of
patients that can be seen by that nurse each day? Identifying work load burden-related barriers in
the development stage may lead to consideration as to whether, for example, a task-sharing
approach will be necessary to effectively roll out the intervention at scale.
Consider impact of staff turnover on policy implementation. Teams should consider the
impact of staff turnover on policy implementation and training.(7, 34, 36, 37, 40, 41, 44, 46, 49-
51) Many health systems, especially in rural areas, suffer from chronic turnover of staff.
Frequent turnover can undermine training health care providers and other implementers on a new
policy. Online or virtual learning modalities may be one method to help address the impact of
staff turnover by allowing new staff to be oriented to all relevant policies during their initial
orientation process. In addition, long processes for mentorship or supervision may also be
challenging to implement in areas with high staff turnover.
Conduct a policy conflict analysis. As part of the analysis process, the literature showed the
importance of conducting a policy conflict analysis before adopting the policy.(3, 6, 9, 10, 16,
30, 31) Conflict analyses compare a draft policy with existing policies and laws and can help
identify other policies that may need to be updated to ensure a consistent policy framework.
Reliable access to a searchable, comprehensive database of governmental policies and laws is
necessary to conduct effective policy conflict analyses.
Conduct a costing analysis that estimates resource needs over time. A costing analysis of
policy proposal should estimate potential changes in resource needs over time.(3, 27, 36, 40-42,
48, 52-66) Frequently the resource needs of specific policies fluctuate over time. For example, a
policy may require relatively high resources at the outset to fund the initial rollout, but then its
resource needs may decline over time once the delivery system is established. Alternatively, a
policy may require relatively few resources at the outset with significant additional resources
required over time as the service is made available at a wider array of facilities or beneficiaries.
Identify sources of funding. Policy processes should identify sources (e.g., dedicated funds,
general funds, donor funds) and levels of funding for implementation, including supply chain.(3,
27, 35, 38, 48, 54, 55, 63, 67-71) In many countries, budget processes occur separately from
policy processes led by ministries or departments of health. This bifurcation often leads to
policies being adopted by ministries of health without clear costing analysis or, if costing
analysis is conducted, adequate funds are not allocated during the budget process to effectively
implement the policy. The literature emphasized the need to better align budget, finance, and
taxation processes with policy development processes overseen by ministries of health.
Policies should be clear and areas of flexibility should be expressly acknowledged. The
literature pointed to the importance of drafting policies in plain language and expressly
acknowledging areas of flexibility.(3, 11, 29, 31, 40, 44, 60-66, 69, 72-79) This clarity is critical
to facilitate consistent and reliable interpretation of the policy by implementers, community
members, and other key stakeholders. Clarity in national policies may also be necessary to
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
ensure consistent adoption and implementation by subnational units in decentralized countries,
which may have some authority and autonomy to adapt national policies to their local contexts.
Clearly define targets, objectives, goals and indicators. Policies should have clearly defined
targets, objectives, goals, and indicators.(29, 33, 40, 41, 52, 59-61, 67, 68, 80-84) Policies often
have a great deal of variability in whether and how policy targets, objectives, goals, and
indicators are included and defined.
Include clear implementation targets with timelines. Policy targets should include timelines
against which progress can be measured.(27, 29, 33, 40, 52, 54, 60, 61, 67, 79-83) These
timelines are critical to performance management of policy implementation processes.
Establish consistent framework for M&E plans. To facilitate management of policies across
a ministry or department of health, the literature supported establishing consistent frameworks
for M&E plans.(11, 21, 29, 33, 41, 57, 60, 68, 72, 74, 83, 85-88) Having a consistent M&E
framework to outline expected reporting systems, frequency, and data will allow ministry
leadership to more easily assess implementation progress across a range of policies.
Identify and coordinate M&E system(s)/data sources. When developing policy
implementation M&E plans, existing M&E system(s) and data sources should be used when
possible instead of creating a new or standalone M&E system for each new policy.(33, 47, 52-
54, 70, 83, 87, 89) Establishing new M&E systems and data feeds can be costly and time-
consuming, which can deplete limited resources that may be better targeted at policy
implementation activities. In addition, establishing new data collection processes can take many
months or even years to establish.
STAGE 3 DECISION-MAKING. Our review identified two potential best practices applicable to
the decision-making or adoption stage.
Standardize definitions for different types of policies. The literature discuss the importance of
standardizing definitions for different types of policies. Often ministries of health develop a
range of different types of policies with different purposes, including guidelines, strategies,
frameworks, and standard operating procedures. Often the content and objectives of these
different policy types overlap, but developing standard definitions will be important for
standardizing structure and review procedures for different policy types.(7, 14, 16, 18, 29, 69, 77,
86, 90)
Establish consistent requirements for review and approval of different types of policies.
The literature pointed to the importance of standardizing the review and approval processes for
different policy types. The level of review may be different depending on the type of policy.
For example, a policy may require a higher level of review than a standard operating procedure.
Standardizing these review and approval processes could make the processes more predictable
and potentially more streamlined and efficient.(3, 10, 12, 16, 52, 69, 91-93)
STAGE 4 - IMPLEMENTATION. Our review identified eight potential best practices for the
implementation stage.
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
Disseminate policies through push and pull mechanisms to all relevant stakeholders.
Policies should be disseminated through push and pull mechanisms to all relevant
stakeholders.(7, 19, 52, 54, 58, 59, 61, 64, 68, 70, 72, 77-79, 91, 94-101) Push communication
strategies include mechanisms to proactively send content to implementers and community
members, such as distributing hardcopies of policies at health facilities. Pull communication
mechanisms refers to passive dissemination mechanisms that allow users to access the policy
when needed by the user, such as by posting the policy on an accessible website. Push and pull
approaches recognize that some implementers may only need access to a policy intermittently,
and at those times they should be able to access the policy in a central location, in paper or
electronic form.
Provide sufficient role-specific training on policy details. Sufficient education and training
should be provided to implementers on policy details, and this training must be relevant to their
role in policy implementation. (7, 28, 29, 31, 33, 35, 36, 38, 39, 41, 42, 51, 54, 58, 59, 61, 62, 64,
68, 70, 72, 74, 95, 102-104) This may require that different training curriculum or materials be
developed for different cadres.
Educate key stakeholders on policy components. Key components of the policy should be
communicated to all key stakeholders, not just implementers (e.g., consumers, traditional
practitioners or private sector).(7, 11, 19, 28, 29, 36, 39, 52, 54, 61, 68, 78, 86, 88, 98, 105-107)
Community education initiatives can take many forms, including media campaigns, civil society
outreach, and making policy documents publicly available on governmental or facility websites.
Making policies available in local languages and dialects and with nontechnical language
summaries may also be necessary to ensure that key stakeholders can understand how policies
may affect them.
Verify knowledge of policy details by key stakeholders. The knowledge of key implementers
about policy details should be verified.(7, 28, 29, 31, 38, 47, 54, 68, 95, 98) Often, policy
training programs may fail to effectively transfer the necessary knowledge to key implementers.
To ensure that policy trainings are transferring the necessary information to implementers,
trainings should verify trainee knowledge and understanding of their role in the policy process.
These training verifications can be implemented via paper tests or online training modules that
ask the trainees to correctly answer certain key questions before they can proceed to the next
section of the training.
Empower managers to provide guidance and support to front line implementers. Frontline
managers should be empowered to provide guidance and support to front line implementers.(29,
31, 32, 35, 36, 38, 39, 41, 43, 51, 61, 66, 68, 69, 75, 92, 96, 102, 107-110) This may require
more in-depth training for managers so implementers have a local resource to answer questions
about how a policy should be interpreted in a particular situation. These managers may also
need to be connected with other managers or resources at district, provincial, or national
departments of health who can provide guidance to them when required.
Empower frontline implementers to engage in policy development and implementation
processes. Frontline implementers should be empowered to engage in policy development and
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
implementation processes.(29, 31, 36, 45, 50, 51, 56, 64, 65, 69, 92, 95, 102, 104, 106-108, 111-
113) Engagement of frontline implementers in the policy development and implementation
process was cited broadly in the literature as key to policy implementation success. The power
of frontline implementers to affect policy implementation is sometimes referred to as “street-
level bureaucracy” because often frontline implementers have a tremendous amount of power in
practice to decide whether and how to implement policies.(107) Engaging these implementers in
the policy development process can help improve the likelihood that they will be accepting of
and willing to play their role in the policy implementation process, as envisioned in the adopted
policy.
Designate champions/ leaders responsible for implementation at each level. Champions and
leaders responsible for implementation should be designated at each level (e.g., provincial,
district, and facility-level).(7, 22, 23, 28, 32, 35, 36, 43, 44, 51, 53, 60, 77, 96) The literature
revealed the importance of identifying these champions and leaders at each level to provide
accountability and support for implementation at each level of government.
