Health Policy Triangle Framework Research Articles

Exploring gaps, opportunities, barriers and enablers in malnutrition policy through key informant interviews: a qualitative inquiry from the CANDReaM initiative

ObjectivesDisease-related malnutrition (DRM) presents in up to half of adults and one-third of children admitted to Canadian hospitals and significantly impacts health outcomes. Strategies to screen, diagnose and treat DRM...

Stakeholder perspectives on factors that influence global prioritization for MNH in humanitarian settings.

Maternal and newborn mortality rates are disproportionately high in crisis and conflict-affected countries. This study aims to understand factors influencing how MNH in humanitarian and fragile settings (HFS) is prioritized on the global health agenda during the Sustainable Development Goal (SDG) era. This includes examining the policies and processes driving agenda setting and decision-making, as well as the perceptions of global actors. It further reflects on the role of global milestones, reports, convenings, and high-level champions, based on the premise that global prioritization leads to increased attention and resource allocation, ultimately contributing to improved outcomes for mothers and newborns in crisis-affected areas. A qualitative study conducted from April 2022 to June 2023, employing a desk review and 23 semi-structured key informant interviews with global actors from donor agencies, implementing organizations, research institutes, United Nations agencies, professional associations, and coalitions, predominantly based in the Global North. Data were analyzed using inductive thematic analysis and the research was guided by the Walt and Gibson Health Policy Triangle framework. Participants believe that global agenda-setting and investment decisions for MNH are primarily driven by UN agencies, donors, and implementing organizations at the global level. Although the Millennium Development Goal era successfully prioritized MNH, this focus has diminished during the SDGs, especially for HFS. Identified barriers include the complexity of reducing mortality rates in these contexts, limited political will, MNH investment fatigue, and a preference for quick wins. Fragmentation between humanitarian and development sectors and unclear mandates in protracted crises also hinder progress. Without enhanced global advocacy, accountability, and targeted investments in HFS, respondents deem global MNH targets unattainable. While waning donor interest and the siloing of HFS in global MNH decision-making pose challenges, targeted actions to address these barriers may include designating quotas for humanitarian actors in global MNH convenings, developing shared messages that convey common interests, and adopting an equity lens. Prioritizing MNH in HFS on the global agenda demands sustained commitment to ensure these settings are not an afterthought through dedicated advocacy and accountability, high-level political engagements, global milestones, and by leveraging opportunities to capture mainstream interest. Failing to shift global priorities will result in continued stagnation and worsening MNH outcomes across HFS.

Information and health literacy policies during pandemics: A narrative review.

The COVID-19 pandemic has compelled governments globally to formulate policies addressing the unique needs of their populations. These policies are critical in disseminating accurate information and enhancing health literacy during crises. This narrative review aims to identify and assess effective information and health literacy policies implemented during pandemics. A comprehensive literature search was performed across five electronic information sources (PubMed, Science Direct, ProQuest, Emerald Insight, Scopus), supplemented by Google Scholar. The analysis employed Walt and Gilson's health policy triangle framework to categorize and evaluate the findings. The review revealed that the policies could be grouped into several key categories: educational programs, laws and regulations, knowledge sharing, national programs, and different information sources. The development of these policies involved multifaceted processes influenced by political, scientific, economic, cultural and social factors, as well as the involvement of multiple stakeholders. This review offers significant insights and actionable recommendations for policymakers and stakeholders. By understanding the dimensions and components of effective information and health literacy policies, stakeholders can better prepare for and respond to future pandemics and similar health crises.

