National-level Decision-making Research Articles

Transition and change: opportunities and challenges of CHW programme reform for community health systems and vertical disease programmes in Liberia

BackgroundGlobally, community health worker (CHW) programmes are critical to addressing health worker shortages and have been recognised as critical pillars within the drive towards universal health coverage (UHC). In 2016, the Liberian Ministry of Health launched the National Community Health Services Policy 2016–2021, which included significant CHW programme reform to address ongoing health workforce capacity gaps in the country. However, little consideration was given to the impact of such reforms on ongoing health interventions that rely heavily on the use of CHW cadres. Our study explores how CHW programme reform in Liberia influenced performance of CHWs involved in the delivery of Neglected Tropical Disease (NTD) programmes to elucidate how health systems reform can impact the delivery of routine health interventions and vice versa.MethodsWe used a qualitative case study approach conducted between March 2017 and August 2018. Our instrumental case study approach uses qualitative methods, including document review of five CHW and NTD program-related policy documents; 25 key informant interviews with facility, county, and national level decision-makers; and 42 life and job histories with CHWs in Liberia. Data were analysed using a thematic framework approach, guided by Kok et al. framework of CHW performance. Data were coded in QRS NVIVO 11 Pro.ResultsOur findings show that CHW programme reform provides opportunities and challenges for supporting enhanced CHW performance. In relation to health system hardware, we found that CHW programme reform provides better opportunities for: formal recognition of CHWs; strengthening capacity for effective healthcare delivery at the community level through improved and formalised training; a more formal supervision structure; and provision of monthly incentives of 70 US dollars. Efficiency gaps in routine intervention delivery can be mitigated through the strengthening of these hardware components. Conversely, supervision deficits in routine CHW functioning can be supported through health interventions. In relation to systems software, we emphasise the ongoing importance of community engagement in CHW selection that is responsive to gendered power hierarchies and accompanied by gendered transformative approaches to improving literacy.ConclusionsThis study shows how CHW programme reform provides opportunities and challenges for health system strengthening that can both positively and negatively impact the functioning of routine health interventions. By working together, CHW programmes and routine health interventions have the opportunity to leverage mutually beneficial support for CHWs, which can enhance overall systems functioning by enhancing CHW performance.

Greenhouse gas emissions mitigation potential of municipal solid waste management: A case study of 13 prefecture-level cities in Jiangsu Province, China

Municipal solid waste (MSW) treatment is one of the main anthropogenic sources of greenhouse gases (GHGs). To mitigate the GHG emissions of the MSW sector, it is crucial to describe their emissions evolutions and mechanisms and propose localized mitigation measures on that basis. The logarithmic mean Divisia index model is used to identify the driving forces of MSW-related GHG emissions and explore the mitigation potential. Jiangsu, a typical province in China with 13 prefecture-level cities, is selected as the case study. The results showed that GHG emissions from Jiangsu's MSW treatment has increased by nearly 2.5 Mt in the last 20 years, as incineration replaces landfills. Economic development was the dominant positive driving force, and MSW generation intensity was the dominant negative driving force. Scenario analysis revealed that the carbon peak of MSW management could appear if MSW source separation and recycling (SSR) were implemented, reducing GHG accumulation emissions by approximately 0.3–0.4 Gt during 2022–2060. Referencing the SSR of the Shanghai pattern will generate the greatest mitigation potential of GHG emissions among the different scenario designs. Finally, policy recommendations for priority cities, consideration of population and economic factors, optimization of MSW treatment structures and improvements to SSR are proposed, which could help local- and national-level decision makers in China and other countries design policy guides to promote carbon neutrality, while simultaneously linking current research areas to waste management practices as well as promoting practices in environment and sustainability.

