Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa

BMJ Global Health, Volume 7, No. 12, Year 2022

Interpretation

Background Lack of political will is frequently invoked as a rhetorical tool to explain the gap between commitment and action for health reforms in sub-Saharan Africa (SSA). However, the concept remains vague, ill defined and risks being used as a scapegoat to actually examine what shapes reforms in a given context, and what to do about it. This study sought to go beyond the rhetoric of political will to gain a deeper understanding of what drives health reforms in SSA. Methods We conducted a scoping review using Arksey and O’Malley (2005) to understand the drivers of health reforms in SSA. Results We reviewed 84 published papers that focused on the politics of health reforms in SSA covering the period 2002-2022. Out of these, more than half of the papers covered aspects related to health financing, HIV/AIDS and maternal health with a dominant focus on policy agenda setting and formulation. We found that health reforms in SSA are influenced by six; often interconnected drivers namely (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) policy diffusion. Conclusion Political will is relevant but insufficient to drive health reform in SSA. A framework of differential reform politics that considers how the power and beliefs of policy elites is likely to shape policies within a given context can be useful in guiding future policy analysis. This article used scoping review methods developed by Arksey and O’Malley32 to understand the drivers of health reforms in SSA. We selected this approach because of its emphasis on flexibility, reliance on an abductive logic of enquiry, and its bias towards narrative driven summation.33 The framework is presented as an iterative, qualitative review with five distinct stages: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data and (5) collating, summarising and reporting the results. It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research. ‘What is known from existing literature about the drivers of (non) health reforms in SSA?’ In line with prior studies,34 we developed a search strategy that covered three dimensions of the relevant studies: (1) the policy area of interest (health reforms), (2) the object of interest (policy processes/change) and (3) the geographical coverage (SSA). To refine the search, key health reforms such as primary healthcare (PHC) and universal health coverage (UHC) were expressly included in the search strategy based on the authors’ priori knowledge on health system reform efforts in SSA. While previous reviews have focused on specific policy areas, we maintained a wider policy interest to determine whether certain reform areas dominate research coverage and its potential implications. Between May and July 2022, we conducted a comprehensive literature search in three electronic databases: MEDLINE/PubMed, Academic Complete and WHO Global Medicus. A variety of search terms were used: Health AND Politics AND Africa, Limit to geography-Africa, South of Sahara, Political economy AND Health AND Africa, Primary health care AND politics AND Africa, Political economy AND Universal Health Coverage AND Low-middle income countries, Political economy AND Primary Health Care AND Low-middle income countries, Health AND power AND Africa. We also searched Google, Google scholar and the BioMed central (BMC) database through the ‘search all BMC articles’ portal: https://www.biomedcentral.com/. We purposively selected the BMC database due to its wider collection of journals with a focus on health systems in Low -and Middle -income Countries (LMICs) and the open access nature of the publications since we did not have access to other relevant paid-for databases such as CINAHL, Scopus and Web of Science. We also selected relevant papers from the International Journal of Health Policy and Management (IJHPM) Special Issue on Analysing the Politics of Health in Low-Middle-Income countries published in 2021: https://www.ijhpm.com/article_4039.html. We also reviewed the publications by members of the Social Science Approaches for Research and Engagement in Health Policy and Systems (SHAPES) Thematic Working Group (TWG) which are shared through a fortnightly email update. We reviewed the fortnightly updates from 1 September 2021 to 17 August 2022 which coincides with the period of the authors’ membership to the SHAPES TWG. We purposively selected the fortnightly updates from SHAPES because it focuses on key thematic areas related to this study such as power and policy analysis. Due to the centrality of power in health reforms, we also reviewed the ‘10 best resources on power in health policy and systems in low- and middle-income countries’ published by the Health Policy and Planning Journal in 2018 