Ensure strong financial management throughout implementation. Ministries of health and
finance must ensure strong financial management throughout implementation.(16, 27, 28, 35, 48,
52-55, 63, 89, 101, 114) Costing analysis, budget impact analysis, and financial planning are
important to successful policy implementation, but these resources must also be managed
effectively during policy implementation phases. Financial management and accounting systems
will be necessary to strengthen financial management of funds and resources critical to policy
implementation.
STAGE 5 Evaluation. Our review identified five potential best practices that primarily align
with the evaluation stage.
Engage in regular implementation monitoring. Ministries and departments of health should
engage in regular implementation monitoring using indicators identified in the monitoring
plan.(15, 16, 29, 33, 39-41, 48, 52, 54, 62, 64, 83, 87, 106) Regular monitoring, using readily
and inexpensively available information, can help identify unforeseen barriers to implementation
early in the rollout or on an ongoing basis so they can be addressed in real-time.
Monitor availability of inputs/supplies/medicines for policy compliance. The literature
emphasized the need to monitor the availability of policy inputs, such as medical supplies and
medicines.(33, 35, 55, 60, 63, 64, 67, 68, 79, 95, 101, 103) Various supply chain management
systems have been established to monitor health system input availability and access.
Establishing and maintaining such a system will be critical for the successful implementation of
policies that rely on the availability of certain commodities. The quality of these commodities
will also need to be monitored to identify substandard commodities that may compromise quality
of health service provision.
Conduct evaluation when required by policy. An evaluation should be conducted when
required by the policy.(27, 28, 33, 52, 54, 64, 80, 81, 85, 103, 106, 115) Many policies include a
requirement that a policy evaluation be conducted a certain number of years after
implementation. Unfortunately, these evaluations are frequently not conducted either due to
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
management oversight, lack of human resources capacity, or lack of funding to conduct the
evaluation. The cost of conducting the evaluation should be included in the costing analysis to
help ensure that funding is available for policy evaluation activities. Due to financial or time
constraints, it may not be feasible to conduct an in-depth evaluation of every policy, so ministries
and departments of health, in consultation with key stakeholders, should think strategically about
what evaluation methods are appropriate for each policy.
Ensure evaluation is transparent and verifiable. Policy evaluations should be transparent.(15,
28, 33, 53, 54, 82, 83, 109, 114) Policy evaluations are more powerful if their methodologies can
be validated by key stakeholders and the public. Publishing the evaluation results, including the
methodology used to conduct the evaluation, can help build the credibility of the
recommendations.
Use results of policy evaluation to inform policymaking processes. The results of policy
monitoring and evaluation should be used to inform policy revisions and future policy
development.(15, 21, 33, 37, 81, 85, 87, 94, 103, 116-119) For example, policy monitoring and
evaluation results could be required to be presented to ministry leadership and/or to public
stakeholders to improve the likelihood of the results being used to inform future policy decisions.
Evaluation results can also be shared publicly to facilitate buy-in or advocacy by civil society
organizations for continuous performance improvement.
Discussion
The 34 potential best practices in this manuscript present a framework for governments,
especially in LMICs, to review their existing processes with an eye toward greater
standardization and improved management.
One step that governments could take to integrate these considerations into practice is to develop
a manual, guide, or internal directive that standardizes policy processes and incorporates these
best practices at the appropriate stage. Table 3 lists examples of these types of guides.
The South Africa NDoH has developed a Manual on the Development and Management of
National Health Policies that was informed by best practices identified in this manuscript. The
manual includes sections on definitions and key terms, required processes, and formats (or
structure) of different types of policies. The manual also includes resource guides on defining
public health problems and conducting a situational analysis; analyzing possible policy
interventions; stakeholder analysis; implementation modeling; policy costing; implementation
monitoring; policy evaluation; and tools and checklists to support these key policy activities.
NDoH hopes this manual will act as both an educational resource and management tool to
strengthen NDoH policy processes and improve programmatic rollout of strategic priorities.
The South Africa NDoH also identified a need for a digitsed system to manage the policy
development and implementation processes. To address this need, NDoH developed a policy
information management system which aims to: improve the ability of leadership to know the
status of policies and to monitor progress in developing and reviewing policies; provide tools for
NDoH managers to support the policy development and review process; aggregate documents
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
and data associated with specific policies to improve policy implementation and monitoring; and
make policies more readily accessible to frontline clinicians and the public. The system was
designed to include a comprehensive database of policies organized by type of policy and health
topic. The system also includes functionality for managing policy drafts and associated
situation and health policy analysis documents, to support managers during the policy
development process.
Conclusion
The 34 potential best practices presented in this manuscript provides a structure for standardizing
and strengthening the very complex processes of health policy development, management and
implementation by ministries of health in LMICs. This list is intended as illustrative and not
exclusive. The authors hope that health policy professionals and researchers build on and refine
this list in support of strengthening health policy processes globally. Champions will also be
required to translate policy best practices into operationalized procedures and practices within
ministries and departments of health. South Africa’s NDoH is embarking on such a path by
adopting a Manual for the Development and Management for National Health Policies, and an
associated policy information management system. Its approach may be a useful model for
ministries and departments of health in other LMICs.
REFERENCES
1. Lavis JN, Oxman AD, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed
health Policymaking (STP) 3: Setting priorities for supporting evidence-informed policymaking.
Health Res Policy Syst. 2009;7 Suppl 1:S3.
2. Gottret P, Schieber G. Health Financing Revisited: A Practitioner's Guide. Washington,
DC: World Bank; 2006.
3. Erasmus E, Orgill M, Schneider H, Gilson L. Mapping the existing body of health policy
implementation research in lower income settings: what is covered and what are the gaps? Health
Policy Plan. 2014;29 Suppl 3:iii35-50.
4. Organization WH. Global spending on health: a world in transition. Geneva; 2019.
Contract No.: WHO/HIS/HGF/HFWorkingPaper/19.4.
5. Howlett M, Ramesh M, Perl A. Studying Public Policy Policy Cycles & Policy
Subsystems. 3rd ed: Oxford University Press; 2009.
6. Dar OA, Hasan R, Schlundt J, Harbarth S, Caleo G, Dar FK, et al. Exploring the evidence
base for national and regional policy interventions to combat resistance. Lancet.
2016;387(10015):285-95.
7. Draper CA, Draper CE, Bresick GF. Alignment between chronic disease policy and
practice: case study at a primary care facility. PLoS One. 2014;9(8):e105360.
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
8. Ellen ME, Leon G, Bouchard G, Ouimet M, Grimshaw JM, Lavis JN. Barriers,
facilitators and views about next steps to implementing supports for evidence-informed decision-
making in health systems: a qualitative study. Implement Sci. 2014;9:179.
9. Berlan D, Buse K, Shiffman J, Tanaka S. The bit in the middle: a synthesis of global
health literature on policy formulation and adoption. Health Policy Plan. 2014;29 Suppl 3:iii23-
34.
10. Awenva AD, Read UM, Ofori-Attah AL, Doku VC, Akpalu B, Osei AO, et al. From
mental health policy development in Ghana to implementation: what are the barriers? Afr J
Psychiatry (Johannesbg). 2010;13(3):184-91.
11. Singh S, Myburgh NG, Lalloo R. Policy analysis of oral health promotion in South
Africa. Glob Health Promot. 2010;17(1):16-24.
12. Cliff J, Lewin S, Woelk G, Fernandes B, Mariano A, Sevene E, et al. Policy development
in malaria vector management in Mozambique, South Africa and Zimbabwe. Health Policy Plan.
2010;25(5):372-83.
13. Lavis JN, Oxman AD, Grimshaw J, Johansen M, Boyko JA, Lewin S, et al. SUPPORT
Tools for evidence-informed health Policymaking (STP) 7: Finding systematic reviews. Health
Res Policy Syst. 2009;7 Suppl 1:S7.
14. Politis CE, Halligan MH, Keen D, Kerner JF. Supporting the diffusion of healthy public
policy in Canada: the Prevention Policies Directory. Online J Public Health Inform.
2014;6(2):e177.
15. Gilson L, Raphaely N. The terrain of health policy analysis in low and middle income
countries: a review of published literature 1994-2007. Health Policy Plan. 2008;23(5):294-307.
16. Sheikh K, Saligram PS, Hort K. What explains regulatory failure? Analysing the
architecture of health care regulation in two Indian states. Health Policy Plan. 2015;30(1):39-55.
17. Shiffman J, Smith S. Generation of political priority for global health initiatives: a
framework and case study of maternal mortality. Lancet. 2007;370(9595):1370-9.