Temporality shaping lessons learned from COVID-19 - Follow-up study of Finnish pandemic governance

Abstract Background Public health crises require and offer unique opportunities for learning. Despite abundant “lessons learned” -literature on the COVID-19, follow-up research designs are scarce. To fill in this gap we analyse how key national level decision-makers in Finland discuss the lessons from COVID-19 at its’ different stages, since they are in key positions to develop health system preparedness and crises response policies based on lessons from past shocks. Methods The qualitative interview study includes unique follow-up data on Finnish national-level decision-makers’ interpretations of the lessons learned from COVID-19. The interviewees represent key ministries, other governmental organisations with responsibilities in pandemic governance, expert organisations and authorities responsible for preparedness. The data were collected from the same informants 1) at the acute stage of the epidemic in Finland (2021, n = 21) and 2) after the vaccination coverage was at high level and the acute stage of the epidemic had passed (2022-2023, n = 16). Analyses included abductive and thematical content analyses. Results The lessons learned from COVID-19 were defined differently at different stages of the pandemic. In addition, the possibilities to assess or implement the lessons or reform the system were hampered by scarce resources and the political agenda already shifting to other crises and challenges. Results further showed the short-term nature of many of the crisis measures taken during the acute stage. Conclusions The follow-up design enabled analysis of the nature of the lessons learned during and after the acute stage of COVID-19. Temporal framing of data illustrated the changing and emergent nature of the lessons learned, highlighting the need for broad ranging analyses across multiple time spots and crisis cycles in the future. Scarce human and financial resources in the health system compel to focus on most topical issues, hampering long-term development. Key messages • Preparation for future crises requires practical measures during normal times. • Comprehensive analyses of lessons learned beyond a single crisis cycle supports continuity of crisis preparedness and management.

Role of Personality on Psychological Well-being in Public Services: Theorizing the Self-Determination Theory Perspective

Public services constitute an important aspect in government functioning. The well-being of such employees becomes increasingly important, as they play a crucial role in national level decisionmaking. The study is focused on two objectives, that is whether individual resources lead to positive organizational outcomes and whether the organizational outcomes lead to creating positive workplaces. In order to explore the above objectives, two hypotheses are drawn: (a) Individual personality variables (individual resources) will lead to a positive impact on organizational citizenship behaviour (OCB) and (b) OCB will mediate the relationship between personality and perceived well- being (PWB) (conceptualized as primary component to happy workplaces). Data were collected on 399 employees from the Indian Ministry of Commerce and Industry. The results showed that OCB fully mediated the relationship between agreeableness, conscientiousness and intellect, with PWB, while OCB partially mediated the relationship between extraversion and neuroticism, with PWB. The results are explained in juxtaposition with Self-Determination Theory (SDT) to provide a new theoretical perspective of eudemonic well-being in the public sector. The study highlights the importance of personality of the employees to be considered for selection in public services, which is an important determinant for their discretionary behaviour towards organization and their well-being.

Cross-country analysis of national mental health investment case studies in sub-Saharan Africa and Central, South and South-East Asia.

Despite the increasing interest in and political commitment to mental health service development in many regions of the world, there remains a very low level of financial commitment and corresponding investment. Assessment of the projected costs and benefits of scaling up the delivery of effective mental health interventions can help to promote, inform and guide greater investment in public mental health. A series of national mental health investment case studies were carried out (in Bangladesh, Kenya, Nepal, Philippines, Uganda, Uzbekistan and Zimbabwe), using standardized guidance developed by WHO and UNDP and implemented by a multi-disciplinary team. Intervention costs and the monetized value of improved health and production were computed in national currency units and, for comparison, US dollars. Benefit-cost ratios were derived. Across seven countries, the economic burden of mental health conditions was estimated at between 0.5%-1.0% of Gross Domestic Product. Delivery of an evidence-based package of mental health interventions was estimated to cost US$ 0.40-2.40 per capita per year, depending on the country and its scale-up period. For most conditions and country contexts there was a return of >1 for each dollar or unit of local currency invested (range: 0.0-10.6 to 1) when productivity gains alone are included, and >2 (range: 0.4-30.3 to 1) when the intrinsic economic value of health is also considered. There was considerable variation in benefit-cost ratios between intervention areas, with population-based preventive measures and treatment of common mental, neurological and conditions showing the most attractive returns when all assessed benefits are taken into account. Performing a mental health investment case can provide national-level decision makers with new and contextualized information on the outlays and returns that can be expected from renewed local efforts to enhance access to quality mental health services. Economic evidence from seven low- and middle-income countries indicates that the economic burden of mental health conditions is high, the investment costs are low and the potential returns are substantial.