https://academic.oup.com/heapol/article/33/4/611/4868632. ATM conducted the screening process. The initial search generated 1844 papers. No time limit was set for the studies. Screening of the retrieved papers involved three sequential stages. The first stage involved title screening of all the papers. From this process, 83 duplicates were immediately removed. A further 1232 papers were removed for either being non-health related or being from outside SSA. In the context of this study, SSA is, geographically the area of the continent of Africa south of the Sahara. Countries from the Middle East/North Africa region: Algeria, Egypt, Libya, Morocco and Tunisia were therefore excluded. Non-health papers included general country profiles and coverage of reforms in other social sectors such as education, agriculture and housing and politics in general. After the title screening, 529 papers were eligible for the second stage which involved abstract screening. Out of these, 411 were excluded chiefly for not focusing on policy process. These papers were largely descriptive without explaining the drivers of such (non) reforms and fell into three broad categories: (1) those elaborating the importance of policy (2) those highlighting the risks of not implementing a given policy and (3) those showcasing benefits of reforms. Of the 118 papers that were eligible for full article screening, 45 were removed because they either included theory or framework ex post or frameworks announced but none referred to explicitly during analysis. This left a final list of 73 articles for data extraction and analysis. An additional 11 articles were obtained from the reference list of selected papers. A final list of 84 papers was eligible for full analysis. A detailed inclusion and exclusion criteria is shown in table 1. Inclusion and exclusion criteria for relevant studies Adapted from Jones et al (2021). SSA, sub-Saharan Africa. After identifying eligible articles, ATM conducted the data charting. Data charting is a technique for synthesising and interpreting qualitative data by sifting, charting and sorting material according to themes. Themes can be known or pre-established before data extraction (inductive approach) or emerge as data extraction begins and patterns start to form (deductive approach). In this study, we drew themes using both an inductive and deductive approach. Inductively, we drew themes from two papers that examined the concept of political will as an explanatory variable for (non) health reforms. The first paper by Baum et al used eight case studies from Australia to examine the determinants of political will for pro-health equity policies and how political will can be created through analysis of public policy.35 The second paper by Michael Reich synthesises relevant critiques on the application of the concept of political will to understand health reform process, including in LMICs.30 We also examined the main themes from the two supplements that focused on the politics of health reforms namely the Special Issue on Analysing the Politics of Health in LMICs published in the IJHPM in 2021 and the 10 best resources on power in health policy and systems in LMICs published by the Health Policy and Planning Journal in 2018. Through an integrative synthesis of these sources, we identified five relevant themes (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies and (5) elite interests. A data charting tool (extraction tool) was developed in Microsoft Excel capturing essential characteristics such as the title of the paper, year of publication, policy issue under study, theory used, the policy stage, reform drivers and other relevant attributes as shown in detail in table 2. Publication characteristics and reform aspects We conducted a thematic analysis by categorising the contents of each eligible article according to the five themes mentioned above. The first step involved verbatim extraction of text excerpts from the selected articles, which were categorised according to the themes in the data charting tool. The second step involved an iterative process of interpretive data analyses and refining, including an analysis of how a given reform driver played out similarly or diverged across geography and time. Through this iterative process, a sixth theme emerged: the influence of transnational and national policy diffusion as a reform driver. This emerging theme was incorporated into the data extraction tool and all the papers were examined against the emergent theme. Pivot tables were run in Microsoft Excel to collate and summarise the results on publication characteristics and reform aspects. The selection process is shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram in figure 1. The policy studies were drawn from more than 30 different countries from Southern, Central, East and West Africa. Out of the 