Policy Adoption and the Implementation Woes of the Intersectoral First 1000 Days of Childhood Initiative, In the Western Cape Province of South Africa

Document Type : Original Article

Authors

1 Department of Community and Health Sciences, School of Public Health, University of the Western Cape, Cape Town, South Africa

2 UWC/SAMRC Health Services to Systems Research Unit, School of Public Health, University of the Western Cape, Cape Town, South Africa

Abstract

Background
There 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.

 
Methods
The 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.

 
Results
In 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.

 
Conclusion
This 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.

Keywords

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References

  1. Gilson L, Orgill M. Policy implementation. In: Gilson L, Orgill M, Shroff ZC, eds. A health policy analysis reader: the politics of policy change in low- and middle-income countries. Geneva: World Health Organization; 2018:81-92. Available from: https://www.who.int/alliance-hpsr/resources/publications/Alliance-HPA-Reader-web.pdf.
  2. 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. doi:10.1093/heapol/czu063
  3. Elder CD, Cobb RW. The politics of agenda-building: an alternative perspective for modern democratic theory. J Polit. 1971;33(4):892-915. doi:10.2307/2128415
  4. Kingdon JW. The policy window, and joining the streams. In: Kingdon JW, ed. Agendas, Alternatives, and Public Policies. Boston: Little, Brown and Company; 1995:172-189.
  5. Fischer F, Miller G, Sidney M. Handbook of Public Policy Analysis: Theory, Politics, and Methods. CRC Press; 2006.
  6. Nilsen P, Ståhl C, Roback K, Cairney P. Never the twain shall meet?--a comparison of implementation science and policy implementation research. Implement Sci. 2013;8:63. doi:10.1186/1748-5908-8-63
  7. 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. doi:10.1093/heapol/czn019
  8. 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. doi:10.1093/heapol/czu060
  9. Khayatzadeh-Mahani A, Breton E, Ruckert A, Labonté R. Banning shisha smoking in public places in Iran: an advocacy coalition framework perspective on policy process and change. Health Policy Plan. 2017;32(6):835-846. doi:10.1093/heapol/czx015
  10. Pelletier DL, Frongillo EA, Gervais S, et al. Nutrition agenda setting, policy formulation and implementation: lessons from the Mainstreaming Nutrition Initiative. Health Policy Plan. 2012;27(1):19-31. doi:10.1093/heapol/czr011
  11. Crichton J. Changing fortunes: analysis of fluctuating policy space for family planning in Kenya. Health Policy Plan. 2008;23(5):339-350. doi:10.1093/heapol/czn020
  12. Phillips C, Fisher M, Baum F, MacDougall C, Newman L, McDermott D. To what extent do Australian child and youth health policies address the social determinants of health and health equity?: a document analysis study. BMC Public Health. 2016;16:512. doi:10.1186/s12889-016-3187-6
  13. Skeen S, Kleintjes S, Lund C, Petersen I, Bhana A, Flisher AJ. 'Mental health is everybody's business': roles for an intersectoral approach in South Africa. Int Rev Psychiatry. 2010;22(6):611-623. doi:10.3109/09540261.2010.535510
  14. Exworthy M. Policy to tackle the social determinants of health: using conceptual models to understand the policy process. Health Policy Plan. 2008;23(5):318-327. doi:10.1093/heapol/czn022
  15. de Leeuw E. Engagement of sectors other than health in integrated health governance, policy, and action. Annu Rev Public Health. 2017;38:329-349. doi:10.1146/annurev-publhealth-031816-044309
  16. De Leeuw E, Peters D. Nine questions to guide development and implementation of Health in All Policies. Health Promot Int. 2015;30(4):987-997. doi:10.1093/heapro/dau034
  17. Shawar YR, Shiffman J. Generation of global political priority for early childhood development: the challenges of framing and governance. Lancet. 2017;389(10064):119-124. doi:10.1016/s0140-6736(16)31574-4
  18. Aarts MJ, Jeurissen MP, van Oers HA, Schuit AJ, van de Goor IA. Multi-sector policy action to create activity-friendly environments for children: a multiple-case study. Health Policy. 2011;101(1):11-19. doi:10.1016/j.healthpol.2010.09.011