18. Akhlaq A, McKinstry B, Muhammad KB, Sheikh A. Barriers and facilitators to health
information exchange in low- and middle-income country settings: a systematic review. Health
Policy Plan. 2016;31(9):1310-25.
19. El-Jardali F, Lavis J, Moat K, Pantoja T, Ataya N. Capturing lessons learned from
evidence-to-policy initiatives through structured reflection. Health Res Policy Syst. 2014;12:2.
20. Andermann A, Pang T, Newton JN, Davis A, Panisset U. Evidence for Health II:
Overcoming barriers to using evidence in policy and practice. Health Res Policy Syst.
2016;14:17.
21. Nabyonga-Orem J, Mijumbi R. Evidence for informing health policy development in
Low-income Countries (LICs): perspectives of policy actors in Uganda. Int J Health Policy
Manag. 2015;4(5):285-93.
22. Woelk G, Daniels K, Cliff J, Lewin S, Sevene E, Fernandes B, et al. Translating research
into policy: lessons learned from eclampsia treatment and malaria control in three southern
African countries. Health Res Policy Syst. 2009;7:31.
23. Wenger E. How we learn. Communities of practice. The social fabric of a learning
organization. Healthc Forum J. 1996;39(4):20-6.
24. Burris SC, Anderson ED. Making the case for laws that improve health: the work of the
Public Health Law Research National Program Office. J Law Med Ethics. 2011;39 Suppl 1:15-
20.
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
25. Mirelman A, Mentzakis E, Kinter E, Paolucci F, Fordham R, Ozawa S, et al. Decision-
making criteria among national policymakers in five countries: a discrete choice experiment
eliciting relative preferences for equity and efficiency. Value Health. 2012;15(3):534-9.
26. Organization WH. Strategizing national health in the 21st century: a handbook. 2016.
27. Rasanathan K, Muniz M, Bakshi S, Kumar M, Solano A, Kariuki W, et al. Community
case management of childhood illness in sub-Saharan Africa - findings from a cross-sectional
survey on policy and implementation. J Glob Health. 2014;4(2):020401.
28. Mugwagwa J, Edwards D, de Haan S. Assessing the implementation and influence of
policies that support research and innovation systems for health: the cases of Mozambique,
Senegal, and Tanzania. Health Res Policy Syst. 2015;13:21.
29. Belaid L, Ridde V. An implementation evaluation of a policy aiming to improve financial
access to maternal health care in Djibo district, Burkina Faso. BMC Pregnancy Childbirth.
2012;12:143.
30. Ditlopo P, Blaauw D, Penn-Kekana L, Rispel LC. Contestations and complexities of
nurses' participation in policy-making in South Africa. Glob Health Action. 2014;7:25327.
31. Sheikh K, Porter J. Discursive gaps in the implementation of public health policy
guidelines in India: the case of HIV testing. Soc Sci Med. 2010;71(11):2005-13.
32. Gilson L, Elloker S, Olckers P, Lehmann U. Advancing the application of systems
thinking in health: South African examples of a leadership of sensemaking for primary health
care. Health Res Policy Syst. 2014;12:30.
33. Kawonga M, Blaauw D, Fonn S. Aligning vertical interventions to health systems: a case
study of the HIV monitoring and evaluation system in South Africa. Health Res Policy Syst.
2012;10:2.
34. Cailhol J, Craveiro I, Madede T, Makoa E, Mathole T, Parsons AN, et al. Analysis of
human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in
response to GFATM and PEPFAR-funded HIV-activities. Global Health. 2013;9:52.
35. Olinyk S, Gibbs A, Campbell C. Developing and implementing global gender policy to
reduce HIV and AIDS in low- and middle-income countries: policy makers' perspectives. Afr J
AIDS Res. 2014;13(3):197-204.
36. Daniels K, Clarke M, Ringsberg KC. Developing lay health worker policy in South
Africa: a qualitative study. Health Res Policy Syst. 2012;10:8.
37. Buchan J, Couper ID, Tangcharoensathien V, Thepannya K, Jaskiewicz W, Perfilieva G,
et al. Early implementation of WHO recommendations for the retention of health workers in
remote and rural areas. Bull World Health Organ. 2013;91(11):834-40.
38. Moetlo GJ, Pengpid S, Peltzer K. An evaluation of the implementation of integrated
community home-based care services in vhembe district, South Africa. Indian J Palliat Care.
2011;17(2):137-42.
39. Sato M, Gilson L. Exploring health facilities' experiences in implementing the free
health-care policy (FHCP) in Nepal: how did organizational factors influence the implementation
of the user-fee abolition policy? Health Policy Plan. 2015;30(10):1272-88.
40. Crawley J, Hill J, Yartey J, Robalo M, Serufilira A, Ba-Nguz A, et al. From evidence to
action? Challenges to policy change and programme delivery for malaria in pregnancy. The
Lancet Infectious Diseases. 2007;7(2):145-55.
41. Uwimana J, Jackson D, Hausler H, Zarowsky C. Health system barriers to
implementation of collaborative TB and HIV activities including prevention of mother to child
transmission in South Africa. Trop Med Int Health. 2012;17(5):658-65.
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
42. Hanefeld J. The impact of Global Health Initiatives at national and sub-national level - a
policy analysis of their role in implementation processes of antiretroviral treatment (ART) roll-
out in Zambia and South Africa. AIDS Care. 2010;22 Suppl 1:93-102.
43. Dieleman M, Shaw DM, Zwanikken P. Improving the implementation of health
workforce policies through governance: a review of case studies. Hum Resour Health.
2011;9:10.
44. Dambisya YM, Matinhure S. Policy and programmatic implications of task shifting in
Uganda: a case study. BMC Health Serv Res. 2012;12:61.
45. Minzi OM, Haule AF. Poor knowledge on new malaria treatment guidelines among drug
dispensers in private pharmacies in Tanzania: the need for involving the private sector in policy
preparations and implementation. East Afr J Public Health. 2008;5(2):117-21.
46. Deller B, Tripathi V, Stender S, Otolorin E, Johnson P, Carr C. Task shifting in maternal
and newborn health care: key components from policy to implementation. Int J Gynaecol Obstet.
2015;130 Suppl 2:S25-31.
47. Agyepong IA, Abankwah DN, Abroso A, Chun C, Dodoo JN, Lee S, et al. The
"Universal" in UHC and Ghana's National Health Insurance Scheme: policy and implementation
challenges and dilemmas of a lower middle income country. BMC Health Serv Res.
2016;16(1):504.
48. Sheikh K, Uplekar M. What Can We Learn About the Processes of Regulation of
Tuberculosis Medicines From the Experiences of Health Policy and System Actors in India,
Tanzania, and Zambia? Int J Health Policy Manag. 2016;5(7):403-15.
49. Hanefeld J, Musheke M. What impact do Global Health Initiatives have on human
resources for antiretroviral treatment roll-out? A qualitative policy analysis of implementation
processes in Zambia. Hum Resour Health. 2009;7:8.
50. Kouanda S, Yameogo WM, Ridde V, Sombie I, Baya B, Bicaba A, et al. An exploratory
analysis of the regionalization policy for the recruitment of health workers in Burkina Faso. Hum
Resour Health. 2014;12 Suppl 1:S6.
51. Schneider H, English R, Tabana H, Padayachee T, Orgill M. Whole-system change: case
study of factors facilitating early implementation of a primary health care reform in a South
African province. BMC Health Serv Res. 2014;14:609.
52. Faydi E, Funk M, Kleintjes S, Ofori-Atta A, Ssbunnya J, Mwanza J, et al. An assessment
of mental health policy in Ghana, South Africa, Uganda and Zambia. Health Res Policy Syst.
2011;9:17.
53. Jenkins R, Mussa M, Haji SA, Haji MS, Salim A, Suleiman S, et al. Developing and
implementing mental health policy in Zanzibar, a low income country off the coast of East
Africa. Int J Ment Health Syst. 2011;5:6.
54. Witter S, Garshong B, Ridde V. An exploratory study of the policy process and early
implementation of the free NHIS coverage for pregnant women in Ghana. Int J Equity Health.
2013;12:16.
55. Sambo LG, Kirigia JM, Ki-Zerbo G. Health financing in Africa: overview of a dialogue
among high level policy makers. BMC Proc. 2011;5 Suppl 5:S2.
56. Jolley G, Freeman T, Baum F, Hurley C, Lawless A, Bentley M, et al. Health policy in
South Australia 2003-10: primary health care workforce perceptions of the impact of policy
change on health promotion. Health Promot J Austr. 2014;25(2):116-24.