84 studies included, two countries accounted for more than 40% of the total studies, with South Africa accounting for 22% of the total studies while Ghana accounted for 19%. PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The general profile of the selected papers is shown in table 3. Profile of reviewed studies ARV, Antiretroviral; CBHI, Community-Based Health Insurance; NHI, National Health Insurance; PBF, Perfomance-Based Financing; PMTCT, Prevention of Mother To Child Transmission; VMMC, Voluntary Medical Male Circumcision. The next sections present how the drivers for health reforms identified earlier influenced (non) health reforms in SSA: (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) transnational and national policy diffusion. Health policy reform efforts face resistance because they commonly place concentrated new costs on well-organised, powerful groups while seeking to make new benefits available to non-organised and powerless groups.30 In Ghana, the transition from the pay for service arrangement or ‘cash and carry system’ to a National Health Insurance (NHI) in the early 2000s received popular support because the working middle class wanted to be relieved of the burden to cater for their own health and that of extended families36 37 and parliamentarians desired to offload the constituents’ incessant demand for money to cater for personal health needs.22 Contrary, the middle class in South Africa showed apathy towards advocating for the NHI policy because they benefited from a labour structure that provided them with private sector health.38 At institutional or bureaucratic level, reforms with fiscal implications were slowed down or derailed due to divergent frames between the Ministry of Health (MOH) and the Ministry of Finance (MOF) as in the case of South Africa.39 40 Through its power to set the macroeconomic agenda and control the government budget, the MOF’s lack of support technically vetoed the NHI off the policy agenda. In contrast, in Uganda the coalition of MOF and other ministries facilitated the NHI’s ascension and maintenance on the policy agenda41; a coalition that similarly favoured the development of the AIDS Trust fund.42 However, the Social Health Insurance (SHI) was resisted because it was viewed as threat to the authority and influence of the existing insurance management entity.41 The other reform driver relates to the extent to which the private sector perceives the costs and benefits arising from reforms. Private sector interests, particularly market protectionism dampened SHI and NHI oriented reforms in Ghana,43 Uganda,41 Zimbabwe24 and South Africa.39 Reform propsects are also dampened if they are perceived as a threat to non-material benefits such as professional status which explained nurses’ resistance to community health worker programmes in Zambia44 and Burkina Faso.45 Studies have also found that reforms with public health benefits but with commercial costs and fiscal implications are subject to corporate resistance and under-prioritisation by governments particularly those aimed at controlling the production and use of tobacco,46 47 alcohol48 and sugar.49 While these examples portray the distribution of benefits and costs as the basis of interest group competition that derails reforms, there are examples to the contrary. In Ghana, the framing of Anti-Microbial Resistance (AMR) not as a health problem but a multisectorial threat enabled stakeholder cohesion that helped to set and sustain the AMR agenda under the OneHealth Approach.50 Power is defined as the ability or capacity to ‘do something or act in a particular way’ and to ‘direct or influence the behaviour of others or the course of events’. Koduah et al43 combined Mintzberg’s power concept, arenas of conflict of Grindle and Thomas28 and Sterman’s concept of policy resistance (2006) to examine the rise and fall of primary care maternal services from Ghana’s capitation policy.43 During the agenda setting and policy formulation stages; predominantly technical policy actors within the bureaucratic arena used their expertise and authority for consensus to influence the capitation basket. However, the political momentum was dampened during implementation when providers used their knowledge, skills, authority, social and professional identity to resist the policy changes. McCollum et al conducted an analysis of power within priority-setting for health following devolution in Kenya using Gaventa’s power cube and Veneklasen’s expressions of power.51 ‘Power over’—which involves direct decision-making power over other actors—was by far the most common expression of power as for the case of Ghana’s capitation policy. As a result of concentrated power and closed spaces for meaningful citizen participation, priority setting reforms in Kenya were manipulated in favour of elite