  19. 19 Chircop A, Bassett R, Taylor E. Evidence on how to practice intersectoral collaboration for health equity: a scoping review. Crit Public Health. 2015;25(2):178-191. doi:10.1080/09581596.2014.887831
  20. Embrett MG, Randall GE. Social determinants of health and health equity policy research: exploring the use, misuse, and nonuse of policy analysis theory. Soc Sci Med. 2014;108:147-155. doi:10.1016/j.socscimed.2014.03.004
  21. Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan. 1994;9(4):353-370. doi:10.1093/heapol/9.4.353
  22. Mauti J, Gautier L, De Neve JW, Beiersmann C, Tosun J, Jahn A. Kenya's Health in All Policies strategy: a policy analysis using Kingdon's multiple streams. Health Res Policy Syst. 2019;17(1):15. doi:10.1186/s12961-019-0416-3
  23. Baum F, Delany-Crowe T, MacDougall C, Lawless A, van Eyk H, Williams C. Ideas, actors and institutions: lessons from South Australian Health in All Policies on what encourages other sectors' involvement. BMC Public Health. 2017;17(1):811. doi:10.1186/s12889-017-4821-7
  24. United Nations. Transforming our World: The 2030 Agenda for Sustainable Development. New York: United Nations; 2015.
  25. Britto PR, Lye SJ, Proulx K, et al. Nurturing care: promoting early childhood development. Lancet. 2017;389(10064):91-102. doi:10.1016/s0140-6736(16)31390-3
  26. World Health Organization (WHO). Closing the Gap in A Generation: Health Equity Through Action on the Social Determinants of Health. WHO; 2006.
  27. Engle PL, Black MM, Behrman JR, et al. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. Lancet. 2007;369(9557):229-242. doi:10.1016/s0140-6736(07)60112-3
  28. Republic of South Africa. National Integrated Early Childhood Development Policy. Pretoria: Government Printers; 2015.
  29. World Health Organization (WHO). Nurturing Care for Early Childhood Development: Linking Survive and Thrive to Transform Health and Human Potential. Geneva: WHO; 2018.
  30. World Health Organization (WHO). The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030). WHO; 2016.
  31. Engle PL, Fernald LC, Alderman H, et al. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. Lancet. 2011;378(9799):1339-1353. doi:10.1016/s0140-6736(11)60889-1
  32. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. Developmental potential in the first 5 years for children in developing countries. Lancet. 2007;369(9555):60-70. doi:10.1016/s0140-6736(07)60032-4
  33. Black MM, Walker SP, Fernald LCH, et al. Early childhood development coming of age: science through the life course. Lancet. 2017;389(10064):77-90. doi:10.1016/s0140-6736(16)31389-7
  34. National Planning Commission. National Development Plan 2030: Our Future - Make it Work. South Africa; 2012.
  35. Western Cape Department of Health. The First 1000 Days Initiative. Cape Town: South Africa; 2016.
  36. Hall K, Richter L, Mokomane Z, Lake L. South African Child Gauge 2018. Cape Town: Children’s Institute, University of Cape Town; 2018.
  37. Western Cape Department of Community Safety. Provincial Crime Report 2016/17: Analysis of SAPS Crime Statistics. Cape Town: Western Cape Government; 2018.
  38. Western Cape Department of Community Safety. Annual Report 2016/17. Vol. 7. Cape Town: Western Cape Government; 2016.
  39. Patton M. Qualitative Evaluation and Research Methods. 3rd ed. California: Sage Publications; 2002.
  40. Yin RK. Case Study Research: Design and Methods. 5th ed. Vol. 26. California: Sage Publications; 2014:93-96.
  41. Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson L. 'Doing' health policy analysis: methodological and conceptual reflections and challenges. Health Policy Plan. 2008;23(5):308-317. doi:10.1093/heapol/czn024
  42. Timmermans S, Tavory I. Theory construction in qualitative research: from grounded theory to abductive analysis. Sociol Theory. 2012;30(3):167-186. doi:10.1177/0735275112457914
  43. Lichbach MI, Zuckerman AS, Hall PA. Comparative politics: rationality, culture, and structure. In: Lichbach MI, Zuckerman AS, eds. In: Hall PA, ed. The Role of Interests, Institutions, and Ideas in the Comparative Political Economy of the Industrialized Nations. Cambridge: Cambridge University Press; 1997:174-207.
  44. Béland D. Ideas, institutions, and policy change. J Eur Public Policy. 2009;16(5):701-718. doi:10.1080/13501760902983382
  45. Bennett S, Glandon D, Rasanathan K. Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge. BMJ Glob Health. 2018;3(Suppl 4):e000880. doi:10.1136/bmjgh-2018-000880