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
57. Paul C, Kramer R, Lesser A, Mutero C, Miranda ML, Dickinson K. Identifying barriers
in the malaria control policymaking process in East Africa: insights from stakeholders and a
structured literature review. BMC Public Health. 2015;15:862.
58. Witter S, Dieng T, Mbengue D, Moreira I, De Brouwere V. The national free delivery
and caesarean policy in Senegal: evaluating process and outcomes. Health Policy Plan.
2010;25(5):384-92.
59. Ganaba R, Ilboudo PGC, Cresswell JA, Yaogo M, Diallo CO, Richard F, et al. The
obstetric care subsidy policy in Burkina Faso: what are the effects after five years of
implementation? Findings of a complex evaluation. BMC Pregnancy Childbirth. 2016;16:84.
60. Tumwesigye BT, Nakanjako D, Wanyenze R, Akol Z, Sewankambo N. Policy
development, implementation and evaluation by the AIDS control program in Uganda: a review
of the processes. Health Res Policy Syst. 2013;11(1):7.
61. Ditlopo P, Blaauw D, Rispel L, Thomas S, Bidwell P. Policy implementation and
financial incentives for nurses in South Africa: a case study on the occupation-specific
dispensation. Global Health Action. 2013;6(1).
62. Olivier de Sardan JP, Ridde V. Public policies and health systems in Sahelian Africa:
theoretical context and empirical specificity. BMC Health Serv Res. 2015;15 Suppl 3:S3.
63. Chuma J, Musimbi J, Okungu V, Goodman C, Molyneux C. Reducing user fees for
primary health care in Kenya: Policy on paper or policy in practice? Int J Equity Health.
2009;8:15.
64. Witter S, Khalid Mousa K, Abdel-Rahman ME, Hussein Al-Amin R, Saed M. Removal
of user fees for caesareans and under-fives in northern Sudan: a review of policy implementation
and effectiveness. Int J Health Plann Manage. 2013;28(1):e95-e120.
65. Naude CE, Zani B, Ongolo-Zogo P, Wiysonge CS, Dudley L, Kredo T, et al. Research
evidence and policy: qualitative study in selected provinces in South Africa and Cameroon.
Implement Sci. 2015;10:126.
66. El-Jardali F, Lavis JN, Ataya N, Jamal D. Use of health systems and policy research
evidence in the health policymaking in eastern Mediterranean countries: views and practices of
researchers. Implement Sci. 2012;7:2.
67. Rispel LC, de Sousa CA, Molomo BG. Can social inclusion policies reduce health
inequalities in sub-Saharan Africa?--A rapid policy appraisal. J Health Popul Nutr.
2009;27(4):492-504.
68. Luhalima TR, Netshandama VO, Davhana-Maselesele M. An evaluation of the
implementation of tuberculosis policies at a regional hospital in the Limpopo Province.
Curationis. 2008;31(4):31-8.
69. Kamuzora P, Gilson L. Factors influencing implementation of the Community Health
Fund in Tanzania. Health Policy Plan. 2007;22(2):95-102.
70. Colvin CJ, Leon N, Wills C, van Niekerk M, Bissell K, Naidoo P. Global-to-local policy
transfer in the introduction of new molecular tuberculosis diagnostics in South Africa. Int J
Tuberc Lung Dis. 2015;19(11):1326-38.
71. Boateng D, Awunyor-Vitor D. Health insurance in Ghana: evaluation of policy holders'
perceptions and factors influencing policy renewal in the Volta region. Int J Equity Health.
2013;12:50.
72. Eamer GG, Randall GE. Barriers to implementing WHO's exclusive breastfeeding policy
for women living with HIV in sub-Saharan Africa: an exploration of ideas, interests and
institutions. Int J Health Plann Manage. 2013;28(3):257-68.
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
73. Blas E, Ataguba JE, Huda TM, Bao GK, Rasella D, Gerecke MR. The feasibility of
measuring and monitoring social determinants of health and the relevance for policy and
programme a qualitative assessment of four countries. Global Health Action. 2016;9(1).
74. Rao KD, Nagulapalli S, Arora R, Madhavi M, Andersson E, Ingabire MG. An
Implementation Research Approach to Evaluating Health Insurance Programs: Insights from
India. Int J Health Policy Manag. 2016;5(5):295-9.
75. Bennett S, Corluka A, Doherty J, Tangcharoensathien V, Patcharanarumol W, Jesani A,
et al. Influencing policy change: the experience of health think tanks in low- and middle-income
countries. Health Policy Plan. 2012;27(3):194-203.
76. Nabyonga-Orem J, Ousman K, Estrelli Y, Rene AK, Yakouba Z, Gebrikidane M, et al.
Perspectives on health policy dialogue: definition, perceived importance and coordination. BMC
Health Serv Res. 2016;16 Suppl 4:218.
77. Nabyonga Orem J, Marchal B, Mafigiri D, Ssengooba F, Macq J, Da Silveira VC, et al.
Perspectives on the role of stakeholders in knowledge translation in health policy development in
Uganda. BMC Health Serv Res. 2013;13:324.
78. Orem JN, Mafigiri DK, Marchal B, Ssengooba F, Macq J, Criel B. Research, evidence
and policymaking: the perspectives of policy actors on improving uptake of evidence in health
policy development and implementation in Uganda. BMC Public Health. 2012;12:109.
79. Agyepong IA, Nagai RA. "We charge them; otherwise we cannot run the hospital" front
line workers, clients and health financing policy implementation gaps in Ghana. Health Policy.
2011;99(3):226-33.
80. Gomez PP, Gutman J, Roman E, Dickerson A, Andre ZH, Youll S, et al. Assessment of
the consistency of national-level policies and guidelines for malaria in pregnancy in five African
countries. Malar J. 2014;13:212.
81. Wan X, Stillman F, Liu H, Spires M, Dai Z, Tamplin S, et al. Development of policy
performance indicators to assess the implementation of protection from exposure to secondhand
smoke in China. Tob Control. 2013;22 Suppl 2:ii9-15.
82. Peterson PJ, bin Mokhtar M, Chang C, Krueger J. Indicators as a tool for the evaluation
of effective national implementation of the Globally Harmonized System of Classification and
Labelling of Chemicals (GHS). J Environ Manage. 2010;91(5):1202-8.
83. Hargreaves JR, Goodman C, Davey C, Willey BA, Avan BI, Schellenberg JR. Measuring
implementation strength: lessons from the evaluation of public health strategies in low- and
middle-income settings. Health Policy Plan. 2016;31(7):860-7.
84. Dickson KE, Tran NT, Samuelson JL, Njeuhmeli E, Cherutich P, Dick B, et al. Voluntary
medical male circumcision: a framework analysis of policy and program implementation in
eastern and southern Africa. PLoS Med. 2011;8(11):e1001133.
85. Church K, Kiweewa F, Dasgupta A, Mwangome M, Mpandaguta E, Gomez-Olive FX, et
al. A comparative analysis of national HIV policies in six African countries with generalized
epidemics. Bull World Health Organ. 2015;93(7):457-67.
86. Langlois EV, Becerril Montekio V, Young T, Song K, Alcalde-Rabanal J, Tran N.
Enhancing evidence informed policymaking in complex health systems: lessons from multi-site
collaborative approaches. Health Res Policy Syst. 2016;14:20.
87. Gelli A, Espejo F. School feeding, moving from practice to policy: reflections on
building sustainable monitoring and evaluation systems. Public Health Nutr. 2013;16(6):995-9.
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
88. Armstrong CE, Lange IL, Magoma M, Ferla C, Filippi V, Ronsmans C. Strengths and
weaknesses in the implementation of maternal and perinatal death reviews in Tanzania:
perceptions, processes and practice. Trop Med Int Health. 2014;19(9):1087-95.
89. Starkl M, Brunner N, Stenstrom TA. Why do water and sanitation systems for the poor
still fail? Policy analysis in economically advanced developing countries. Environ Sci Technol.
2013;47(12):6102-10.
90. Bowen S, Zwi AB. Pathways to "evidence-informed" policy and practice: a framework
for action. PLoS Med. 2005;2(7):e166.
91. Beran D, Miranda JJ, Cardenas MK, Bigdeli M. Health systems research for policy
change: lessons from the implementation of rapid assessment protocols for diabetes in low- and
middle-income settings. Health Res Policy Syst. 2015;13:41.
92. Erasmus E, Gilson L. How to start thinking about investigating power in the
organizational settings of policy implementation. Health Policy Plan. 2008;23(5):361-8.
93. Daniels K, Lewin S. Translating research into maternal health care policy: a qualitative
case study of the use of evidence in policies for the treatment of eclampsia and pre-eclampsia in
South Africa. Health Res Policy Syst. 2008;6:12.