preferences. In a study conducted in South Africa, Schneider et al showed that power over was a necessary condition for effective implementation of a maternal and child health initiative52; aided by self-efficacy (power to) and agency (power within). Usher38 used Power Resources Theory to demonstrate that the lack of support from the working class derailed support for the NHI in South Africa.38 Studies have also found that African Presidents have highly personalised power to decide what becomes or ceases to be policy. Studies have also shown the power of global actors in influencing reforms. A study on malaria control in seven countries showed how the concentration of technical and financial resources in few donors provides them the power to distort local priority needs,53 a similar finding from a study on Perfommace-Based Financing (PBF) in Sierra Leonne.54 Crises also provides a window of opportunity for external agencies to wield additional levers of power. In Zimbabwe, the World Bank wielded financial and ideational power to steer Results Based Financing (RBF) post the socioeconomic crisis of the late 2000s55 as the case of the United Kingdom’s Department for International Development (DFID) in South Sudan.56 In addition, crises enhance the attention of global actors towards previously marginalised issues, particularly if such a crisis is perceived as a global health security as the case with health system strengthening efforts in Guinea post the Ebola crisis.57 However, studies from countries such as Malawi and Zimbabwe have also shown that the influence of external agencies is moderated or resisted due to historical, cultural and political considerations at the implementation stage.53 55 58 The power of global actors is also constrained by the own rules that espouse adherence to the ideals of local ownership59 and lack of local ownership has been shown to derail reforms.60 Although power is often analysed from a top-down approach, application of Lipsky’s Street Level bureaucracy have found that health workers possess considerable discretionary power over the services, benefits and sanctions received by their clients on a daily basis. Such practices—often driven by personal values and necessitated by the realities of daily work demands—effectively become public policy, rather than the intentions or objectives of documents and statements developed at a central level.61–67 Although discretionary power is often viewed as active defiance to national policy that is fraught with negative consequences, studies have shown that it can be associated with desirable outcomes as health workers devise positive coping behaviours to deal with the imperative of service delivery within severely constrained environments62 63 67 or as a managerial innovation within a decision space.68 Whether an issue would impact on staying in or winning government influences reforms35. This is based on an assumption that the ambition to gain power drives electoral competitors to pledge action on voters’ demands.36 In the aftermath of a democratic transition in Ghana in the early 1990s, the cash and carry system that was deeply despised by many Ghanaians became an attractive ground on which the opposition could challenge the ruling party36 69 and the repeal and replacement of the system with an NHI emerged as a cornerstone of its electoral campaign pledges.22 37 On electoral victory in 2000, the then newly elected president swiftly introduced the NHI to show the electorate that their party had fulfilled an election pledge, in the process bolstering the electoral chances for the next plebiscite. After the initial adoption of the NHI, political parties continued to propose technical changes with an electoral appeal,70 although the technical merits of such reforms were trumped by partisan politics, which culminated in non-implementation.71 Partisan politics, including competition for credit and counter-blaming for policy failures, have continued to characterise healthcare policies in Ghana, a phenomenon that was laid bare during the COVID-19 pandemic.72 In Uganda, user fees were hastily removed just before the 2001 presidential elections to bolster re-election chances41 and electorally appealing projects which could be easily showcased during election campaigns were prioritised for maternal health policies73 as in the case of priority setting reforms in Kenya.51 74 In Ethiopia, the massive expansion of PHC in the mid 2000s was partly driven by the government’s desire to win back opposition voters.75 Political declarations also provide a window of opportunity for reforms. The launch of the Free Health Care Initiative by the then president of Sierra Leone in 2000 was a key driver for the PBF reforms,54 while the Cameronian president’s electoral promise to fight against corruption favoured similar reforms.76 Studies have