Analysis the Healthy School Campaign in Indonesia: A Health Policy Triangle Approach

The School Health Program policy was initiated by the Indonesian government in 2014. However, by 2021, student health service coverage was still suboptimal. The Healthy Schools Campaign Program was introduced in 2022 as an alternative policy to revitalize the School Health Programme. The study aimed to analyze the Healthy School Campaign Program using the health policy triangle framework, which includes actors, content, process, and context. This research uses qualitative methods with secondary data sourced from electronic document searches. The main actors in this policy involve official government institutions, supported by collaboration with non-government partners. Policy selection is based on situational, structural, cultural and international contextual factors. The program content focuses on physical health, healthy nutrition, and student immunization. The conclusion is that the selection of content is influenced by how actors identify health problems in the early stages of policy preparation. Implementation of this program requires a clear collaboration system as a reference for its implementation in educational units. Teacher and parent involvement is also very important to increase the effectiveness and sustainability of the program.

What is said about #donateliver or #liverdonor? Reflexive thematic analysis of Twitter (X) posts from 2012 to 2022

BackgroundThere is sustained interest in understanding the perspectives of liver transplant recipients and living donors, with several qualitative studies shedding light on this emotionally charged subject. However, these studies have relied primarily on traditional semi-structured interviews, which, while valuable, come with inherent limitations. Consequently, there remains a gap in our comprehension of the broader public discourse surrounding living liver donation. This study aims to bridge this gap by delving into public conversations related to living liver donation through a qualitative analysis of Twitter (now X) posts, offering a fresh perspective on this critical issue.MethodsTo compile a comprehensive dataset, we extracted original tweets containing the hashtags “#donateliver” OR “#liverdonor”, all posted in English from January 1, 2012, to December 31, 2022. We then selected tweets from individual users whose Twitter (X) accounts featured authentic human names, ensuring the credibility of our data. Employing Braun and Clarke’s reflexive thematic analysis approach, the study investigators read and analysed the included tweets, identifying two main themes and six subthemes. The Health Policy Triangle framework was applied to understand the roles of different stakeholders involved in the discourse and suggest areas for policy improvement.ResultsA total of 361 unique tweets from individual users were analysed. The major theme that emerged was the persistent shortage of liver donors, underscoring the desperation faced by individuals in need of life-saving liver transplants and the urgency of addressing the organ shortage problem. The second theme delved into the experiences of liver donors post-surgery, shedding light on a variety of aspects related to the transplantation process, including the visibility of surgical scars, and the significance of returning to physical activity and exercise post-surgery.ConclusionThe multifaceted experiences of individuals involved in the transplantation process, both recipients and donors, should be further studied in our efforts to improve the critical shortage of liver donors.

Implementation of the Macao dementia policy: a scoping review for the way forward.

The implementation of dementia policy is a complex process of translating policy goals to actions to address the changing needs of people living with dementia. Leveraging on others' experiences would help policy decision-makers and actors better prepare for the challenges. This study explored the development, the implementation and the impact of the dementia policy in Macao, a "role model" recognized by the Alzheimer's Disease International. A scoping review of policies, strategies, and news articles, as well as scholarly work from 6 scientific databases dated till March 2023 was conducted under the guidance of the Health Policy Triangle Framework. According to 284 documents, the dementia policy in Macao, driven by government leadership and supported with public-private partnership, aimed to integrate health and social services to achieve the goals of "Early prevention, Early detection, Early diagnosis, Early treatment and Early support." Promoting the preparedness according to the dementia burden trajectory, empowering the public and the service providers with training and education, and encouraging services-related research were among the key actions. With major changes in dementia care configuration, a dementia service network, a dementia-friendly community and a one-stop service model for disease screening, diagnosis, treatment and support have been developed. Reconfiguring existing resources in the health and social services to form an integrated service network at the community level could be considered a priority of action. Continuous engagement, collaboration and empowerment at different levels across these sectors is crucial for the sustainability of a dementia policy.

Prioritization of maternal and newborn health policies and their implementation in the eastern conflict affected areas of the Democratic Republic of Congo: a political economy analysis.

Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu. Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation. The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones. MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.

Implementation of Medicines Pricing Policies in Ghana: The Interplay of Policy Content, Actors' Participation, and Context.