Implementation of adaptation to climate change in public health in Europe: qualitative thematic analysis

BackgroundIncreasingly, climate change policies are emerging across Europe. Policies addressing adaptation (adjusting the effects of climate change on public health) are being implemented after the COVID-19 pandemic. This study aims to identify issues in climate adaptation implementation for public health and understand the health implications from responses after COVID-19. MethodsKey informant interviews were undertaken with decision makers in international, national, and local governments across 20 European countries (Norway, England, Cyprus, Spain, Ireland, Finland, Lithuania, Belgium, the Netherlands, Sweden, Latvia, Italy, Estonia, Austria, Croatia, France, Germany, Hungary, Denmark, and Scotland). A WHO stakeholder analytical framework was followed for developing the interview themes. Participants were recruited if based in European governments, working in public or environmental health, and involved in climate adaptation policy. Participants were recruited through known networks and geographical coverage was obtained (eight per European region). An interview schedule with key themes (barriers, public health agenda, levers, networks, evidence needs, and COVID-19 recovery) was used. Interviews were conducted online, recorded, transcribed, and analysed through Nvivo. Findings32 interviews were completed between June and October, 2021; four international stakeholders, five national-level decision makers, 23 city-level decision makers or network representatives. Most reported inadequate resources for health adaptation implementation (funding, training, and personnel) and the marginal role of health in climate adaptation policy. A key reported challenge was limited departmental cross-collaboration across governance levels, because city-level stakeholders were less aware of the public health role in climate change policy. COVID-19 recovery strategies were not perceived as opportunistic for future adaptation. However, several respondents identified benefits for health system resilience, for example improved emergency planning and disaster management. InterpretationAcross Europe, there is varied progress in the implementation of climate change and health adaptation. Providing appropriate resource, inter-departmental collaboration, knowledge mobilisation, and multi-level governance support will facilitate climate and health policy implementation. Overcoming these barriers and learning from COVID-19 through strengthened emergency planning and responses to climate events can strengthen UK public health system resilience and beyond. FundingThis project has received part-funding from the Enhancing Belmont Research Action to support EU policy making on climate change and health project, which is part of the EU's Horizon 2020 research and innovation programme (grant agreement number 101003966). The research was part-funded by the National Institute for Health Research Health Protection Research Unit in Environmental Change and Health at the London School of Hygiene and Tropical Medicine in partnership with Public Health England, the Met Office, and University College London (grant number PHSEZT6210). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or PHE.

EDUCATION OF MIGRANTS IN THE SCANDINAVIAN COUNTRIES

The article examines the level of education in the Scandinavian countries, educational opportunities for first- and second-generation migrants. The research demonstrates the high level of education provided by Scandinavian higher education institutions not only for the local population, but also for international students. The developed Scandinavian education system with good learning conditions and relatively low tuition fees for foreigners attracts foreign students. We also examined the economic component of the success of Scandinavian education systems. The level of education in the Scandinavian countries is one of the highest in the world, the state budget for the development of the education sector is much larger than in other EU countries. Annually the countries of the Scandinavian region allocate the largest share of the budget among European states to education. Decentralization of decision-making and administration of basic education to regional and local bodies is typical in all Nordic region countries. National-level decision-making is also divided between ministries and one or several national agencies in all these countries. The article provides statistics on the level of education of the general population and a comparison of the level of labor migrants’ education. In order to understand the comprehensive picture of education and employment of immigrants, we carefully examined the migration waves and trends in Northern Europe from the second half of the last century to the present. The article provides detailed statistical data on migrants and their descendants in Scandinavia in general and on individual countries, the status and statistics on family migration. Scandinavian scientists and statisticians comprehensively study the issue of migrants and their integration into society, they realize the fact that new arrivals should be considered and treated as individuals with specific problems. That’s why they need a thorough study of their immigrant background, providing opportunities to learn English or the required Scandinavian language, as well as opportunities and prospects for Ukrainian migrants under martial law.