also shown that electoral competition generates incentives for incumbents to pursue vote-maximising policies that favour the basic health conditions of the rural population which constitutes the largest segment of voters.77 We found that political ideologies significantly influenced health reforms, particularly those with widespread redistributive effects. In the 1980s, a socialist political orientation facilitated the adoption of a well-elaborated PHC strategy in Zimbabwe that was influenced by the desire to dismantle the colonial legacy of racially driven health inequities24; a similar path taken by South Africa during the postpartheid era.40 In Ethiopia, the decision to embark on widesperead PHC reforms was rooted in the ruling coalition’s developmental state strategy with a rural bias.31 Studies have also shown the influence of market economy ideologies. The neoliberal agenda of the 1980s–1990s had adverse effects in Ghana,36 Zimbabwe24 and Uganda.78 In South Africa, the SHI lost momentum when the country adopted the neoliberal-laden Growth, Employment and Redistribution (GEAR) 40 which favoured efficiencies and control of public sector expenditure.38 39 Political ideologies also intersect with social values. In Ghana, the NHI received popular support because it resonated with certain established societal values, norms and customs anchored on societal cohesion and mutual solidarity.79 In Zimbabwe, the Results Bsed Financing (RBF) model was initially resisted because of the perceived contradiction with the entrenched values of professionalism and labour market harmonisation.55 Social values also influence how scientific and epidemiological evidence can be used to inform or back policy. In Malawi, despite overwhelming evidence on the epidemiological and social burden of abortion in the country and generation of political will for action, abortion law reforms could not be effected due to religiously based opposition from the Christian and Muslim community.58 In Ghana, more political attention was directed towards breast cancer although there was evidence of more epidemiological and social burden for cervical cancer.80 This was because Ghanaian women’s organisations successfully drew attention to breast cancer by connecting it to powerful societal values associated with the breast such as breast feeding and motherhood while the social construction of cervical cancer as a disease caused by a sexually transmitted infection and poor genital hygiene dampened public appeal.Studies have also shown that political figures can selectively use or modify data to boost reforms that appeal to their own values and interests. In South Africa, the Minister of Health piled pressure on the committee working on health financing options to adapt its conclusions towards the Minister’s preferred insurance option39 while in Uganda political figures imposed ambitious targets for ending preventable maternal deaths to court political legitimacy.73 In Zimbabwe, the initial scale up RBF preceded sharing of the impact since there was no demand for robust evidence from the MOH due to the urgent need for funding while there was perceived bias towards positive evaluative results on the part of funders.55 Studies have also found that evidence is unlikely to induce reforms unless it resonates with the prevailing political philosophy as the case with population health policies in Ethiopia.81 Personal beliefs have also been shown to shape advocacy work. Application of Sabatier and Jenkins’ advocacy coalition framework on maternal health in Nigeria82 and access to HIV/AIDS treatment in South Africa83 showed that resonance of the core belief (personal philosophy) that health is an individual right motivated the formation of coalitions that pushed for reforms in those areas. Besides influencing advocacy coalitions, core beliefs have an important influence on policy choices. Reforms that threaten the core beliefs of policy makers and the public such as religion, culture and morality are generally subjected to doubt, defiance and resistance as in the case of male circumcision in Uganda and Malawi84 85 and abortion in Ethiopia, Tanzania and Uganda.86–88 Core beliefs also reinforce political ideologies which significantly influence policy reforms through discursive practices that are shaped by history, including challenging dominant narratives and the pre-eminence of transnational actors. The framing of the cholera epidemic in Zimbabwe as a global health security necessitating some external intervention threatened the core belief that Zimbabwe was a sovereign country free from outside interference.89 As a result, the government mounted a vicious counter narrative that framed Cholera as a calculated racist terrorist attack by the former colonial power Britain and its allies as part of a grand strategy to recolonise Zimbabwe, tapping