Implementing medicines pricing policy effectively is important for ensuring equitable access to essential medicines and ultimately achieving universal health coverage. However, published analyses of policy implementations are scarce from low- and middleincome countries. This paper contributes to bridging this knowledge gap by reporting analysis of implementation of two medicines pricing policies in Ghana: value-added tax (VAT) exemptions and framework contracting (FC) for selected medicines. We analysed implications of actor involvements, contexts, and contents on the implementation of these policies, and the interplay between these. This paper should be of interest, and relevance, to policy designers, implementers, the private sector and policy analysts. Data were collected through document reviews (n=18), in-depth interviews (n=30), focus groups (n=2) and consultative meetings (n=6) with purposefully identified policy actors. Data were analysed thematically, guided by the four components of the health policy triangle framework. The nature and complexity of policy contents determined duration and degree of formality of implementation processes. For instance, in the FC policy, negotiating medicines prices and standardizing the tendering processes lengthened implementation. Highly varied stakeholder participation created avenues for decision-making and promoted inclusiveness, but also raised the need to manage different agendas and interests. Key contextual enablers and constraints to implementation included high political support and currency depreciation, respectively. The interrelatedness of policy content, actors, and context influenced the timeliness of policy implementations and achievement of intended outcomes, and suggest five attributes of effective policy implementation: (1) policy nature and complexity, (2) inclusiveness, (3) organizational feasibility, (4) economic feasibility, and (5) political will and leadership. Varied contextual factors, active participation of stakeholders, nature, and complexity of policy content, and structures have all influenced the implementation of medicines pricing policies in Ghana.

Health policy analysis in Eastern Mediterranean region using a health policy triangle framework: Historical and ethical insights from a systematic review.

SummaryBackgroundHealth policy can be defined as an agreement and consensus on a health-related program and set of actions taken to achieve the goals expected by programs in the area of policy. Policy analysis involves a wide range of methods, techniques, and tools in a way to reach awareness of the impacts of the developed and implemented policies. Whereas policy analysis in developed countries has a long history, in developing countries, it is instead in its first developing stages. Our paper aimed to collect systematically the studies using health policy triangle framework in doing analysis in one of the health policy issues in the Eastern Mediterranean region organization.MethodsTo conduct our literature search, ISI/Web of Science, PubMed/MEDLINE, Embase, The Cochrane Library, Global Health Database, Scopus, as well as Google Scholar from 2003 up to June 2020 were systematically mined. To evaluate the methodological quality of the included studies, the Critical Appraisal Skills Program checklist was used.ResultsWe selected 30 studies, conducted between 2011 and 2020. According to the findings of these studies, in the Eastern Mediterranean region, organization region, and the role of evidence-based research in policy-making has been repeatedly emphasized, but its use in health program decision-making has been limited, and health research systems in Eastern Mediterranean region organization are still under scrutiny. There is still a gap between evidence-based research in health systems and its use in policy-making.DiscussionBased on the present systematic review, studies based on policy analysis should focus on all the elements of health policies and provide evidence to inform decisions that can strengthen health systems, improve health and improve existing inequalities.

DONOR POWER AND PRIORITIZATION IN DEVELOPMENT ASSISTANCE FOR HEALTH POLICIES: THE CASE OF UGANDA

Purpose: The study sought to fill the knowledge gap by examining whether there were changes in Health Financing policies for Uganda’s health care system from 2002 to 2015 and their impact.
 Methodology: Literature on aid for health in low and middle-income countries was reviewed, while data on major donors to Uganda’s health care system obtained from their websites, as well as the Creditor Reporting System. Walt and Gilson’s health policy triangle framework was used to examine how different donors operated in Uganda’s health financing space. Vertical, horizontal, earmarked and budget support, as well as disease-specific fund allocation modes were also explored.
 Findings: Overall, donors influenced decisions on the selection of priority areas as well as fund allocation, despite efforts to involve the government in health policy formulation. The results were intended as an overarching guide for both donors and health policy-makers in future health financing decision making processes.
 Unique contribution to theory, practice and policy: Country engagement and policy ownership are critical to ensure harmonization of donor interests and country health needs. Increased aid for Health Systems Strengthening, Primary Health Care and Non-Communicable Diseases would also go a long way in improving population outcomes. Further studies on the sustainability of Development Assistance for health for middle and low-income countries are recommended.