94. Juma PA, Mohamed SF, Wisdom J, Kyobutungi C, Oti S. Analysis of Non-
communicable disease prevention policies in five Sub-Saharan African countries: Study
protocol. Arch Public Health. 2016;74:25.
95. Djellouli N, Quevedo-Gomez MC. Challenges to successful implementation of HIV and
AIDS-related health policies in Cartagena, Colombia. Soc Sci Med. 2015;133:36-44.
96. Witter S, Boukhalfa C, Cresswell JA, Daou Z, Filippi V, Ganaba R, et al. Cost and
impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and
Morocco. Int J Equity Health. 2016;15(1):123.
97. Cooper D, Mantell JE, Moodley J, Mall S. The HIV epidemic and sexual and
reproductive health policy integration: views of South African policymakers. BMC Public
Health. 2015;15:217.
98. Idd A, Yohana O, Maluka SO. Implementation of pro-poor exemption policy in
Tanzania: policy versus reality. Int J Health Plann Manage. 2013;28(4):e298-309.
99. Shroff Z, Aulakh B, Gilson L, Agyepong IA, El-Jardali F, Ghaffar A. Incorporating
research evidence into decision-making processes: researcher and decision-maker perceptions
from five low- and middle-income countries. Health Res Policy Syst. 2015;13:70.
100. Gilson L, McIntyre D. The interface between research and policy: experience from South
Africa. Soc Sci Med. 2008;67(5):748-59.
101. Maluka SO. Why are pro-poor exemption policies in Tanzania better implemented in
some districts than in others? Int J Equity Health. 2013;12:80.
102. Scott V, Mathews V, Gilson L. Constraints to implementing an equity-promoting staff
allocation policy: understanding mid-level managers' and nurses' perspectives affecting
implementation in South Africa. Health Policy Plan. 2012;27(2):138-46.
103. Ucakacon PS, Achan J, Kutyabami P, Odoi AR, Kalyango NJ. Prescribing practices for
malaria in a rural Ugandan hospital: evaluation of a new malaria treatment policy. Afr Health
Sci. 2011;11 Suppl 1:S53-9.
104. Twum-Danso NA, Dasoberi IN, Amenga-Etego IA, Adondiwo A, Kanyoke E, Boadu
RO, et al. Using quality improvement methods to test and scale up a new national policy on early
post-natal care in Ghana. Health Policy Plan. 2014;29(5):622-32.
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
105. Odoch WD, Kabali K, Ankunda R, Zulu JM, Tetui M. Introduction of male circumcision
for HIV prevention in Uganda: analysis of the policy process. Health Res Policy Syst.
2015;13:31.
106. Kleintjes S, Lund C, Swartz L, Flisher A, The Mhapp Research Programme C. Mental
health care user participation in mental health policy development and implementation in South
Africa. Int Rev Psychiatry. 2010;22(6):568-77.
107. Erasmus E. The use of street-level bureaucracy theory in health policy analysis in low-
and middle-income countries: a meta-ethnographic synthesis. Health Policy Plan. 2014;29 Suppl
3:iii70-8.
108. Lehmann U, Gilson L. Actor interfaces and practices of power in a community health
worker programme: a South African study of unintended policy outcomes. Health Policy Plan.
2013;28(4):358-66.
109. Cheung KK, Mirzaei M, Leeder S. Health policy analysis: a tool to evaluate in policy
documents the alignment between policy statements and intended outcomes. Aust Health Rev.
2010;34(4):405-13.
110. Hill Z, Dumbaugh M, Benton L, Källander K, Strachan D, ten Asbroek A, et al.
Supervising community health workers in low-income countries a review of impact and
implementation issues. Global Health Action. 2014;7(1).
111. Shung-King M. From 'stepchild of primary healthcare' to priority programme: lessons for
the implementation of the National Integrated School Health Policy in South Africa. S Afr Med
J. 2013;103(12):895-8.
112. Gilson L, Schneider H, Orgill M. Practice and power: a review and interpretive synthesis
focused on the exercise of discretionary power in policy implementation by front-line providers
and managers. Health Policy Plan. 2014;29 Suppl 3:iii51-69.
113. Aniteye P, Mayhew SH. Shaping legal abortion provision in Ghana: using policy theory
to understand provider-related obstacles to policy implementation. Health Res Policy Syst.
2013;11:23.
114. Waweru E, Goodman C, Kedenge S, Tsofa B, Molyneux S. Tracking implementation and
(un)intended consequences: a process evaluation of an innovative peripheral health facility
financing mechanism in Kenya. Health Policy Plan. 2016;31(2):137-47.
115. Ngoasong MZ. Transcalar networks for policy transfer and implementation: the case of
global health policies for malaria and HIV/AIDS in Cameroon. Health Policy Plan.
2011;26(1):63-72.
116. Daire J, Khalil D. Analysis of maternal and child health policies in Malawi: The
methodological perspective. Malawi Med J. 2015;27(4):135-9.
117. Panisset U, Koehlmoos TP, Alkhatib AH, Pantoja T, Singh P, Kengey-Kayondo J, et al.
Implementation research evidence uptake and use for policy-making. Health Res Policy Syst.
2012;10:20.
118. Thow AM, Sanders D, Drury E, Puoane T, Chowdhury SN, Tsolekile L, et al. Regional
trade and the nutrition transition: opportunities to strengthen NCD prevention policy in the
Southern African Development Community. Global Health Action. 2015;8(1).
119. Onwujekwe O, Uguru N, Russo G, Etiaba E, Mbachu C, Mirzoev T, et al. Role and use
of evidence in policymaking: an analysis of case studies from the health sector in Nigeria. Health
Res Policy Syst. 2015;13:46.
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
Table 1. Literature Review Methodology
Dates Searches Conducted
November 30, 2016 December 2, 2016
Databases
PubMed
Inclusion Criteria
published between 2006 and 2016; indexed on PubMed;
accessible through the Library at the authors' institution (online
or in print); available in English
Search Terms
“policy surveillance”; "policy adoption" AND (Africa OR Low
and middle income countries OR LMIC); "policy
development" AND (Africa OR Low and middle income
countries OR LMIC); "policy analysis" AND (Africa OR low
and middle income countries OR LMIC); “policy
implementation” AND (Africa OR low and middle income
country OR LMIC); “policy evaluation” AND (Africa OR low
and middle income countries OR LMIC); “policy process”
AND (Africa OR low and middle income countries OR
LMIC).
Articles responsive after
search terms
642
Secondary inclusion criteria
used for abstract screening
Abstract indicates that article addresses how and why policies
are analyzed, developed and/or adopted, including influential
actors, processes, and context.
Responsive articles after
abstract screen
190
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
Table 2. Potential Best Practices for Policy Development and Management by Stage
Policy Stage(s)
Potential Best Practices
1
Conduct robust situation analysis
1,2
Facilitate ideas and feedback from key stakeholders (e.g., providers, clients, &
researchers) to policymakers
1,2
Develop clearly defined problem statements
1,2
Provide policymakers access to resources with current evidence (e.g. eLibrary
access, access to researchers)
1,2
Conduct stakeholder analysis
2
Brainstorm possible interventions to address problem statement
2
Analyze potential interventions using expressly defined criteria (e.g. multi-criteria
decision analysis)
2,3
Develop stakeholder engagement plan to ensure input from all relevant stakeholders
(e.g., geographic, key populations, implementers)
2
Model implementation to identify potential implementation barriers
2
Model policy implementation on work load burden
2
Consider impact of staff turnover on policy implementation
2
Conduct a policy conflict analysis
2
Estimate potential change in resource needs over time
2,4
Identify sources of funding
2
Policies should be clear and areas of flexibility should be expressly acknowledged
2,5
Clearly define targets, objectives, goals and indicators
2,5
Include clear implementation targets with timelines
2,5
Establish consistent framework for M&E plans
2,5
Identify and coordinate M&E system(s)/data sources
3
Standardize definitions & adoption processes for different types of policies
3
Establish consistent requirements for who should review and who must adopt
different types of policies
4
Disseminate policies through push and pull mechanisms to all relevant stakeholders
4
Provide sufficient role-specific training on policy details
4
Educate all key stakeholders on policy components (e.g., implementers, consumers,
traditional practitioners, private sector)
4
Verify knowledge of policy details by key stakeholders
4
Empower managers to provide guidance and support to front line implementers
4
Empower frontline implementers to engage in policy development and
implementation processes
4
Designate champions/ leaders responsible for implementation at each level
4
Ensure strong financial management throughout implementation
5
Engage in regular implementation monitoring using implementation indicators
identified in monitoring plan
5
Monitor availability of inputs/supplies/drugs for Policy compliance
5
Conduct evaluation when required by policy
5
Ensure evaluation is transparent and verifiable
5,1
Use results of policy evaluation to inform policymaking processes
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
Table 3. Examples Policy Development Manuals
Table 3. Example Policy Development Manuals
Title
Year
A Practical Guide to Policy Making in Northern
Ireland
2016
A Guide to Policy Development
2003
Alberta Health Services Policy Development
Framework
2016
A Guide to Policy Development and Management
2013
National Guide for the Health Sector and Strategic
Plan Development
2014
Standard Operating Procedures of the Directorate
General of Planning and Health Information
System
2014
Policy Development Guidelines for Ministry of
Health
2014
A Manual for Policy Analysts
2002
Policy for the Development of the North West
Department of Health Policies and Standard
Operating Procedures
2017
Departmental Policy Development Framework
2012
Amathole District Municipality Policy
Development Framework
2014
Policy on Policies (Development, Writing, and
Implementation)
2013
Framework for the Development and Quarterly
Monitoring of the Annual Performance Plans
(APPs) and the Operational Plans of the National
Department of Health
2012
Figure 1
Journal Pre-proof
Journal Pre-proof
Title Page: 15 October, 2019
Highlights:
Health policy development processes are often ad hoc, potentially undermining effective
implementation
Standardizing health policy development could improve effectiveness of health programs
The literature reveals 34 potential best practices for health policy systems
Standardized policy development processes and policy information systems could
facilitate uptake of these best practices
Journal Pre-proof
Figure 1
... Several departments are working to create awareness among the people about the spreadness and high risk of Novel Virus. Beyond the health department, the living status, hygienic condition, and availability of basic prerequisites play a key role to maintain the health environment in a society (Agbo et al., 2019;Habitat for Humanity, 2017;Lane et al., 2020). The national coordination agency prepared the framework and mechanism for the development of coordination about financial and policy activities among all stakeholders. ...
