Introduction to the Special Issue on “Analysing the Politics of Health Policy Change in Low- and Middle-Income Countries: The HPA Fellowship Programme 2017-2019”
Lucy
Gilson
Health Policy and Systems Division, School of Public Health and Family
Medicine, University of Cape Town, Cape Town, South Africa
author
Zubin Cyrus
Shroff
The Alliance for Health Policy and Systems Research,
World Health Organization, Geneva, Switzerland
author
Maylene
Shung-King
Health Policy and Systems Division, School of Public Health and Family
Medicine, University of Cape Town, Cape Town, South Africa
author
text
article
2021
eng
This special issue presents a set of seven Health Policy Analysis (HPA) papers that offer new perspectives on health policy decision-making and implementation. They present primary empirical work from four countries in Asia and Africa, as well as reviews of literature about a wider range of low- and middle-income country (LMIC) experience.
International Journal of Health Policy and Management
Kerman University of Medical Sciences
2322-5939
10
v.
Special Issue on Analysing the Politics of Health Policy Change in LMICs
no.
2021
360
363
https://www.ijhpm.com/article_4039_b4f5fbc966cc4233e5b064c66ede0c4f.pdf
dx.doi.org/10.34172/ijhpm.2021.43
Policy Adoption and the Implementation Woes of the Intersectoral First 1000 Days of Childhood Initiative, In the Western Cape Province of South Africa
Ida
Okeyo
Department of Community and Health Sciences, School of Public Health,
University of the Western Cape, Cape Town, South Africa
author
Uta
Lehmann
Department of Community and Health Sciences, School of Public Health,
University of the Western Cape, Cape Town, South Africa
author
Helen
Schneider
UWC/SAMRC
Health Services to Systems Research Unit, School of Public Health, University
of the Western Cape, Cape Town, South Africa
author
text
article
2021
eng
BackgroundThere is a growing interest in implementing intersectoral approaches to address social determinants especially within the Sustainable Development Goals (SDGs) era. However, there is limited research that uses policy analysis approaches to understand the barriers to adoption and implementation of intersectoral approaches. In this paper we apply a policy analysis lens in examining implementation of the first thousand days (FTD) of childhood initiative in the Western Cape province of South Africa. This initiative aims to improve child outcomes through a holistic intersectoral approach, referred to as nurturing care. MethodsThe case of the FTD initiative was constructed through a triangulated analysis of document reviews (34), in depth interviews (22) and observations. The analysis drew on Hall’s ‘ideas, interests and institutions’ framework to understand the shift from political agendas to the implementation of the FTD. ResultsIn the Western Cape province, the FTD agenda setting process was catalysed by the increasing global evidence on the life-long impacts of brain development during the early childhood years. This created a window of opportunity for active lobbying by policy entrepreneurs and a favourable provincial context for a holistic focus on children. However, during implementation, the intersectoral goal of the FTD got lost, with limited bureaucratic support from service-delivery actors and minimal cross-sector involvement. Challenges facing the health sector, such as overburdened facilities, competing policies and the limited consideration of implementation realities (such as health providers’ capacity), were perceived by implementing actors as the key constraints to intersectoral action. As a result, FTD actors, whose decision-making power largely resided in health services, reformulated FTD as a traditional maternal-child health mandate. Ambiguity and contestation between key actors regarding FTD interventions contributed to this narrowing of focus. ConclusionThis study highlights conditions that should be considered for the effective implementation of intersectoral action - including engaging cross-sector players in agenda setting processes and creating spaces that allow the consideration of actors’ interests especially those at service-delivery level. Networks that prioritise relationship building and trust can be valuable in allowing the emergence of common goals that further embrace collective interests.
International Journal of Health Policy and Management
Kerman University of Medical Sciences
2322-5939
10
v.
Special Issue on Analysing the Politics of Health Policy Change in LMICs
no.
