Financing and Prioritizing Diabetes and Other Non-Communicable Diseases in Ghana: A Qualitative Policy Analysis of the Barriers, Enablers and Opportunities

HIV and NCDs: the need to build stronger health systems

Despite a robust literature applying the Multiple Streams Framework (MSF) to national government institutions, there remains a dearth of research examining the theory’s explanatory power in US state legislative contexts. This omission is problematic given the critical role state legislatures play in driving policy change in a host of policy domains, including healthcare, emergency preparedness and voting rights policy, to name a few. To fill this gap in the research, this study applies the MSF to the case of climate adaptation policy making in the Massachusetts State Legislature. Using a mixed methods design, it assesses the effect of all three of the MSF’s streams (the problem, politics and policy streams), as well as the concept of policy entrepreneurship on the climate adaptation policy agenda of the Massachusetts State Legislature between the years 2001 and 2020. The findings suggest that agenda activity was largely driven by changes within the political stream, namely the election of a Republican governor. In addition to advancing the MSF by providing one of the most comprehensive quantitative analyses of the framework to date, this article draws on new data from the State House News Service and other sources of state legislative floor debates to present a new methodological approach for measuring agenda change. In this way, the article makes a clear theoretical contribution to the MSF literature as well as providing new analysis of state-level climate adaptation policy adoption.

Background: Priority setting and resource allocation in decentralised planning is often not in line with the social and economic burden associated with non-communicable diseases (NCD). This is a protocol developed for the purpose of analysing the pattern of budgetary allocation and utilisation of funds for health sector projects on non-communicable diseases by the local self-government (LSG) institutions in Kerala. It is also proposed to document the processes along with the stakeholders’ role in planning. Methods: Following explanatory design, first we will do secondary data analysis of health sector projects on NCD fund allocation and utilisation, followed by document analysis and key informant interviews in LSGs at selected districts of Kerala. Following policy framework used in public health related policy processes, will perform descriptive analysis, based on stages heuristic in decentralised planning. Multiple dimensions of priority setting and allocation process will be studied. Explanatory analysis for resource allocation process will be studied using Kingdon’s multiple streams framework. Conclusions: The study will help in understanding the decision-making process for fund allocation with the specific focus on NCD. It will also help in building an evidenced based framework for decentralized health planning. Trial Registration: No: SCT/IEC/1849/FEBRUARY/2022.

The impact of social, economic and political forces on emerging HIV epidemics.

Kingdon's multiple streams framework (MSF) is very influential, but problems exist with its application. Most applications neither fully use the MSF's problem stream, policy stream, politics stream, policy entrepreneur, and policy window concepts nor all their subcomponents. These trends indicate a lack of shared language and understanding of the policy process necessary for the MSF's theoretical development. Most applications employing the concepts identify subcomponents but disregard their operationalizations. Moreover, research overwhelmingly cites Kingdon's 1984 publication while neglecting studies contributing to new MSF understandings. Using the Obama administration's No Child Left Behind waiver policy, this article applies the MSF concentrating on its contemporary understandings, the focus concepts, and the concepts' subcomponents while operationalizing them. This allows an enhanced analysis and MSF's policy process understanding, identifies the MSF's strengths and weaknesses, notes nuances, offers new insights, and recommends future research.Related ArticlesDavid, Charles‐Philippe. 2015. “Policy Entrepreneurs and the Reorientation of National Security Policy under the G. W. Bush Administration (2001‐04).” Politics & Policy 43 (1): 163‐195. https://doi.org/10.1111/polp.12106Rawat, Pragati, and John Charles Morris. 2016. “Kingdon's ‘Streams’ Model at Thirty: Still Relevant in the 21st Century?” Politics & Policy 44 (4): 608‐638. https://doi.org/10.1111/polp.12168Tanaka, Yugo, Andrew Chapman, Tetsuo Tezuka, and Shigeki Sakurai. 2020. “Multiple Streams and Power Sector Policy Change: Evidence from the Feed‐In Tariff Policy Process in Japan.” Politics & Policy 48 (3): 464‐489. https://doi.org/10.1111/polp.12357