Rice Commercialization in Mngeta Kilombero District, Tanzania: Policy Implications for Inclusive Poverty Reduction

Agricultural commercialization is sought for its effect on productivity, income and livelihood improvement. Rising agricultural commercialization also contributes to employment, foreign currency and government revenue through taxes. It may however have various undesirable outcomes. Rising commercialization from area expansion may increase the smallholders’ vulnerability if they sell part or all of their land. Meanwhile, intensification can have negative effects from increasing use and poor handling of agrochemicals. This paper used pooled cross section data on rice commercialization from Mngeta division in Kilombero valley, Tanzania; collected in two waves (2017 and 2019), to assess commercialization levels among different farmer categories and its impact of on livelihoods and social inclusion. The paper addresses three basic questions; Are commercialization levels dynamic over time? Do commercialization levels differ across farmer categories? Is rice commercialization poverty reducing at all levels? The analysis compares across farmer categories, the effect of commercialization influencing factors and the subsequent effect of rice commercialization on livelihood outcomes. The findings show that commercialization is happening through intensification and extensification but it is not yet on a steady increasing trend and both options have sustainability implication. Meanwhile, poverty reduction is observed across all farmer categories due to rice commercialization and diversified livelihood options, however it is only significant above the fourth quintile (>60% with a social difference). Gender, age and cultural norms are identified as exclusion barrier that need to be addressed in order to enhance inclusion of those benefiting less from agricultural commercialization processes. These finding inform village, district and national level decision makers as they strive to overcome inclusion barriers Keywords: Commercialization, inclusion, diversification, rice, poverty reduction, Kilombero, Tanzania DOI: 10.7176/DCS/12-7-04 Publication date: September 30 th 2022

A macroeconomic disaster risk analysis: The case study of Chile

From a macroeconomic perspective, the occurrence of disasters, especially high-impact events, can lead to financial stress in a country due to the sudden high demand for resources to restore affected exposed assets. Disaster risk is a sovereign risk and implies a non-explicit contingent liability that, in many cases, has a major impact on fiscal sustainability. Two risk composite indicators have been used to measure the impact that potential disasters can mean for a country: (i) The Disaster Deficit Index (DDI), which measures a country's financial capacity to cover the economic losses generated after the occurrence of high-impact events; and (ii) A complementary index (DDI′), which indicates the fraction that the expected annual loss would represent to the annual surplus of a country. This paper describes the overall macroeconomic impact of disasters and presents DDI results for Chile, which allows national-level decision-makers to understand the economic implications of disasters for the country and the need to consider this kind of information in the long-term policies. Results of the DDI for Chile illustrate that extreme disasters would imply the need for a significant amount of budgetary resources from the government. Estimated losses would be double the available budget resources and the financing of the recovery could mean restrictions to invest in other ongoing social and development needs of the country. This macroeconomic risk in Chile may be hedged by strategically setting up a risk financial structure based on adequate loss estimation criteria, using different available alternatives such as public and private assets insurance, disasters' reserves, contingency credits contracts, and investing in prevention and mitigation to reduce potential economic losses.

The Coronavirus Pandemic and Global Governance: The Domestic Diffusion of Health Norms in Global Health Security Crises

The recent outbreak of the COVID-19 pandemic demands imperative discussions in the field of health security and global governance. Traditional studies on health care and global governance have acknowledged the significance of “global” as it rested on the fact that epidemics and pandemics are not restricted within national boundaries. The COVID-19 pandemic has challenged the hierarchical division of norm diffusion. Despite the structural inequalities, the patterns of behavior of various countries, such as China, the USA, Italy, South Korea, and India, in managing the crisis suggest a favorable ground for bringing in the importance of national-level decision-making in the global versus local debate. Building upon the arguments from norm theories of diffusion, the article contributes to our understanding that for an effective analysis of the politics of global health governance, the power of local channels in the diffusion of essential health norms cannot be undermined. The article studies the role played by the local-level diffusion processes, in this case, the national state actors in reshaping and integrating essential health norms to make it workable for broader global relevance. As a result, following the norm theories of diffusion, this article analyzes the global–local dynamics with regard to public health in the context of the spread of the COVID-19 health security threat.