into the collective colonial memory when the British engaged in pathogen terrorism during the liberation struggle. This bioterror-colonial interdiscursivity resurfaced during the COVID-19 pandemic.90 Similarly, the racial and geographical profiling of AIDS as a disease that disproportionately affected black people explains President Thabo Mbeki’s denialist approach to the science of HIV/AIDS and the magnitude of the problem in South Africa since such ‘Black profiling’ was perceived to reimport the core belief of White supremacy that was perpetuated during the apartheid era.91 92 Elites consist of minority individuals or organised groups who wield substantial capacity to influence policy by virtue of possessing, such characteristics as power, wealth, skill, deference and monopoly to vital information.93 In this paper, we found one study that explicitly applied elite theory to analyse how actors’ interests and power influenced maternal health policies in Uganda between 2000 and 2015.73 In that study, Mukuru et al conceptualise elite interests as varying from self-interest (maximise personal benefits), to pragmatism (less powerful elites adjusting to accommodate the interests of the dominant elites) and public interest/altruism (genuine pursuit for public welfare). We found this characterisation to be useful in analysing elite behaviour in general, therefore it was applied to other studies that we reviewed although they did not explicitly apply elite theory. In Uganda, elites holding dominant power were mainly motivated by self interest such as the desire to secure electoral votes, establish personal legacies, maintain political appointments and accruing personal benefits from donor funds.73 On the other hand, elites with altruistic motives often lacked the power and clout to shape reform. Consequently, resulting policies often appeared to be skewed towards elites’ personal political and economic interests, rather than maternal mortality reduction. In Ghana, breast cancer was given more prominence because it affects elite women from higher socioeconomic groups who have access to political structures, while cervical cancer more frequently affects women of lower socioeconomic status.80 A study on priority setting under devolution in Kenya found that that elites often have unwielding influence on policy because they make decisions behind closed doors; akin to elite capture51 which aligns with the findings from Zimbabwe for the implementation of good governance for medicines (GGM) initiative94 and the abolishment of user fees in Uganda.41 Elites have also been found to be instrumental in public positioning of issues and construction of social problems (framing) to garner political support for reforms. In Malawi, doctors possessing first-hand knowledge of unsafe abortion persistently argued that the government must address unsafe abortion as part of its effort to reduce maternal mortality while lawyers framed access to abortion services as a human right that required a supportive legislative environment.58 Studies have also found that individual elites draw substantial power from their political and personal ties to push for desired reforms. In Ethiopia, the then Minister of Health Dr Tedros Adhanom Ghebreyesus managed to push for PHC expansion and other health financing reforms partly due to his close relationship with the then Prime Minister Meles Zenawi75; similar acquaintances that facilitated the establishment of the AIDS trust fund in Uganda.42 Elites from international organisations also draw from similar proximity to power structures. In Uganda, some health development partners took advantage of their access to policy elites to influence maternal health policies, including conditioning grants towards areas aligned with their own interests.73 Personal characteristics of the policy elites also influence their leverage on reforms. In Zambia, the tactical ability and charismatic characterof the second Minister of Health was noted as instrumental in driving hospital reforms, a move that was also seen as part of his personal agenda to pro-up his own political profile40 while the then Ethiopian Minister of Health Dr Tedros Adhanom Ghebreyesus is regarded as ‘the prime mover’ for reforms in his country.75 Studies have also identified how political elites can manipulate the policy agenda through partisan appointees who ignore technical considerations to align with the interests of appointing authorities.37 We also found that the characterisation of elites as driven by altruistic motives or self-interests depends on who is ‘losing ‘or ‘winning’ from intended policies, a phenomenon that played it self out when pharmacists pushed for stricter laws to regulate medicine vendors in Uganda.95 Despite these self-interest motives, we found examples where elites were moved by altruistic