Global health 2035: a world converging within a generation

ABSTRACTIntroduction: The implementation of a publicly-funded immunization program results from a complex decision-making process. John Kingdon’s ‘Multiple Streams Framework’ has been extensively used to analyze how and why governmental policies were adopted.Area covered: Ideas that will ultimately end up in a proposal for a new immunization program develop gradually along three main streams: (i) the problem stream, which focuses on a particular vaccine-preventable disease and its perception by stakeholders; (ii) the policy stream, which is centered on experts’ views on the optimal use of available vaccines; and (iii) the politics stream, which consists of socio-political factors, including budgetary constraints. Ideas are progressively shaped by policy entrepreneurs into a proposal with concrete implementation strategies. The three streams then converge within a policy window, during which adoption is especially likely to occur. To survive, the proposed program should be operationally feasible, consistent with mainstream social values, and financially affordable. The timing of the policy window is usually unpredictable and of short duration.Expert opinion: Analytical frameworks traditionally used to assess immunization programs focus on the technical aspects of the disease, the vaccine, and the program. The ‘Multiple Streams Framework’ brings added analytical value by enlarging the scope of the analysis into the political arena.

Following the development of a vaccine for COVID-19, the expectation was instantaneous widespread distribution and uptake to halt further spread, severe illness and deaths from the virus. However, studies show very low uptake, especially in resource-poor settings, and little is documented about the drivers of vaccine uptake in populations classified as high-risk. In this study, we explored access and uptake of COVID-19 vaccines among people living with non-communicable diseases (PLWNCDs) in Ghana. A qualitative study using in-depth interviews and focus group discussions was conducted among adults (>18 years) PLWNCDs stratified by sex, age, and type of non-communicable diseases (NCDs) at the community level (non-users of the health service) and health facility levels. Purposive sampling was used to select eligible participants. Topic guides were used to facilitate the face-to-face in-depth interviews and focus group discussions. The interviews and discussions were all digitally audio recorded. All transcripts and field notes were thematically analysed. Overall, 62 participants were recruited for this study. Family members, friends/peers, health workers and media were identified as the main sources of information for COVID-19 vaccines. Several barriers that mediated access to the COVID-19 vaccines in Ghana were reported including mistrust of vaccine efficacy and fears of vaccine side-effects, long distance to and waiting hours at vaccination centres, shortages of vaccines at vaccination centres and non-prioritization of NCD patients for the vaccine. To improve uptake, intensified education and sensitization, house-to-house vaccination, expansion of vaccination centers and increased supply of vaccines were recommended by participants. Compared to studies elsewhere, misinformation and disinformation were not major causes of vaccine hesitancy. If policymakers can improve community-based vaccine delivery, reduce queues and waiting times, prioritize PLWNCDs and other vulnerable groups, and improve sensitization and communication-our findings suggest there will be major improvements in COVID-19 vaccine coverage in Ghana.

Introduction: Africa faces a double burden of communicable and non-communicable diseases (NCDs). Already, health systems in Africa are overwhelmed with a high burden of communicable diseases with perennial outbreaks of highly infectious diseases. The rise in NCDs comprises an already fragile health system challenging its ability to provide comprehensive care to people living with these diseases. Without responsive social support systems, NCDs will draw more people into catastrophic health financing, worsening health outcomes, and poverty. This study explores how vulnerable people negotiate major disease burdens with the social protection supports available in Ghana. Methods: The study applied a cross-sectional design with a qualitative approach involving healthcare professionals and non-healthcare professionals in 4 regions in Ghana with a total of 32 qualitative interviews analyzed thematically. Results: The main social protection support for the health sector in Ghana is the National Health Insurance Scheme. Other social protection supports such as free maternal healthcare, Livelihood Empowerment Against Poverty, and conventional informal social protection mechanisms do not directly target people afflicted with NCDs. Even though national health insurance covers about 90% of diseases, the quality of care is questionable. Again, the exclusion of diagnostic investigations makes national health insurance a setback to NCD disease management. Also, NCD patients still do out-of-pocket expenses though they have valid national health insurance. Informal social protection supports which used to be effective sometime back are dwindling due to the rising cost of living, gradual breakdown of the African system of reciprocity, and infiltration of Western lifestyles. Conclusion: NCD patients have very limited social protection for the management of their condition. Health insurance which is the only option for many has limited applications. A multidisciplinary body is established by the government to outline more effective ways of offering social protection support for health services, especially chronic conditions such as NCDs which affect a greater proportion of the population.