2021
364
375
https://www.ijhpm.com/article_3912_6239a2bf623451aa935b220d72726e33.pdf
dx.doi.org/10.34172/ijhpm.2020.173
Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats
Sudha
Ramani
School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai,
India
author
Lucy
Gilson
Division of Health Policy and Systems, University of Cape Town, Cape
Town, South Africa
author
Muthusamy
Sivakami
Center for Health and
Social Sciences, School of Health Systems Studies, Tata Institute of Social
Sciences, Mumbai, India
author
Nilesh
Gawde
School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai,
India
author
text
article
2021
eng
BackgroundIn this study, we use the case of medical doctors in the public health system in rural India to illustrate the nuances of how and why gaps in policy implementation occur at the frontline. Drawing on Lipsky’s Street Level Bureaucracy (SLB) theory, we consider doctors not as mechanical implementors of policies, but as having agency to implement modified policies that are better suited to their contexts. MethodsWe collected data from primary care doctors who worked in the public health system in rural Maharashtra, India between April and September 2018 (including 21 facility visits, 29 in depth interviews and several informal discussions). We first sorted the data inductively into themes. Then we used the SLB theoretical framework to categorise and visualise relationships between the extracted themes and deepen the analysis. ResultsDoctors reported facing several constraints in the implementation of primary care- including the lack of resources, the top-down imposition of programs that were not meaningful to them, limited support from the organization to improve processes as well as professional disinterest in their assigned roles. In response to these constraints, many doctors ‘routinized’ care, and became resigned and risk-averse. Most doctors felt a deep loss of professional identity, and accepted this loss as an inevitable part of a public sector job. Such attitudes and behaviours were not conducive to the delivery of good primary care. ConclusionThis study adds to empirical literature on doctors as Street Level Bureaucrats in lower and middle income countries. Doctors from these settings have often been blamed for not living up to their professional standards and implementing policies with rigour. This study highlights that doctors’ behaviours in these settings are ways through which they ‘cope’ with their loss of professional identity and organizational constraints; and highlights the need for appropriate interventions to counter their weak motivation.
International Journal of Health Policy and Management
Kerman University of Medical Sciences
2322-5939
10
v.
Special Issue on Analysing the Politics of Health Policy Change in LMICs
no.
2021
376
387
https://www.ijhpm.com/article_3942_8fbeebac93696212afcd432c2d352c29.pdf
dx.doi.org/10.34172/ijhpm.2020.206
“The Actor Is Policy”: Application of Elite Theory to Explore Actors’ Interests and Power Underlying Maternal Health Policies in Uganda, 2000-2015
Moses
Mukuru
Department of Health Policy, Planning and Management, School of Public
Health, College of Health Sciences, Makerere University, Kampala, Uganda
author
Suzanne N.
Kiwanuka
Department of Health Policy, Planning and Management, School of Public
Health, College of Health Sciences, Makerere University, Kampala, Uganda
author
Lucy
Gilson
Health Policy and Systems Division, School of Public Health and Family
Medicine, University of Cape Town, Cape Town, South Africa
author
Maylene
Shung-King
Health Policy and Systems Division, School of Public Health and Family
Medicine, University of Cape Town, Cape Town, South Africa
author
Freddie
Ssengooba
Department of Health Policy, Planning and Management, School of Public
Health, College of Health Sciences, Makerere University, Kampala, Uganda
author
text
article
2021
eng
BackgroundThe persistence of high maternal mortality and consistent failure in low- and middle-income countries to achieve global targets such as Millennium Development Goal five (MDG 5) is usually explained from epidemiological, interventional and health systems perspectives. The role of policy elites and their interests remains inadequately explored in this debate. This study examined elites and how their interests drove maternal health policies and actions in ways that could explain policy failure for MDG 5 in Uganda. MethodsWe conducted a retrospective qualitative study of Uganda’s maternal health policies from 2000 to 2015 (MDG period). Thirty key informant interviews and 2 focus group discussions (FGDs) were conducted with national policy-makers, who directly participated in the formulation of Uganda’s maternal health policies during the MDG period. We reviewed 9 National Maternal Health Policy documents. Data were analysed inductively using elite theory. ResultsMaternal health policies were mainly driven by a small elite group comprised of Senior Ministry of Health (MoH) officials, some members of cabinet and health development partners (HDPs) who wielded more power than other actors. The resulting policies often appeared to be skewed towards elites’ personal political and economic interests, rather than maternal mortality reduction. For a few, however, interests aligned with reducing maternal mortality. Since complying with the government policy-making processes would have exposed elites’ personal interests, they mainly drafted policies as service standards and programme documents to bypass the formal policy process. ConclusionUganda’s maternal health policies were mainly influenced by the elites’ personal interests rather than by the goal of reducing maternal mortality. This was enabled by the formal guidance for policy-making which gives elites control over the policy process. Accelerating maternal mortality reduction will require re-engineering the policy process to prevent public officials from infusing policies with their interests, and enable percolation of ideas from the public and frontline.
International Journal of Health Policy and Management
Kerman University of Medical Sciences
2322-5939
10
v.
Special Issue on Analysing the Politics of Health Policy Change in LMICs
no.
2021
388
401
https://www.ijhpm.com/article_3966_6281a5910b5d1d02ad6b19058ab02de8.pdf
dx.doi.org/10.34172/ijhpm.2020.230
The Practice of Power by Regional Managers in the Implementation of an Indigenous Peoples Health Policy in the Philippines
Ryan C.