The coordination problem in European defence planning

The European Union has taken several steps since 1999 to achieve its so-called ‘headline goal’ for defence coordination: the ability to create and deploy a multinational rapid-reaction force comprised of up to one army corps (50,000–60,000 soldiers) within one to two months. Yet these steps have yielded little, and a subset of EU member states is debating how it might form a single modular brigade of 3,000–5,000 soldiers for a similar purpose. The reason that coordination at the EU level has proved difficult – even as the concept of ‘strategic autonomy’ receives increasing attention – is that member states remain hesitant to subordinate national-level decision-making on defence issues.

The Economic Burden of Influenza-Like Illness among Children, Chronic Disease Patients, and the Elderly in China: A National Cross-Sectional Survey.

Background: The disease burden of seasonal influenza is substantial in China, while there is still a lack of nationwide economic burden estimates. This study aims to examine influenza-like illness (ILI) prevalence, healthcare-seeking behaviors, economic impact of ILI, and its influencing factors among three priority groups during the 2018–19 influenza season. Methods: From August to October 2019, 6668 children’s caregivers, 1735 chronic disease patients, and 3849 elderly people were recruited from 10 provinces in China to participate in an on-site survey. The economic burden of ILI consisted of direct (medical or non-medical) and indirect burdens, and a two-part model was adopted to predict the influencing factors of total economic burden. Results: There were 45.73% children, 16.77% chronic disease patients, and 12.70% elderly people reporting ILI, and most participants chose outpatient service or over-the-counter (OTC) medication after ILI. The average economic burden was CNY 1647 (USD 237.2) for children, CNY 951 (USD 136.9) for chronic disease patients, and CNY 1796 (USD 258.6) for the elderly. Two-part regression showed that age, gender, whether the only child in the family, region, and household income were important predictors of ILI economic burden among children, while age, region, place of residence, basic health insurance, and household income were significant predictors of ILI economic burden among chronic disease patients and the elderly. Conclusions: A large economic burden of ILI was highlighted, especially among the elderly with less income and larger medical burdens, as well as children, with higher prevalence and higher self-payment ratio. It is important to adopt targeted interventions for high-risk groups, and this study can help national-level decision-making on the introduction of influenza vaccination as a public health project.

User-Centered Design: Developing the RELI Delivery System - a Low-Cost, Non-Electric, Pneumatic Infusion Pump.

PurposeInfusion pumps are the preferred method for intravenous delivery of drugs and fluids, and an essential tool in health facilities. Their high cost, complexity and reliance on electricity pose serious challenges to wide-spread use, availability and access in low- and middle-income countries. PATH developed the RELI Delivery System (RELI), a low cost, non-electric infusion pump to address these challenges. Input collected from fifty-nine newborn and maternal care providers and from seven national level decision makers in Uganda was used to guide product development, further informing product design requirements, and optimal design features to best serve their needs.MethodsA formative evaluation following a mixed methods approach including focus group discussions (FGDs), stakeholder interviews, and observations was used to collect data from end users.ResultsStakeholders provided critical input on the RELI prototype design features, safety criteria, and contexts of use of infusion pumps, as well as recommendations for design refinements. Infusion systems are greatly needed but not readily available and their use is limited to well-resourced higher level facilities, even though the need is high in non-tertiary care hospital where patient volume is high, resources are scarce, power is inconsistent, and facilities are understaffed and overcrowded. Users expressed a need for an affordable and simple device with an intuitive user interface, clear instructions for use, and basic safety features.ConclusionThe study provided important guidance for further design refinements based on input from respondents and confirmed the need for robust, affordable, infusion pumps that meet the requirements for use in low-resource settings.

Dissolving the Internal-External Divide: Sierra Leone’s Path In and Out of Peacekeeping

ABSTRACT This article explores Sierra Leone’s trajectory from host of the world’s largest peace-support operation to post-conflict provider of peacekeepers elsewhere. Building on the authors’ previous research, it aims to nuance contemporary theoretical discussions of why states contribute peacekeepers, arguing that existing frameworks are unable to fully explain such developments in the Sierra Leonean case. A key reason is that these frameworks principally focus on national-level decision-making, overlooking the influence of foreign governments and external political pressures. Sierra Leone’s contribution of peacekeepers became integral to the post-conflict reconstruction of its armed forces, enabled and pushed forward by external partners, most prominently the UK. As such, internal and external factors intertwined to advance this trajectory, from national identity to income generation, international support and domestic crises. Sierra Leone’s trajectory grew from unique circumstances – with international partners playing an exceptionally central role in driving the process forward. These factors make Sierra Leone an important case to interrogate, against the backdrop of existing theoretical frameworks that seek to explain why states contribute troops.