Emotions are central to human behavior and, consequently, play a significant role in policymaking. While the Multiple Streams Framework (MSF) incorporates the notion of “public mood” into the political stream, this concept primarily focuses on a fleeting, less intense, and diffuse emotional state that is not necessarily linked to a specific triggering event or policy‐related object. To address this limitation, the current article draws on robust findings from political psychology, viewing and interpreting the MSF through an emotional lens. It investigates the intersections between emotions, on the one hand, and the assumptions and structural elements of the MSF, on the other, by sharpening existing concepts—such as the emotional agenda (policy) window, emotional decision window, and emotional policy entrepreneurs—to examine emotionality in policy dynamics. It concludes by discussing how an emotional perspective on the MSF can help scholars generate nuanced hypotheses, overcome the MSF's metaphorical language, and gauge when policy may be in search of a rationale.

Background Nepal has been undergoing demographic and epidemiological transitions, marked by an increasing burden of non-communicable diseases (NCDs) and injuries. These transitions have led to financial implications, including rising out-of-pocket (OOP) expenses. This study reviews and synthesizes evidence on the status, issues and challenges in health financing system, policies, and programs to achieve universal health coverage (UHC) in Nepal. Methods We conducted a scoping review of literature on Nepal’s health financing system, policies, and programs. A search strategy was developed using keywords related to two core concepts: health financing and universal health coverage. Grey literature was identified from the web pages of relevant ministries and organizations. A total of 148 studies/policy documents published in Nepali and English up to 31 December 2024 were included. Policies and content related to the health financing system were reviewed to understand the status, issues and challenges of health financing functions, and UHC . A framework-guided deductive content analysis approach was employed, and findings were interpreted using the three UHC components: service coverage, population coverage, and financial coverage. Results Nepal’s health policy documents prioritize financial protection for low-income people and target groups through social health protection programs/schemes. However, multiple social health protection schemes coexist with fragmented risk pooling and low efficiency in health financing. OOP expenditure is high at 54.2%, with 10% of the population facing catastrophic health expenditures. Injuries and chronic morbidities contribute significantly to this burden, with 70% of injury-related and 62% of NCD-related expenses borne through OOP payments. Despite efforts to improve financial risk protection, the National Health Insurance Program (NHIP) suffers from low population coverage (28%), low renewal rate (54%), and financial sustainability issues (as provider payments exceed revenue collection). The UHC service coverage index, though improving, was only 54 out of 100 in 2021 reflecting limited health system capacity and insufficient readiness to address health challenges, including those posed by shifting demographics and the growing burden of NCDs. Nepal’s total health expenditure remains around 2% of GDP, with persistent inefficiencies in resource allocation, fiscal decentralization, and budget absorption. Conclusions Nepal’s health financing policies align with UHC goals, yet critical gaps remain in multiple dimensions . Issues such as inefficiencies, underfunding, and fragmented social health protection schemes limit equitable access to quality health care. Therefore, comprehensive structural reforms-spanning legal, institutional, and policy frameworks-are urgently needed. Key reforms include: (1) merging or harmonizing existing social health protection schemes for efficient pooling and purchasing; (2) enhancing domestic health financing through increased health funding (≥5% of GDP) via payroll contributions, progressive taxation, and earmarked sin taxes; (3) reforming NHIP to mandatory enrollment starting from formal sector, subsidizing premium for informal sector and free coverage for disadvantaged groups, alongside strengthening policy implementation including accrediting of health facilities, ensuring service quality, prioritising and expanding coverage packages with strategic purchasing from all public and private health facilities; and (4) equitable public financing to ensure needs-based allocation across government levels that respond to demographic and epidemiological patterns. Further research is needed to assess hybrid tax and premium based insurance models, strategic purchasing optimization, and digital health innovations for financial sustainability.