... In real life, the consistency for improving the policy options is required by the regular communication and coordination between all stakeholders to increase the net benefits for society (Lane et al., 2020;Sen, 1999). The critical evaluation of trade-off between consistent improvement and net-social benefits is required and found in the best possible way. ...
... Additionally, the private sector does not consider the local and social effects of their decisions and services, their private interests must be fulfilled whether the social interests are achieved or not (Lane et al., 2020;WDR, 2019). Thus, the variability in social and private interest often generates the optimum social benefits such as community health and transportation, good hygienic condition, safe and secure working and living place, appropriate educational infrastructure, and innovative research may produce broad social positive externalities. ...
Article
Full-text available
COVID-19 has big health issues which affect worldwide beyond their borders, race, and ethnicity. All the countries faced this pandemic challenge but most of the underdeveloped countries are facing more dangerous situations due to limited financial and health infrastructure to respond against it. Overall, more than 100 million people are affected by the Novel Virus which results in 2.15 million people dying within a small interval of time. The current pandemic has brought unpredicted challenges to societies and also threatened humanity and global resilience. According to the National Command Operation Center, Pakistan, more than 0.534 million people are suffering with COVID-19 with more than 11 thousand deaths across the country. The Government of Pakistan has taken different initiatives like complete and smart lockdown to control the pandemic as much as possible. After the removal of the first lockdown, the high peak was observed across the country and created a panic situation among people and the government again closed all the educational and religious institutions with immediate effect to tackle the second wave of pandemic. Further, the interconnected nature of COVID-19 crises demands an integrated approach and coordination between all stakeholders to handle the pandemic in a significant way. Identifying the best set of policies and guidelines to handle COVID-19 challenges, and align them for the sustainable recovery from pandemic. The basic challenge facing the policy makers of underdeveloped countries is how to utilize limited resources to achieve interconnected goals for managing health recovery, economic crises, and creating environmental sustainability. We present a framework for identifying and prioritizing policy action to address COVID-19 and ensure sustainable recovery. The framework outlines principles and criteria, and shared policy goals, identifying smart strategies, accessing policy compatibility, aligning policy instruments and improving sustainability in short and long term policy decisions. This framework can be helpful for policy makers in the short and long run for mapping policy options and accessing cross-sectoral implementation. This framework is also helpful for policy makers to prioritize policy choice and allocate limited resources in such a way that they are directed toward actions and achieve interconnected solutions of health, economy, and environment.
... This study's findings highlight that policy-making for vivax malaria and likely for other anti-malarial guidelines is characterized by under documentation and complex and often time-consuming processes. In the medium to longer term, better integration of policymaking processes for malaria into the overall national health policy-making processes (assuming those exist) would potentially strengthen overall health governance and would address the limited connection between the NMP and the MOH in the policy-making process [76]. Thereby ensuring any guidance provided to NMPs to facilitate their decision and policy-making processes is institutionalized within the MoH and aligns with its overarching guidance on policy-making and national health strategies [77,78]. ...
Article
Full-text available
Background The changing global health landscape has highlighted the need for more proactive, efficient and transparent health policy-making. After more than 60 years of limited development, novel tools for vivax malaria are finally available, but need to be integrated into national policies. This paper maps the malaria policy-making processes in seven endemic countries, to identify areas where it can be improved to align with best practices and optimal efficiency. Methods Data were collected during a workshop, convened by the Asia Pacific Malaria Elimination Network’s Vivax Working Group in 2019, and subsequent interviews with key stakeholders from Cambodia, Ethiopia, Indonesia, Pakistan, Papua New Guinea (PNG), Sri Lanka and Vietnam. Documentation of policy processes provided by respondents was reviewed. Data analysis was guided by an analytic framework focused on three a priori defined domains: “context,” “actors” and “processes”. Results The context of policy-making varied with available funding for malaria, population size, socio-economic status, and governance systems. There was limited documentation of the process itself or terms of reference for involved actors. In all countries, the NMP plays a critical role in initiating and informing policy change, but the involvement of other actors varied considerably. Available evidence was described as a key influencer of policy change; however, the importance of local evidence and the World Health Organization’s endorsement of new treatments and diagnostics varied. The policy process itself and its complexity varied but was mostly semi-siloed from other disease specific policy processes in the wider Ministry of Health. Time taken to change and introduce a new policy guideline previously varied from 3 months to 3 years. Conclusions In the medium to long term, a better alignment of anti-malarial policy-making processes with the overall health policy-making would strengthen health governance. In the immediate term, shortening the timelines for policy change will be pivotal to meet proposed malaria elimination milestones.
... Therefore, improvement in accessibility is considered a vital factor to achieve equity in the access to healthcare at both the local and regional levels toward achieving the SDGs [5]. However, identifying and measuring access to healthcare are quite challenging and complex; therefore, when developing a health policy, many nations still face a major challenge in delivering healthcare services in terms of enhancing accessibility [6][7][8][9][10]. ...
Article
Full-text available
Reducing the disparities in healthcare access is one of the important goals in healthcare services and is significant for national health. However, measuring the complexity of access in truly underserved areas is the critical step in designing and implementing healthcare policy to improve those services and to provide additional support. Even though there are methods and tools for modeling healthcare accessibility, the context of data is challenging to interpret at the local level for targeted program implementation due to its complexity. Therefore, the purpose of this study is to develop a concise and context-specific methodology for assessing disparities for a remote province in Thailand to assist in the development and expansion of the efficient use of additional mobile health clinics. We applied the geographic information system (GIS) methodology with the travel time-based approach to visualize and analyze the concealed information of spatial data in the finer analysis resolution of the study area, which was located in the border region of the country, Ubon Ratchathani, to identify the regional differences in healthcare allocation. Our results highlight the significantly inadequate level of accessibility to healthcare services in the regions. We found that over 253,000 of the population lived more than half an hour away from a hospital. Moreover, the relationships of the vulnerable residents and underserved regions across the province are underlined in the study and substantially discussed in terms of expansion of mobile health delivery to embrace the barrier of travel duration to reach healthcare facilities. Accordingly, this research study addresses regional disparities and provides valuable references for governmental authorities and health planners in healthcare strategy design and intervention to minimize the inequalities in healthcare services.
... 2,3 Many of the remaining 5 billion of the world's population without safe and affordable surgical and anesthesia care live in low and middle-income countries, of which South Africa is an example. [4][5][6][7] There is a severe shortage of anesthesia providers in African countries, with only an average of 1.36 physician anesthesia providers per 100,000 population in Africa. 4,3 South Africa has 16.18 physician anesthesia providers per 100,000 population, which is one of the highest densities in Africa. ...