Cyber-weapons in nuclear counter-proliferation

ABSTRACT Under what conditions are cyber-weapons effective in nuclear counter-proliferation? With continued interest in nuclear proliferation professed by Iran, North Korea, and Saudi Arabia, a discussion of the effectiveness of counter-proliferation measures remains relevant. Cyber-attacks as military option in a state-on-state conflict still requires additional corroborating evidence to make conclusions about its long-term effectiveness. This work analyses the general applicability of cyber-weapons and their usefulness in nuclear counter-proliferation. Through a comparative case study of Operation Orchard, Stuxnet, and recent “Left-of-Launch” operations against North Korea, the essay finds that cyber-operations are not particularly effective against nuclear programmes that are in the later stages of their development. They can disrupt and delay a nuclear programme temporarily, if the attack remains clandestine, but cannot halt nuclear proliferation all together. However, effectiveness increases if they are used in combination with conventional weapons. The article addresses a topic of interest to national-level decision-makers: whether cyber-operations can and should play a role in nuclear counter-proliferation.

Strategic analysis of medal markets at the Winter Olympics

PurposeThis paper aims to propose the concept of market potential analysis, which is commonly applied in economics, as a method to enable these investment decisions to be based on sound evidence.Design/methodology/approachThe markets for Olympic awards, i.e. medals (top three places) and diplomas (i.e. top eight places) are compared in alpine skiing, biathlon, cross country, speed skating, freestyle skiing, short track and snowboarding from 1992 to 2018.FindingsThe most notable changes are identified in cross country (2002), biathlon (2006), freestyle skiing (2014), snowboarding (2006 and 2014) and speed skating (2018).Originality/valueIn spite of the evidence of nations investing strategically in their elite sport systems to produce Olympic success, there is a lack of knowledge on how national-level decision makers can use a strategy to analyse the competitive environment concerning sports contested in the Olympic Winter Games.

Model forests in Russia as landscape approach: Demonstration projects or initiatives for learning towards sustainable forest management?

Implementing sustainable forest management (SFM) policy on the ground is not straightforward, and depends on the social-ecological context. To meet the need for place-based stakeholder collaboration towards regionally adapted knowledge production and learning in support of SFM an integrated landscape approach can assist. Hosting most of the circumboreal forest Russia is a key global player. To transition boreal forestry in the Russian Federation from wood mining towards SFM after the collapse of USSR several initiatives were initiated. Our aim is to review the outcomes and consequences of the initiatives employing the international Model Forest concepts' six principles in Russia. To identify candidates for the study we identified 12 local initiatives using this term, all in Russia's boreal forest biome. However, while seven demonstration forests focused on improving wood production practices, five were long-term stakeholder-driven development processes aimed at SFM, and were approved members of the International Model Forest Network. The five latter were selected for a detailed study to understand their temporal dynamic in the circumboreal Model Forest context, and the extent to which they complied with the six principles of the Model Forest concept as an example of a landscape approach. The sources, amounts and durations of these initiatives' funding affected both outcomes and consequences on the ground. All five had developed a partnership that formally shared a commitment to SFM. However, not all areas were large enough to represent all dimensions of SFM. Not all Model Forests developed a representative, participative, transparent, and accountable governance structure, which affected the programs of their activities. Finally, knowledge-sharing, capacity-building and networking at multiple levels was variable. In spite of Russia hosting most of the circumboreal forest the Model Forest concept was not sustained in Russia due to ending of foreign project funding, to limited continuity of committed local capacity, and poor support from national-level decision makers. The exception is the Komi Model Forest's transition to a successful consulting company focusing on SFM. To develop regionally adapted approaches to implement SFM policy we stress the importance of sharing experiences from Model Forests as well as other landscape approach concepts among countries and regions with different landscape histories and governance arrangements. To enhance this, we propose a general analytic framework for learning through evaluation about place-based long-term initiatives that integrate evidence-based knowledge about states and trends of sustainability and cross-sector multi-level governance.

