Exploring Politics and Contestation in the Policy Process: The Case of Zambia’s Contested Community Health Strategy

Document Type : Short Communication

Authors

1 Department of Health Promotion and Education, School of Public Health, The University of Zambia, Lusaka, Zambia

2 Department of Health Policy and Management, School of Public Health, The University of Zambia, Lusaka, Zambia

3 The Ministry of Health, Lusaka, Zambia

4 Department of Epidemiology and Biostatistics, School of Public Health, The University of Zambia, Lusaka, Zambia

5 School of Public Health, University of the Western Cape, Cape Town, South Africa

6 South African Medical Research Council Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa

Abstract

There have been increased calls for low- and middle-income countries to develop community health systems (CHS) policies or strategies. However, emerging global guidance brackets the inherent complexity and contestation of policy development at the country level. This is explored through the case of Zambia’s 5-year Community Health Strategy (CH Strategy), formulated in 2017 and then summarily withdrawn and reissued two years later, with largely similar content. This paper examines the events, actors, and contexts behind this abrupt change in the Strategy, through an analysis of documentary sources and interviews with 21 stakeholders involved in the policy process. We describe an environment of contestation, characterised by numerous international partners weighing in on the CH Strategy, interfacing with shifting loci of responsibility for the CHS in the Ministry of Health (MoH). Despite the rhetoric of participation, providers and communities played no part in the policy process. These dynamics created the conditions for the abrupt change in strategy, illustrating the inherently fraught and political nature of policy development on the CHS in many countries. Going forward, we conclude that paying attention to processes of CHS policy development, and in particular the interaction between events, actors, and contexts, is as important as ensuring meaningful policy content.

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References

  1. Agarwal S, Kirk K, Sripad P, Bellows B, Abuya T, Warren C. Setting the global research agenda for community health systems: literature and consultative review. Hum Resour Health. 2019;17(1):22. doi:1186/s12960-019-0362-8
  2. Schneider H, Lehmann U. From community health workers to community health systems: time to widen the horizon? Health Syst Reform. 2016;2(2):112-118. doi:1080/23288604.2016.1166307
  3. George AS, LeFevre AE, Schleiff M, Mancuso A, Sacks E, Sarriot E. Hubris, humility and humanity: expanding evidence approaches for improving and sustaining community health programmes. BMJ Glob Health. 2018;3(3):e000811. doi:1136/bmjgh-2018-000811
  4. Zulu JM, Sandøy IF, Moland KM, Musonda P, Munsaka E, Blystad A. The challenge of community engagement and informed consent in rural Zambia: an example from a pilot study. BMC Med Ethics. 2019;20(1):45. doi:1186/s12910-019-0382-x
  5. World Health Organization (‎WHO)‎. People-Centred and Integrated Health Services: An Overview of the Evidence: Interim Report. Geneva: WHO; 2015.
  6. Reeves D, Pye S, Ashcroft DM, et al. The challenge of ageing populations and patient frailty: can primary care adapt? BMJ. 2018;362:k3349. doi:1136/bmj.k3349
  7. Tulenko K, Møgedal S, Afzal MM, et al. Community health workers for universal health-care coverage: from fragmentation to synergy. Bull World Health Organ. 2013;91(11):847-852. doi:2471/blt.13.118745
  8. Sacks E, Morrow M, Story WT, et al. Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all. BMJ Glob Health. 2018;3(Suppl 3):e001384. doi:1136/bmjgh-2018-001384
  9. Angwenyi V, Aantjes C, Kondowe K, et al. Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi. BMJ Glob Health. 2018;3(Suppl 3):e000996. doi:1136/bmjgh-2018-000996
  10. Dalglish SL, Surkan PJ, Diarra A, Harouna A, Bennett S. Power and pro-poor policies: the case of iCCM in Niger. Health Policy Plan. 2015;30 Suppl 2:ii84-ii94. doi:1093/heapol/czv064
  11. Zulu JM, Kinsman J, Michelo C, Hurtig AK. Developing the national community health assistant strategy in Zambia: a policy analysis. Health Res Policy Syst. 2013;11:24. doi:1186/1478-4505-11-24
  12. Cailhol J, Gilson L, Lehmann U. A decade of aid coordination in post-conflict Burundi's health sector. Global Health. 2019;15(1):25. doi:1186/s12992-019-0464-z
  13. YIN RK. How to do better case studies. In: Bickman L, ed. The SAGE Handbook of Applied Social Research Methods. 2nd ed. Sage; 2009.
  14. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:1191/1478088706qp063oa
  15. Milford C, Kriel Y, Njau I, et al. Teamwork in qualitative research: descriptions of a multicountry team approach. Int J Qual Methods. 2017;16(1):1609406917727189. doi:1177/1609406917727189
  16. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-112. doi:1016/j.nedt.2003.10.001
  17. Zulu JM, Kinsman J, Hurtig AK, Michelo C, George A, Schneider H. Integrating community health assistant-driven sexual and reproductive health services in the community health system in Nyimba district in Zambia: mapping key actors, points of integration, and conditions shaping the process. Reprod Health. 2019;16(1):122. doi:1186/s12978-019-0788-4
  18. Mulubwa C, Hurtig AK, Zulu JM, Michelo C, Sandøy IF, Goicolea I. Can sexual health interventions make community-based health systems more responsive to adolescents? a realist informed study in rural Zambia. Reprod Health. 2020;17(1):1. doi:1186/s12978-019-0847-x

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History

  • Receive Date: 08 March 2021
  • Revise Date: 16 October 2021
  • Accept Date: 20 October 2021
  • First Publish Date: 23 October 2021

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