motives. In South Africa, government officials who came from underprivileged communities found it important and necessary to change poor maternal health conditions of those communities and successfully lobbied for progressive reforms.96 Transnational policy diffusion involves the mechanisms through which remarkably similar policy innovations spread across widely differing nation-states.97 It is a phenomenon characterised by temporal waves, spatial concentration and content commonality in diverse settings.98 Policy diffusion is influenced by) a) the success or failure of policies elsewhere (learning), b) by policies of other jurisdictions with which they compete for resources (competition), (C) c) by the pressure from international organisations or powerful countries (coercion) and d) by the perceived appropriateness of policies (emulation).99 The period from the 2000s is dominated by diffusion of policies aimed at achieving UHC through health financing reforms such as SHI, NHI, Community-Based Health Insurance (CBHI), abolishment of user fees and PBF.22 38 41 55 75 76 78 79 100–103 While the diffusion of SHI, NHI and abolishment of user fees was mainly through the broad ideational movement towards financial protection, we found that emulation and learning fostered the uptake of CBHI and PBF across diverse settings. The acceptability of PBF in Cameron was influenced by encouraging results from Rwanda and the involvement of senior MOH officials in regional meetings where countries that had started PBF reported quicker progress towards Millennium Development Goals.76 This transnational policy diffusion was driven by networks and experts or diffusion entrepreneurs from the World Bank and other technical agencies. In relation to CBHI, Ethiopian officials conducted feasibility studies to Senegal, then considered the leading African example of CBHI75 but the design was strongly influenced by the success of Rwanda’s Mutuelles de Santé which was considered as a ‘pilot site’ by one official. In relation to HIV/AIDS financing, the adoption of the AIDS trust Fund in Uganda was influenced by the success of a similar mechanism in Zimbabwe.42 The influence of transnational networks was not limited to health financing aspects. In Malawi, the generation of political priority for abortion law reforms was influenced by a network of international and local diffusion entrepreneurs who took advantage of global movements and domestic contexts to push for reforms,58 a similar situation with the generation of political attention for breast cancer in Ghana.80 Studies have also found that the diffusion of certain policies is favoured by prevailing ideational paradigms through the active contribution of diffusion entrepreneurs at global level. That was the case with national medicines policies which were visibly promoted by the third WHO Director general Dr Halfdan Mahler after the inclusion of access to essential drugs as a component of PHC.104 Studies have also found Global Health Institutions (GHIs) can strategically coalesce to endorse the legitimacy or illegitimacy of policies in SSA, often in alignment with the dominant position of institutions with perceived global clout. In the 1980s–1990s, GHIs endorsed the World Bank’s stance on the introduction of user fees and aligned with the same institution when it called for their removal in the 2000s.105 Apart from the geospatial diffusion, studies have also found the temporal diffusion of policies within the same country as the case of CBHIs which served as a learning precursor for the NHI in Ghana.36 This temporal diffusion also explains how Ghana’s fee exemption policy for maternal health initiated in 1963 was maintained over the years in a path-dependent manner.106 While policies are dominantly framed as diffusing from norm-setting agencies at global level to SSA following a rigorous evidentiary process, exceptions exist where country level implementation influenced global policy. Pragmatic considerations influenced Malawi to adopt Option B+for Prevention of Mother To Child Transmission for HIV/AIDS ahead of WHO recommendations and guidelines; a policy that rapidly diffused to other countries in the absence of normative (formalised) guidelines from WHO.107 This ‘bottom-up’ diffusion also occurred within a national jurisdiction when provincial implementation of ARV policy in South Africa fostered federal homogeneity, which eventually became national policy.108 Table 4 shows the drivers for reforms and non-health reforms in SSA. Drivers for reforms and non-health reforms in SSA + positive effect (favours implementation of reforms that promote access to health, particularly for marginalised populations). − negative effect (against reforms that promote access to health). +/− it can be either positive or negative depending on the context. SSA, sub-Saharan Africa.