Article
Full-text available
Purpose: The purpose of this article is to propose a definition for the concept "scope of practice" as it applies to a nurse anesthetist in South Africa. Design: Concept analysis. Methods: Walker and Avant's procedure of concept analysis was followed. The actions included "Select a concept"; "Determine the purpose of analysis"; "Identifying uses of the concept"; "Determining the defining attributes"; "Identifying antecedents and consequences"; "Define empirical referents"; "Identify model case"; and "Identifying additional cases." Findings: The concept 'scope of practice' as it applies to the nurse anesthetist in South Africa can be defined as the individual's competence, accountability, and responsibility as a health professional. The nurse anesthetist is (1) competent: ready to use skills and judgement in practice; (2) accountable: able to be registered as a nurse anesthetist and willing to abide by the regulations; and (3) responsible: upholding professionalism and demanding recognition from the public and peers. Conclusions: A definition (revealing the concept's structure) and it's uses (revealing the concept's function) for "scope of practice" of a South African nurse anesthetist is proposed for the consideration of introducing nurse anesthesia to provide safe and affordable anesthesia services in South Africa. This article forms part of a larger study titled "A Model for Nurse Anaesthesia Practice in South Africa."
... It differs from non-urban policies, such as rural policies, regional policies or national policies, which simply indicate their respective regional dimensions and ignore their own content. Urban development policies are also different from those that indicate their specific content, health policies (Lane et al., 2020), environmental policies, etc., because they are specific but do not indicate the limits of responsibility of authorities at all levels (e.g., national, regional or local authorities) (Mandic et al., 2020). Urban development policies, on the other than possible, clearly state their content and the scope of the authorities, involving cities and authorities at all levels, and are therefore measures taken by the entire government agency (Bai et al., 2010). ...
Article
Full-text available
This study mainly investigates the problems of public management from the two interdisciplinary approaches of regional economic development policy and urban development policy. A qualitative desk review approach has been adopted to contribute the debate and reach the objectives of the study. This study reveals that there is an integral relationship among regional economic development policy, urban development policy and public policy. It also introduces the main essence of regional economic development policy, the analysis of the research difficulties and causes, expounds the relationship and enlightenment between regional economic development policy research perspectives, approach and research methods of public management. It also highlights the relationship and enlightenment between the way and research method and the theory and practice of public management. This paper also analyzes the main similarity and differences between regional economic development policy and urban development policy and forward recommendations based on the findings.
... Further, the interconnected nature of the crisis demands an integrated approach and coordinated action, which complicates decision making even more (14,15). The key practical challenge facing the policy makers of developing countries is how to prioritize policies to achieve interconnected goals of achieving health and well-being (9,16). A clear framework will be needed to ensure effective policy development and prioritization in planning and management of their response. ...
Article
Full-text available
The COVID-19 pandemic has brought unprecedented challenges to societies and threatened humanity and global resilience. All countries are challenged, but low-income and developing countries are facing a more challenging situation than others due to their limited health infrastructure, limited financial and human resources, and limited capacity of governments to respond. Further, the interconnected nature of the COVID-19 pandemic crisis demands an integrated approach and coordinated action, which complicates decision making even more. Identifying the best set of policies and instruments to address COVID-19 challenges, and aligning them with broader social goals will be critically important for sustainable recovery from the pandemic. The key practical challenge facing the policy makers of developing countries is how to prioritize policies to achieve the interconnected goals of managing the health crisis, recovering the economy, and achieving environmental sustainability. We present a framework for identifying and prioritizing policy actions to address the COVID-19 challenges and ensure sustainable recovery. The framework outlines principles and criteria and provides insights into developing shared policy goals, identifying smart strategies, assessing policy compatibility, aligning policy instruments, and factoring sustainability into short and long-term policy decisions. This framework can assist policy makers in linking short and long-term goals, mapping the interactions of different policy options, and assessing anticipated consequences and cross-sectoral implications. This will enable policy makers to prioritize policy choices and allocate limited resources in such a way that they are directed toward actions that generate synergy and co-benefits, have multiplier effects, and achieve interconnected solutions for health, the economy and environment.
Article
Stroke can be prevented through effective management of risk factors. However, current primary stroke prevention approaches are insufficient and often fragmented. Primary stroke prevention strategies are predominantly targeted at behavioural (eg, smoking cessation and lifestyle modifications) and pharmacological interventions (ie, prevention medications). There is also a need to consider interrelating structural factors that support, or hinder, prevention actions and behaviours of individuals. Without addressing these structural factors, it is impossible to maximise the benefits of behavioural and pharmacological interventions at the population level. We propose a tripartite approach to primary stroke prevention, comprising behavioural, pharmacological, and structural interventions, which is superimposed on the socioecological model. This approach could minimise the current fragmentation and inefficiency of primary stroke prevention.
Article
Full-text available
Background: Despite universal population coverage and equity being a stated policy goal of its NHIS, over a decade since passage of the first law in 2003, Ghana continues to struggle with how to attain it. The predominantly (about 70 %) tax funded NHIS currently has active enrolment hovering around 40 % of the population. This study explored in-depth enablers and barriers to enrolment in the NHIS to provide lessons and insights for Ghana and other low and middle income countries (LMIC) into attaining the goal of universality in Universal Health Coverage (UHC). Methods: We conducted a cross sectional mixed methods study of an urban and a rural district in one region of Southern Ghana. Data came from document review, analysis of routine data on enrolment, key informant in-depth interviews with local government, regional and district insurance scheme and provider staff and community member in-depth interviews and focus group discussions. Results: Population coverage in the NHIS in the study districts was not growing towards near universal because of failure of many of those who had ever enrolled to regularly renew annually as required by the NHIS policy. Factors facilitating and enabling enrolment were driven by the design details of the scheme that emanate from national level policy and program formulation, frontline purchaser and provider staff implementation arrangements and contextual factors. The factors inter-related and worked together to affect client experience of the scheme, which were not always the same as the declared policy intent. This then also affected the decision to enrol and stay enrolled. Conclusions: UHC policy and program design needs to be such that enrolment is effectively compulsory in practice. It also requires careful attention and responsiveness to actual and potential subscriber, purchaser and provider (stakeholder) incentives and related behaviour generated at implementation levels.
Article
Full-text available
Background Across the Africa region and beyond, the last decade has seen many countries introducing policies aimed at reducing financial barriers to obstetric care. This article provides evidence of the cost and effects of national policies focussed on improving financial access to caesarean and facility deliveries in Benin, Burkina Faso, Mali and Morocco. Methods The study uses a comparative case study design with mixed methods, including realist evaluation components. This article presents results across 14 different data collection tools, used in 4–6 research sites in each of the four study countries over 2011-13. The methods included: document review; interviews with key informants; analysis of secondary data; structured extraction from medical files; cross-sectional surveys of patients and staff; interviews with patients and observation of care processes. Results The article finds that the policies have contributed to continued increases in skilled birth attendance and caesarean sections and a narrowing of inequalities in all four countries, but these trends were already occurring so a shift cannot be attributed solely to the policies. It finds a significant reduction in financial burdens on households after the policy, suggesting that the financial protection objectives may have been met, at least in the short term, although none achieved total exemption of targeted costs. Policies are domestically financed and are potentially sustainable and efficient, and were relatively thoroughly implemented. Further, we find no evidence of negative effects on technical quality of care, or of unintended negative effects on untargeted services. Conclusions We conclude that the policies were effective in meeting financial protection goals and probably health and equity goals, at sustainable cost, but that a range of measures could increase their effectiveness and equity. These include broadening the exempted package (especially for those countries which focused on caesarean sections alone), better calibrated payments, clearer information on policies, better stewardship of the local health system to deal with underlying systemic weaknesses, more robust implementation of exemptions for indigents, and paying more attention to quality of care, especially for newborns.
Article
Full-text available
Background Countries in the World Health Organization African Region have witnessed an increase in global health initiatives in the recent past. Although these have provided opportunities for expanding coverage of health interventions; their poor alignment with the countries’ priorities and weak coordination, are among the challenges that have affected their impact. A well-coordinated health policy dialogue provides an opportunity to address these challenges, but calls for common understanding among stakeholders of what policy dialogue entails. This paper seeks to assess stakeholders’ understanding and perceived importance of health policy dialogue and of policy dialogue coordination. Methods This was a cross-sectional descriptive study using qualitative methods. Interviews were conducted with 90 key informants from the national and sub-national levels in Lusophone Cabo Verde, Francophone Chad, Guinea and Togo, and Anglophone Liberia using an open-ended interview guide. The interviews were transcribed verbatim, coded and then put through inductive thematic content analysis using QRS software Version 10. Results There were variations in the definition of policy dialogue that were not necessarily linked to the linguistic leaning of respondents’ countries or whether the dialogue took place at the national or sub-national level. The definitions were grouped into five categories based on whether they had an outcome, operational, process, forum or platform, or interactive and evidence-sharing orientation. The stakeholders highlighted multiple benefits of policy dialogue including ensuring stakeholder participation, improving stakeholder harmonisation and alignment, supporting implementation of health policies, fostering continued institutional learning, providing a guiding framework and facilitating stakeholder analysis. Conclusion Policy dialogue offers the opportunity to improve stakeholder participation in policy development and promote aid effectiveness. However, conceptual clarity is needed to ensure pursuance of common objectives. While it is clear that stakeholder involvement is an important component of policy dialogue, numbers must be manageable for meaningful dialogue. Ownership and coordination of the policy dialogue are important aspects of the process, and building the institutional capacity of the ministry of health requires a comprehensive approach as opposed to strengthening selected departments within it. Likewise, capacity for policy dialogue needs to be built at the sub-national level, alongside improving the bottom-up approach in policy processes.