Advancing Nursing Policy Advocacy Knowledge: A Theoretical Exploration.

Nursing policy advocacy continues to be recognized as a key part of a nurse's role by educators, professional associations, and regulators. Despite normative calls on nurses to engage in political action and advocacy, limited theories, models, and frameworks exist to support this practice within nursing. Using Walt and Gilson's Health Policy Triangle Framework, this article explores the theoretical underpinnings of policy advocacy to enhance nursing's contemporary role in advancing social justice. Specific consideration is placed on the type of nursing and policy knowledge and perspectives required to understand policy content, contexts, processes, and actors.

Addressing the challenges of implementing a Health Technology Assessment Policy Framework in South Africa.

South Africa's commitment to progressively achieve universal health coverage can lead to the effective and appropriate use of Health Technology Assessment (HTA) to strengthen the healthcare system. The study aimed to analyze the challenges faced in the formal implementation and utilization of HTA in the public health sector. Review and analysis of health technology policies and legislation introduced in South Africa since 1965 serves as the backbone of this study. Walt and Gilson's health policy triangle framework and Kingdon's model were used for data analysis. In addition, a semi-structured survey was conducted among key stakeholders, including those attending HTA workshops that were held in 2016 and 2017. The document review identified appropriate legislative and policy framework for informing healthcare decisions. Survey participants (n = 55) reported limited political support, local capacity, and awareness of HTA as barriers to implementing HTA. They noted that adequate financial resources and availability and sharing of quality data are primary drivers for HTA development. Effective governance, collaboration, and cooperation between key stakeholders of the healthcare system were suggested as possible ways forward for the institutionalization of HTA. The South African government's goal to introduce the national health insurance program provides an excellent opportunity to formally introduce the use of HTA in decision making. Individual capacity development supported by institutional and organizational environments is urgently needed to achieve its full potential.

Toward universal human papillomavirus vaccination for adolescent girls in Hong Kong: a policy analysis

Studies have assessed early population-level impact of human papillomavirus (HPV) vaccination programs for preventing cervical cancer. Through a case study in Hong Kong we examined stakeholder engagement and interactions to promote a universal HPV vaccination program using the Health Policy Triangle framework for structured health policy analysis. Using data from a document review and semi-structured in-depth interviews, we used thematic and stakeholder analyses to describe the process of policy formation. Given Hong Kong’s political and health system, and a mix of Chinese and Western values, stakeholders judged legitimacy of the process differently. We discuss their varied ethical stances and the role of research evidence for informing policy-making. For effective HPV vaccination policy and promotion of universal free HPV vaccination among adolescent girls, new strategies are needed to broaden acceptance of the process, to frame policies in terms of facts and values, and to connect research to policy-making and improve coalition-building.

Failure of Policy Initiatives in Regulating Health Professional Education: The Case of Dental Education in India

Health professional education and careers have witnessed major changes across the world during the last two decades of the twentieth century, and India is no exception to this. This article examines the current situation of dental education in India and explores the processes which have led to its commercialization, despite the existence of policy initiatives specifically intended for its regulation. Using the health policy triangle framework of Walt and Gilson, we attempt to understand the contexts and processes of commercialization of dental education and the development of the major regulatory policy initiatives in the sector. Secondary data analysis (regarding the growth of dental education), document analysis (policy and legal) and literature review (about higher education in India specifically medical and dental) are the methods used. The analysis brings to light the failure of policy initiatives in the past three decades by the regulatory bodies of the country, to curb the uncontrolled growth and commercialization of dental education. The Indian experience brings home the critical lesson that drafting relevant policies will not guarantee results, especially when they are to be implemented in the absence of a favourable political climate.