  46. Schmidt VA. Discursive institutionalism: the explanatory power of ideas and discourse. Annu Rev Polit Sci. 2008;11(1):303-326. doi:10.1146/annurev.polisci.11.060606.135342
  47. Campbell JL. Institutional analysis and the role of ideas in political economy. Theory Soc. 1998;27(3):377-409.
  48. Western Cape Government. Provincial Strategic Plan 2014-2019. Cape Town: Western Cape Government; 2014.
  49. Western Cape Department of Health. First 1000 Days Situational Analysis Survive Thrive Final Dec 2016. Cape Town: Western Cape Government; 2016.
  50. Center on the Developing Child at Harvard University. The Foundations of Lifelong Health Are Built in Early Childhood. Cambridge: Harvard University; 2010.
  51. Okeyo I, Lehmann U, Schneider H. The impact of differing frames on early stages of intersectoral collaboration: the case of the First 1000 Days Initiative in the Western Cape Province. Health Res Policy Syst. 2020;18(1):3. doi:10.1186/s12961-019-0508-0
  52. Western Cape Department of Health. Provincial Strategic Plan Goal 3: Increase Wellness and Safety, Reduce Social Ills. Project Charter 2017 / 2018 Project. 2017.
  53. Mullan F, Epstein L. Community-oriented primary care: new relevance in a changing world. Am J Public Health. 2002;92(11):1748-1755. doi:10.2105/ajph.92.11.1748
  54. Hoey L, Pelletier DL. Bolivia's multisectoral Zero Malnutrition Program: insights on commitment, collaboration, and capacities. Food Nutr Bull. 2011;32(2 Suppl):S70-81. doi:10.1177/15648265110322s204
  55. Western Cape Department of Social Development. Annual Performance Plan 2015/16. Cape Town: 2014.
  56. Western Cape Department of Social Development. Annual Performance Plan 2017/18. Cape Town: 2017.
  57. Western Cape Department of Social Development. Annual Performance Plan 2018/19. Cape Town: 2018.
  58. Fisher M, Baum FE, MacDougall C, Newman L, McDermott D, Phillips C. Intersectoral action on SDH and equity in Australian health policy. Health Promot Int. 2017;32(6):953-963. doi:10.1093/heapro/daw035
  59. Pelletier D, Gervais S, Hafeez-Ur-Rehman H, Sanou D, Tumwine J. Boundary-spanning actors in complex adaptive governance systems: the case of multisectoral nutrition. Int J Health Plann Manage. 2018;33(1):e293-e319. doi:10.1002/hpm.2468
  60. Stead D. Institutional aspects of integrating transport, environment and health policies. Transp Policy. 2008;15(3):139-148. doi:10.1016/j.tranpol.2007.12.001
  61. Shearer JC, Abelson J, Kouyaté B, Lavis JN, Walt G. Why do policies change? Institutions, interests, ideas and networks in three cases of policy reform. Health Policy Plan. 2016;31(9):1200-1211. doi:10.1093/heapol/czw052
  62. Zheng H, de Jong M, Koppenjan J. Applying policy network theory to policy-making in China: the case of urban health insurance reform. Public Adm. 2010;88(2):398-417. doi:10.1111/j.1467-9299.2010.01822.x
  63. Emerson K, Nabatchi T, Balogh S. An integrative framework for collaborative governance. J Public Adm Res Theory. 2012;22(1):1-29. doi:10.1093/jopart/mur011
  64. Ansell C, Gash A. Collaborative governance in theory and practice. J Public Adm Res Theory. 2008;18(4):543-571. doi:10.1093/jopart/mum032
  65. Walker L, Gilson L. 'We are bitter but we are satisfied': nurses as street-level bureaucrats in South Africa. Soc Sci Med. 2004;59(6):1251-1261. doi:10.1016/j.socscimed.2003.12.020
  66. Tantivess S, Walt G. The role of state and non-state actors in the policy process: the contribution of policy networks to the scale-up of antiretroviral therapy in Thailand. Health Policy Plan. 2008;23(5):328-338. doi:10.1093/heapol/czn023
  67. Percy‐Smith J. What works in strategic partnerships for children: a research review. Child Soc. 2006;20(4):313-323. doi:10.1111/j.1099-0860.2006.00048.x
  68. Zaidi S, Bhutta Z, Hussain SS, Rasanathan K. Multisector governance for nutrition and early childhood development: overlapping agendas and differing progress in Pakistan. BMJ Glob Health. 2018;3(Suppl 4):e000678. doi:10.1136/bmjgh-2017-000678
International Journal of Health Policy and Management
Volume 10, Issue 7
July 2021
Pages 364-375

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History

  • Receive Date: 13 March 2020
  • Revise Date: 23 June 2020
  • Accept Date: 01 September 2020

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