This article applies the Multiple Streams Framework (MSF) to examine post‐Brexit antimicrobial resistance (AMR) governance in UK agriculture, focusing on the contested regulation of prophylactic antibiotic use in farm animals. The study reveals how Brexit created a structural policy window, yet political and ideological dynamics rendered it functionally ineffective. While the problem and policy streams were well developed—supported by strong scientific evidence and viable alternatives—the politics stream, shaped by narratives of sovereignty, deregulation, and trade competitiveness, consistently blocked reform. The paper introduces the concept of a “meta‐policy window” and shows how evidence was strategically mobilized rather than uniformly accepted. This case demonstrates how ideological filtering and institutional ambiguity can constrain policy change, even in moments of apparent opportunity. It contributes to policy theory by refining MSF for complex, post‐crisis environments and offers broader lessons on evidence use, regulatory drift, and the politics of inaction. Related Articles Bache, Ian. 2025. “The Multiple Streams Framework and Non‐Politicized Issues: The Case of Assisted Dying/Assisted Suicide.” Politics and Policy 53(19): e70016. https://doi.org/10.1111/polp.70016 . Angervil, G. 2021. “A Comprehensive Application of Kingdon's Multiple Streams Framework: An Analysis of the Obama Administration's No Child Left Behind Waiver Policy.” Politics and Policy 49, no. 5: 980–1020. https://doi.org/10.1111/polp.12432 . Peterson, Holly L., Mark K. McBeth, and Michael D. Jones. 2020. “Policy Process Theory for Rural Studies: Navigating Context and Generalization in Rural Policy.” Politics and Policy 48(4): 576–617. https://doi.org/10.1111/polp.12366 .

BackgroundDrug use is one of the most common public health problems globally. This study was done to analyze the agenda-setting of policies related to substance use disorder treatment in Iran since 1979.MethodsThe current qualitative study was done through document review and interviews with policymakers and executives. Purposive sampling with snowball strategy was considered for sampling. Semi-structured interviews were done. A total of 22 documents were examined, and the data were saturated with 32 interviews. Kingdon's Multiple Streams Framework was used to analyze the data.ResultsThe results indicated the intersection of problem stream, policy stream, political stream, and opening the opportunity window. In the problem stream, the rapid growth of AIDS among people who inject drugs (PWID), the decrease in the average age of first drug use, the increase in the prevalence of substance use disorder in women, the ineffectiveness of compulsive treatment, and criminological perspectives played key roles. The policy stream included criminological perspective and war on drugs, and harm reduction. The political stream included announcing general anti-narcotics policies by the Supreme Leader of Iran and understanding the need for treatment, rehabilitation, harm reduction, and social support for substance use disorder by officials and policymakers.ConclusionsFor a long time in Iran, policies based on the war on drugs were the dominant approach, and then, policies based on harm reduction and patient-centeredness were considered. The ideology and political parties influenced the executive apparatus's policy stream in this area. In countries with an ideological approach, the political stream plays a critical role in setting issues on the agenda. Therefore, policy entrepreneurs can put the points on the agenda by attracting the attention of political forces to the issue.

The theoretical development of the Multiple Streams Framework (MSF) has been almost nonexistent in Latin America. Hence, the goal of this article is to examine its portability and provide a road map for researchers wanting to apply the framework to this particular policy context. To this end, various characteristic elements of Latin American politics are analyzed along three broad dimensions—delegative democracies, weak and dependent states, and social inequalities—and then discussed in relation to the core elements of the framework. Although the MSF appears to be capable of capturing the different dynamics at play, there are a number of crucial features that may prove to be a challenge for the framework and could arguably merit its modification for a more efficient application in the region. First, we suggest that its political stream could be modified, as it needs to acknowledge political contexts in which legislatures and political parties are weak, whereas powerful interest groups can exert a very strong influence over executives that dominate policymaking. Furthermore, we discuss if the MSF is able to decode the informal institutions based on corruption, which by now have turned into a constant in most political systems of the region and include illegal efforts by politicians and interest groups to influence how policies are formed.

This article suggests theoretical refinements to the multiple streams framework (MSF) that make it applicable to parliamentary systems and the decision‐making stage of the policy process. Regarding the former, the important role of political parties in parliamentary democracies is highlighted. Party policy experts are expected to be members of the policy communities in the policy stream and to promote viable policy alternatives in their respective parties, while the party leadership is concerned with adopting policies in the political stream. With regard to the latter, the introduction of a second coupling process to analyse decision making more rigorously is suggested. Moreover, the article provides operational definitions of the framework's key concepts when applied to parliamentary systems and derives a systematic set of falsifiable hypotheses for agenda‐setting and decision making in these systems, thus addressing one of the main critiques against the MSF – namely that no hypotheses can be derived from it.