Article
Full-text available
Background: The unregulated availability and irrational use of tuberculosis (TB) medicines is a major issue of public health concern globally. Governments of many low- and middle-income countries (LMICs) have committed to regulating the quality and availability of TB medicines, but with variable success. Regulation of TB medicines remains an intractable challenge in many settings, but the reasons for this are poorly understood. The objective of this paper is to elaborate processes of regulation of quality and availability of TB medicines in three LMICs - India, Tanzania, and Zambia - and to understand the factors that constrain and enable these processes. Methods: We adopted the action-centred approach of policy implementation analysis that draws on the experiences of relevant policy and health system actors in order to understand regulatory processes. We drew on data from three case studies commissioned by the World Health Organization (WHO), on the regulation of TB medicines in India, Tanzania, and Zambia. Qualitative research methods were used, including in-depth interviews with 89 policy and health system actors and document review. Data were organized thematically into accounts of regulators' authority and capacity; extent of policy implementation; and efficiency, transparency, and accountability. Results: In India, findings included the absence of a comprehensive policy framework for regulation of TB medicines, constraints of authority and capacity of regulators, and poor implementation of prescribing and dispensing norms in the majority private sector. Tanzania had a policy that restricted import, prescribing and dispensing of TB medicines to government operators. Zambia procured and dispensed TB medicines mainly through government services, albeit in the absence of a single policy for restriction of medicines. Three cross-cutting factors emerged as crucially influencing regulatory processes - political and stakeholder support for regulation, technical and human resource capacity of regulatory bodies, and the manner of private actors' influence on regulatory policy and implementation. Conclusion: Strengthening regulation to ensure the quality and availability of TB medicines in LMIC with emerging private markets may necessitate financial and technical inputs to upgrade regulatory bodies, as well as broader political and ethical actions to reorient and transform their current roles.
Article
Full-text available
Background The burden of non-communicable diseases (NCDs) and their risk factors is increasing in sub-Saharan Africa, and there have been calls for adopting a multi-sectoral approach in developing policies and programs to address this burden. Evidence exists largely from high-income countries on the success (and lack thereof) of multi-sectoral approach in improving population level health outcomes. In sub-Saharan Africa, there is limited research on the application and success of multi-sectoral approach in the formulation and implementation of policies aimed at prevention of non-communicable diseases. Therefore, this protocol describes a study that aims to primarily generate evidence on the extent to which multi-sectoral approach has been applied in developing policies to prevent non-communicable disease in six countries in sub-Saharan Africa –Kenya, Malawi, Nigeria, Cameroon, Togo and South Africa. Methods/Design The study applies a multiple case study design. Data will be collated mainly through document reviews and key informant interviews with the relevant decision makers in various sectors. In each country, a detailed case study analysis will be undertaken of any policy/policies developed, adopted and implemented, aimed at implementing the World Health Organization recommended “best buys” for non-communicable disease prevention. These case studies will be conducted by research teams in each country; each team includes a senior research fellow supported by a doctoral student, and research assistants. Discussion Uptake of the evidence generated from the case studies will be ensured by systematic engagement with policy makers in each country throughout the research process. Ultimately, a forum of experts will be convened to generate actionable recommendations on the use of multi-sectoral approach in non-communicable disease prevention policies in the region.
Article
Full-text available
Burkina Faso, like many low and middle income countries, has been taking a range of actions to address its poor maternal and neonatal health indicators. In 2006 the government introduced an innovative national subsidy scheme for deliveries and emergency obstetric care in public facilities. This article reports on a complex evaluation of this policy, carried out 5 years after its introduction, which examined its effects on utilisation, quality of care, equity and the health system as a whole, as well as its cost and sustainability. The evaluation was carried out in six purposively selected districts, as well as at national level, using a case study approach. Data sources included: national and district routine and survey data, household interviews with women who had recently given birth, data extraction from hospital and medical records, and key informant and health worker interviews. The underlying secular trend of a 1 % annual increase in the facility-based delivery rate (1988-2010) was augmented by an additional 4 % annual increase from 2007 onwards (after the policy was introduced), especially in rural areas and amongst women from poor households. The absence of baseline quality of care data made it difficult to assess the impact of the policy on quality of care, but hospitals with the best level of implementation of the subsidy offered higher quality of care (as measured by health care near-misses), so there is no evidence of a negative impact on quality (as is often feared). Similarly, there is little evidence of unintended negative effects on untargeted services. Household payments for facility-based deliveries have reduced significantly, compared with payments before the policy, and the policy as a whole is affordable, costing about 2 % of total public health expenditure. Concerns include that the amounts paid by households are higher than the rates set by the policy, and also that 7 % of households still say that they cannot afford to pay. Wealthier women have higher utilisation of services, as before, and the policy of fully exempting indigents is not being put into practice. These findings highlight the importance of maintaining the subsidy policy, given the evidence of positive outcomes, but they also point out areas where attention is needed to ensure the poor and most vulnerable population benefit fully from the policy.
Article
Full-text available
One of the distinguishing features of implementation research is the importance given to involve implementers in all aspects of research, and as users of research. We report on a recent implementation research effort in India, in which researchers worked together with program implementers from one of the longest serving government funded insurance schemes in India, the Rajiv Aarogyasri Scheme (RAS) in the state of undivided Andhra Pradesh, that covers around 70 million people. This paper aims to both inform on the process of the collaborative research, as well as, how the nature of questions that emerged out of the collaborative exercise differed in scope from those typically asked of insurance program evaluations. Starting in 2012, and over the course of a year, staff from the Aarogyasri Health Care Trust (AHCT), and researchers held a series of meetings to identify research questions that could serve as a guide for an evaluation of the RAS. The research questions were derived from the application of a Logical Framework Approach ("log frame") to the RAS. The types of questions that emerged from this collaborative effort were compared with those seen in the published literature on evaluations of insurance programs in low- and middle-income countries (LMICs). In the published literature, 60% of the questions pertained to output/outcome of the program and the remaining 40%, relate to processes and inputs. In contrast, questions generated from the RAS participatory research process between implementers and researchers had a remarkably different distribution - 81% of questions looked at program input/processes, and 19% on outputs and outcomes. An implementation research approach can lead to a substantively different emphasis of research questions. While there are several challenges in collaborative research between implementers and researchers, an implementation research approach can lead to incorporating tacit knowledge of program implementers into the research process, research questions that are more relevant to the research needs of policy-makers, and greater knowledge translation of the research findings.
Article
The exchange and use of health information can help healthcare professionals and policymakers make informed decisions on ways of improving patient and population health. Many low- and middle-income countries (LMICs) have however failed to embrace the approaches and technologies to facilitate health information exchange (HIE). We sought to understand the barriers and facilitators to the implementation and adoption of HIE in LMICs. Two reviewers independently searched 11 academic databases for published and on-going qualitative, quantitative and mixed-method studies and searched for unpublished work through the Google search engine. The searches covered the period from January 1990 to July 2014 and were not restricted by language. Eligible studies were independently, critically appraised and then thematically analysed. The searches yielded 5461 citations after de-duplication of results. Of these, 56 articles, three conference abstracts and four technical reports met the inclusion criteria. The lack of importance given to data in decision making, corruption and insecurity, lack of training and poor infrastructure were considered to be major challenges to implementing HIE, but strong leadership and clear policy direction coupled with the financial support to acquire essential technology, improve the communication network, and provide training for staff all helped to promote implementation. The body of work also highlighted how implementers of HIE needed to take into account local needs to ensure that stakeholders saw HIE as relevant and advantageous. HIE interventions implemented through leapfrog technologies such as telehealth/telemedicine and mHealth in Brazil, Kenya, and South Africa, provided successful examples of exchanging health information in LMICs despite limited resources and capability. It is important that implementation of HIE is aligned with national priorities and local needs.