Contracting-out urban primary health care in Bangladesh: a qualitative exploration of implementation processes and experience

BackgroundContracting-out (CO) to non-state providers is used widely to increase access to health care, but it entails many implementation challenges. Using Bangladesh’s two decades of experience with contracting out Urban Primary Health Care (UPHC), this paper identifies contextual, contractual, and actor-related factors that require consideration when implementing CO in Low- and Middle- Income Countries.MethodsThis qualitative case-study is based on 42 in-depth interviews with past and present stakeholders working with the government and the UPHC project, as well as a desk review of key project documents. The Health Policy Triangle framework is utilized to differentiate among multiple intersecting contextual, contractual and actor-related factors that characterize and influence complex implementation processes.ResultsIn Bangladesh, the contextual factors, both intrinsic and extrinsic to the health system, deeply impacted the CO process. These included competition with other health projects, public sector reforms, and the broader national level political and bureaucratic environment. Providing free services to the poor and a target to recover cost were two contradictory conditions set out in the contract and were difficult for providers to achieve. In relation to actors, the choice of the executing body led to complications, functionally disempowering local government institutions (cities and municipalities) from managing CO processes, and discouraging integration of CO arrangements into the broader national health system. Politics and power dynamics undermined the ethical selection of project areas. Ultimately, these and other factors weakened the project’s ability to achieve one of its original objectives: to decentralize management responsibilities and develop municipal capacity in managing contracts.ConclusionsThis study calls attention to factors that need to be addressed to successfully implement CO projects, both in Bangladesh and similar countries. Country ownership is crucial for adapting and integrating CO in national health systems. Concurrent processes must be ensured to develop local CO capacity. CO modalities must be adaptable and responsive to changing context, while operating within an agreed-upon and appropriate legal framework with a strong ethical foundation.

Frameworks for self-management support for chronic disease: a cross-country comparative document analysis

BackgroundIn a number of countries, frameworks have been developed to improve self-management support (SMS) in order to reduce the impact of chronic disease. The frameworks potentially provide direction for system-wide change in the provision of SMS by healthcare systems. Although policy formulation sets a foundation for health service reform, little is currently known about the processes which underpin SMS framework development as well as the respective implementation and evaluation plans.MethodsThe aim of this study was to conduct a cross-country comparative document analysis of frameworks on SMS for chronic diseases in member countries of the Organisation for Economic Cooperation and Development. SMS frameworks were sourced through a systematic grey literature search and compared through document analysis using the Health Policy Triangle framework focusing on policy context, contents, actors involved and processes of development, implementation and evaluation.ResultsEight framework documents published from 2008 to 2017 were included for analysis from: Scotland, Wales, Ireland, Manitoba, Queensland, Western Australia, Tasmania and the Northern Territory. The number of chronic diseases identified for SMS varied across the frameworks. A notable gap was a lack of focus on multimorbidity. Common courses of action across countries included the provision of self-management programmes for individuals with chronic disease and education to health professionals, though different approaches were proposed. The ‘actors’ involved in policy formulation were inconsistent across countries and it was only clear from two frameworks that individuals with chronic disease were directly involved. Half of the frameworks had SMS implementation plans with timelines. Although all frameworks referred to the need for evaluation of SMS implementation, few provided a detailed plan.ConclusionsDifferences across frameworks may have implications for their success including: the extent to which people with chronic disease are involved in policy making; the courses of action taken to enhance SMS; and planned implementation processes including governance and infrastructure. Further research is needed to examine how differences in frameworks have affected implementation and to identify the critical success factors in SMS policy implementation.