Guinaran
Department of Extension Education, College of Agriculture, Benguet State
University, Benguet, Philippines
author
Erlinda B.
Alupias
Department of Extension Education, College of Agriculture, Benguet State
University, Benguet, Philippines
author
Lucy
Gilson
HPS Division, University of Cape Town, Cape
Town, South Africa
author
text
article
2021
eng
BackgroundIndigenous peoples are among the most marginalized groups in society. In the Philippines, a new policy aimed at ensuring equity and culture-sensitivity of health services for this population was introduced. The study aimed to determine how subnational health managers exercised power and with what consequences for how implementation unfolded. Power is manifested in the perception, decision and action of health system actors. The study also delved into the sources of power that health managers drew on and their reasons for exercising power. MethodsThe study was a qualitative case study employing in-depth semi-structured interviews with 26 health managers from the case region and analysis of 15 relevant documents. Data from both sources were thematically analyzed following the framework method. In the analysis and interpretation of data on power, VeneKlasen and Miller’s categorization of the sources and expressions of power and Gilson, Schneider and Orgill’s categorization of the sources and reasons for exercising power were utilized. ResultsKey managers in the case region perceived the implementation of the new Indigenous health policy as limited and weakly integrated into health operations. The forms of power exercised by actors in key administrative interfaces were greatly influenced by organizational context and perceived weak leadership and their practices of power hindered policy implementation. However, some positive experiences showed that personal commitment and motivation rooted in one’s indigeneity enabled program managers to mobilize their discretionary power to support policy implementation. ConclusionThe way power is exercised by policy actors at key interfaces influences the implementation and uptake of the Indigenous policy by the health system. Middle managers are strategic actors in translating central directions to operational action down to frontlines. Indigenous program managers are most likely to support an Indigenous health policy but personal and organizational factors can also override this inclination.
International Journal of Health Policy and Management
Kerman University of Medical Sciences
2322-5939
10
v.
Special Issue on Analysing the Politics of Health Policy Change in LMICs
no.
2021
402
413
https://www.ijhpm.com/article_3983_1b2b4dab67acdeb2de13308a73bb5d5d.pdf
dx.doi.org/10.34172/ijhpm.2020.246
Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis
Eleanor Beth
Whyle
Health Policy and Systems Division, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town,
South Africa
author
Jill
Olivier
Health Policy and Systems Division, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town,
South Africa
author
text
article
2021
eng
BackgroundHealth systems are complex social systems, and values constitute a central dimension of their complexity. Values are commonly understood as key drivers of health system change, operating across all health systems components and functions. Moreover, health systems are understood to influence and generate social values, presenting an opportunity to harness health systems to build stronger, more cohesive societies. However, there is little investigation (theoretical, conceptual, or empirical) on social values in health policy and systems research (HPSR), particularly regarding the capacity of health systems to influence and generate social values. This study develops an explanatory theory for the ‘social value of health systems.’ MethodsWe present the results of an interpretive synthesis of HPSR literature on social values, drawing on a qualitative systematic review, focusing on claims about the relationship between ‘health systems’ and ‘social values.’ We combined relational claims extracted from the literature under a common framework in order to generate new explanatory theory. ResultsWe identify four mechanisms by which health systems are considered to contribute social value to society: Health systems can: (1) offer a unifying national ideal and build social cohesion, (2) influence and legitimise popular attitudes about rights and entitlements with regard to healthcare and inform citizen’s understanding of state responsibilities, (3) strengthen trust in the state and legitimise state authority, and (4) communicate the extent to which the state values various population groups. ConclusionWe conclude that, using a systems-thinking and complex adaptive systems perspective, the above mechanisms can be explained as emergent properties of the dynamic network of values-based connections operating within health systems. We also demonstrate that this theory accounts for how HPSR authors write about the relationship between health systems and social values. Finally, we offer lessons for researchers and policy-makers seeking to bring about values-based change in health systems.
International Journal of Health Policy and Management
Kerman University of Medical Sciences
2322-5939
10
v.
Special Issue on Analysing the Politics of Health Policy Change in LMICs
no.