Non-communicable disease prevention policy process in five African countries authors

BackgroundThe increasing burden of non-communicable diseases (NCDs) in sub-Saharan Africa is causing further burden to the health care systems that are least equipped to deal with the challenge. Countries are developing policies to address major NCD risk factors including tobacco use, unhealthy diets, harmful alcohol consumption and physical inactivity. This paper describes NCD prevention policy development process in five African countries (Kenya, South Africa, Cameroon, Nigeria, Malawi), including the extent to which WHO “best buy” interventions for NCD prevention have been implemented.MethodsThe study applied a multiple case study design, with each country as a separate case study. Data were collected through document reviews and key informant interviews with national-level decision-makers in various sectors. Data were coded and analyzed thematically, guided by Walt and Gilson policy analysis framework that examines the context, content, processes and actors in policy development.ResultsCountry-level policy process has been relatively slow and uneven. Policy process for tobacco has moved faster, especially in South Africa but was delayed in others. Alcohol policy process has been slow in Nigeria and Malawi. Existing tobacco and alcohol policies address the WHO “best buy” interventions to some extent. Food-security and nutrition policies exist in almost all the countries, but the “best buy” interventions for unhealthy diet have not received adequate attention in all countries except South Africa. Physical activity policies are not well developed in any study countries. All have recently developed NCD strategic plans consistent with WHO global NCD Action Plan but these policies have not been adequately implemented due to inadequate political commitment, inadequate resources and technical capacity as well as industry influence.ConclusionNCD prevention policy process in many African countries has been influenced both by global and local factors. Countries have the will to develop NCD prevention policies but they face implementation gaps and need enhanced country-level commitment to support policy NCD prevention policy development for all risk factors and establish mechanisms to attain better policy outcomes while considering other local contextual factors that may influence policy implementation such as political support, resource allocation and availability of local data for monitoring impacts.

Collaboration Between Intelligence and Decisionmakers: The Israeli Perspective

Much has been written on the complex relationship between intelligence personnel and national-level decisionmakers. By the last quarter of the 20th century, with the founding of national intelligen...

Data-driven quality improvement in low-and middle-income country health systems: lessons from seven years of implementation experience across Mozambique, Rwanda, and Zambia

BackgroundWell-functioning health systems need to utilize data at all levels, from the provider, to local and national-level decision makers, in order to make evidence-based and needed adjustments to improve the quality of care provided. Over the last 7 years, the Doris Duke Charitable Foundation’s African Health Initiative funded health systems strengthening projects at the facility, district, and/or provincial level to improve population health. Increasing data-driven decision making was a common strategy in Mozambique, Rwanda and Zambia. This paper describes the similar and divergent approaches to increase data-driven quality of care improvements (QI) and implementation challenge and opportunities encountered in these three countries.MethodsEight semi-structured in-depth interviews (IDIs) were administered to program staff working in each country. IDIs for this paper included principal investigators of each project, key program implementers (medically-trained support staff, data managers and statisticians, and country directors), as well as Ministry of Health counterparts. IDI data were collected through field notes; interviews were not audio recorded. Data were analyzed using thematic analysis but no systematic coding was conducted. IDIs were supplemented through donor report abstractions, a structured questionnaire, one-on-one phone calls, and email exchanges with country program leaders to clarify and expand on key themes emerging from IDIs.ResultsProject successes ranged from over 450 collaborative action-plans developed, implemented, and evaluated in Mozambique, to an increase from <10% to >80% of basic clinical protocols followed in intervention facilities in rural Zambia, and a shift from a lack of awareness of health data among health system staff to collaborative ownership of data and using data to drive change in Rwanda.ConclusionBased on common successes across the country experiences, we recommend future data-driven QI interventions begin with data quality assessments to promote that rapid health system improvement is possible, ensure confidence in available data, serve as the first step in data-driven targeted improvements, and improve staff data analysis and visualization skills. Explicit Ministry of Health collaborative engagement can ensure performance review is collaborative and internally-driven rather than viewed as an external “audit.”