From Scheme to System (Part 1): Notes on Conceptual and Methodological Innovations in the Multicountry Research Program on Scaling Up Results-Based Financing in Health Systems

—This article presents conceptual and methodological developments made in analyzing the scale up of results-based financing (RBF) as part of a multicountry research program supported by the Alliance for Health Policy and Systems Research. Following a brief overview of the research process, the article proposes a new five-dimensional conceptualization of scale-up (population coverage, service coverage, health system integration, cross-sectoral diffusion, and knowledge expansion) to capture various facets of RBF scale-up. It also presents how Walt and Gilson's health policy triangle framework was modified to identify the enablers and barriers to scale-up in the country case studies included in this research program. The article then puts forth a four-phase model of scale-up, including phases of generation, adoption, institutionalization, and expansion, developed for the purpose of this research program. The article concludes by providing some lessons learned on the use of the methods and theoretical frameworks developed for this multicountry research program.

O16.2 Evidence, politics and cultures in policymaking: policy analysis of hpv vaccine introduction in india

Introduction Despite India having the highest burden of cervical cancer globally, the HPV vaccine is not part of the routine immunisation programme. The decision process on HPV vaccine was put-off in 2010 shortly after a high profile vaccine demonstration trial was suspended when five girls died. Although the evidence that the deaths were linked to the vaccine is highly contested, nonetheless a political decision on HPV vaccine introduction differed. The purpose of the current study is to explore the political, socio-economic and cultural factors influencing the HPV policy decision in India. Evidence from the study may have implications for future vaccines targeting STIs in contested policy environments. Methods We used qualitative methods for policy analysis based on primary data collection supplemented with in-depth documentary review. Semi-structured interviews were conducted with 46 participants including policy makers, health system actors and community based organisations at State and National level. We used the Gilson and Walt Health policy triangle framework to analyse the data. Results Interim results have highlighted a number of features of the policy process in India, which may have influenced vaccine policy decision-making. These include: lack of adequate policy space for transparent discussion of concerns; strong suspicion of conflict of interest among researchers and international donors; mistrust of Government officials by civil society members; Government concerns around sustainable funding options; and a dearth of Government initiatives to promote culturally sensitive sexual health issues. Conclusion The [non]-introduction of the HPV vaccine into the Indian policy landscape was influenced by a variety of factors including contested empirical evidence of safety and perceptions of institutional (particularly commercial) interests outweighing public health evidence. This study provides important lessons not only for the future introduction of HPV vaccine in India, but also for any other vaccines targeting STIs. Disclosure of interest statement The study is funded by Wellcome Trust and the Public Health Foundation of India. No pharmaceutical grants were received for this research study.

Policies and Programs for Prevention and Control of Diabetes in Iran: A Document Analysis.

Trend analysis in 2005 to 2011 showed high growth in diabetes prevalence in Iran. Considering the high prevalence of diabetes in the country and likely to increase its prevalence in the future, the analysis of diabetes-related policies and programs is very important and effective in the prevention and control of diabetes. Therefore, the aim of the study was an analysis of policies and programs related to prevention and control of diabetes in Iran in 2014.This study was a policy analysis using deductive thematic content analysis of key documents. The health policy triangle framework was used in the data analysis. PubMed and ScienceDirect databases were searched to find relevant studies and documents. Also, hand searching was conducted among references of the identified studies. MAXQDA 10 software was used to organize and analyze data.The main reasons to take into consideration diabetes in Iran can be World Health Organization (WHO) report in 1989, and high prevalence of diabetes in the country. The major challenges in implementing the diabetes program include difficulty in referral levels of the program, lack of coordination between the private sector and the public sector and the limitations of reporting system in the specialized levels of the program.Besides strengthening referral system, the government should allocate more funds to the program and more importance to the educational programs for the public. Also, Non-Governmental Organizations (NGOs) and the private sector should involve in the formulation and implementation of the prevention and control programs of diabetes in the future.