2021
414
429
https://www.ijhpm.com/article_3902_4ab0a5789566e2b308d75e8225b37d46.pdf
dx.doi.org/10.34172/ijhpm.2020.159
Application of “Actor Interface Analysis” to Examine Practices of Power in Health Policy Implementation: An Interpretive Synthesis and Guiding Steps
Rakesh
Parashar
School of Health System Studies, Tata Institute of Social Sciences, Mumbai,
India
author
Nilesh
Gawde
School of Health System Studies, Tata Institute of Social Sciences, Mumbai,
India
author
Lucy
Gilson
School of Public
Health and Family Medicine, University of Cape Town, Cape Town, South Africa
author
text
article
2021
eng
BackgroundThe difference between ‘policy as promised’ and ‘policy as practiced’ can be attributed to implementation gaps. Actor relationships and power struggles are central to these gaps but have been studied using only a handful of theoretical and analytical frameworks. Actor interface analysis provides a methodological entry point to examine policy implementation and practices of power. As this approach has rarely been used in health policy analysis, this article aims, first, to synthesise knowledge about use of actor interface analysis in health policy implementation and, second, to provide guiding steps to conduct actor interface analysis. MethodsWe conducted an interpretive synthesis of literature using a set of 6 papers, selected using purposeful searches and focusing on actor dynamics and practices of power in policy experiences. Drawing upon the framework synthesis approach and using a guiding framework, the synthesis focused on 4 questions – the type of actor interfaces formed, the power practices observed, the effect of such power practices on implementation and the underpinning factors for the power practices. ResultsMultiple interface encounters and power practices were identified which included domination, control, contestation, collaborations, resistance, and negotiations. The lifeworlds of actors that underpinned the power practices, were rooted in social-organisational power relationships, personal experiences and interests, and social-ideological standpoints like values and beliefs of actors. The power practices influenced implementation both positively and negatively. ConclusionBased on the learnings from synthesis, this paper provides guiding steps for conducting actor interface analysis. Additionally, it presents 2 useful tools for power analysis: (1) ‘actor lifeworlds,’ to understand underpinning factors for power practices and (2) relationships of lifeworlds, interface encounters and power practices with their effect on policy implementation. We suggest that interface analysis should be applied in more empirical settings and across varied health policy experiences to nuance the method better.
International Journal of Health Policy and Management
Kerman University of Medical Sciences
2322-5939
10
v.
Special Issue on Analysing the Politics of Health Policy Change in LMICs
no.
2021
430
442
https://www.ijhpm.com/article_3924_890efb586f07db353f9b1aec71b33454.pdf
dx.doi.org/10.34172/ijhpm.2020.191
A Narrative Synthesis Review of Out-of-Pocket Payments for Health Services Under Insurance Regimes: A Policy Implementation Gap Hindering Universal Health Coverage in Sub-Saharan Africa
Abigail Nyarko Codjoe
Derkyi-Kwarteng
Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra,
Ghana
author
Irene Akua
Agyepong
Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra,
Ghana
author
Nana
Enyimayew
Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra,
Ghana
author
Lucy
Gilson
School of Public Health
and Family Medicine, University of Cape Town, Cape Town, South Africa
author
text
article
2021
eng
Background “Achieve universal health coverage (UHC), including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all” is the Sustainable Development Goal (SDG) 3.8 target. Although most high-income countries have achieved or are very close to this target, low- and middle-income countries (LMICs) especially those in sub-Saharan Africa (SSA) are still struggling with its achievement. One of the observed challenges in SSA is that even where services are supposed to be “free” at point-of-use because they are covered by a health insurance scheme, out-of-pocket fees are sometimes being made by clients. This represents a policy implementation gap. This study sought to synthesise the known evidence from the published literature on the ‘what’ and ‘why’ of this policy implementation gap in SSA. Methods The study drew on Lipsky’s street level bureaucracy (SLB) theory, the concept of practical norms, and Taryn Vian’s framework of corruption in the health sector to explore this policy implementation gap through a narrative synthesis review. The data from selected literature were extracted and synthesized iteratively using a thematic content analysis approach. Results Insured clients paid out-of-pocket for a wide range of services covered by insurance policies. They made formal and informal cash and in-kind payments. The reasons for the payments were complex and multifactorial, potentially explained in many but not all instances, by coping strategies of street level bureaucrats to conflicting health sector policy objectives and resource constraints. In other instances, these payments appeared to be related to structural violence and the ‘corruption complex’ governed by practical norms. Conclusion A continued top-down approach to health financing reforms and UHC policy is likely to face implementation gaps. It is important to explore bottom-up approaches – recognizing issues related to coping behaviour and practical norms in the face of unrealistic, conflicting policy dictates.
International Journal of Health Policy and Management
Kerman University of Medical Sciences
2322-5939
10
v.
Special Issue on Analysing the Politics of Health Policy Change in LMICs
no.
2021
443
461
https://www.ijhpm.com/article_4043_f0ca6a5736aebaf1f62ff5c97a37b45a.pdf
dx.doi.org/10.34172/ijhpm.2021.38