AI Digest

Study Justification:

– The study aims to go beyond the rhetoric of political will and examine the drivers of health reforms in sub-Saharan Africa (SSA).
– The concept of political will is often used as a scapegoat to avoid examining the actual factors that shape health reforms in the region.
– By understanding the drivers of health reforms, policymakers can develop more effective strategies to promote and implement reforms.

Study Highlights:

– The study conducted a scoping review of 84 published papers on the politics of health reforms in SSA.
– The review found that health reforms in SSA are influenced by six interconnected drivers: the distribution of costs and benefits, the form and expression of power among actors, the desire to win or stay in government, political ideologies, elite interests, and policy diffusion.
– The study highlights the importance of considering these drivers in future policy analysis and reform efforts.

Study Recommendations:

– Political will is relevant but insufficient to drive health reform in SSA.
– Policymakers should consider a framework of differential reform politics that takes into account the power and beliefs of policy elites in shaping policies within a given context.
– Future policy analysis should focus on understanding how these drivers interact and influence health reforms in SSA.

Key Role Players:

– Policymakers and government officials responsible for health policy and reform.
– International organizations and donors involved in health financing and reform efforts in SSA.
– Civil society organizations advocating for health reform and representing the interests of marginalized populations.
– Researchers and academics studying health policy and reform in SSA.

Cost Items for Planning Recommendations:

– Research and data collection costs for studying the drivers of health reforms in SSA.
– Costs associated with policy analysis and formulation, including the involvement of experts and consultants.
– Costs for capacity building and training of policymakers and government officials on the differential reform politics framework.
– Costs for stakeholder engagement and consultation processes to ensure the inclusion of diverse perspectives in policy development.
– Costs for monitoring and evaluation of health reform efforts to assess their impact and make necessary adjustments.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a scoping review of 84 published papers, covering a wide range of topics related to health reforms in sub-Saharan Africa. The review used a systematic approach to identify relevant studies and extract data. The findings highlight six drivers of health reforms in the region. The evidence is supported by references to specific studies and includes examples from different countries in sub-Saharan Africa. However, the abstract does not provide information on the quality or methodology of the included studies, which could affect the strength of the evidence. To improve the evidence, it would be helpful to provide more details on the study selection criteria, data extraction process, and any quality assessment conducted. Additionally, including information on the limitations of the scoping review and potential biases would enhance the transparency and reliability of the evidence.

Abstract

This article used scoping review methods developed by Arksey and O’Malley32 to understand the drivers of health reforms in SSA. We selected this approach because of its emphasis on flexibility, reliance on an abductive logic of enquiry, and its bias towards narrative driven summation.33 The framework is presented as an iterative, qualitative review with five distinct stages: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data and (5) collating, summarising and reporting the results. It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research. ‘What is known from existing literature about the drivers of (non) health reforms in SSA?’ In line with prior studies,34 we developed a search strategy that covered three dimensions of the relevant studies: (1) the policy area of interest (health reforms), (2) the object of interest (policy processes/change) and (3) the geographical coverage (SSA). To refine the search, key health reforms such as primary healthcare (PHC) and universal health coverage (UHC) were expressly included in the search strategy based on the authors’ priori knowledge on health system reform efforts in SSA. While previous reviews have focused on specific policy areas, we maintained a wider policy interest to determine whether certain reform areas dominate research coverage and its potential implications. Between May and July 2022, we conducted a comprehensive literature search in three electronic databases: MEDLINE/PubMed, Academic Complete and WHO Global Medicus. A variety of search terms were used: Health AND Politics AND Africa, Limit to geography-Africa, South of Sahara, Political economy AND Health AND Africa, Primary health care AND politics AND Africa, Political economy AND Universal Health Coverage AND Low-middle income countries, Political economy AND Primary Health Care AND Low-middle income countries, Health AND power AND Africa. We also searched Google, Google scholar and the BioMed central (BMC) database through the ‘search all BMC articles’ portal: https://www.biomedcentral.com/. We purposively selected the BMC database due to its wider collection of journals with a focus on health systems in Low -and Middle -income Countries (LMICs) and the open access nature of the publications since we did not have access to other relevant paid-for databases such as CINAHL, Scopus and Web of Science. We also selected relevant papers from the International Journal of Health Policy and Management (IJHPM) Special Issue on Analysing the Politics of Health in Low-Middle-Income countries published in 2021: https://www.ijhpm.com/article_4039.html. We also reviewed the publications by members of the Social Science Approaches for Research and Engagement in Health Policy and Systems (SHAPES) Thematic Working Group (TWG) which are shared through a fortnightly email update. We reviewed the fortnightly updates from 1 September 2021 to 17 August 2022 which coincides with the period of the authors’ membership to the SHAPES TWG. We purposively selected the fortnightly updates from SHAPES because it focuses on key thematic areas related to this study such as power and policy analysis. Due to the centrality of power in health reforms, we also reviewed the ‘10 best resources on power in health policy and systems in low- and middle-income countries’ published by the Health Policy and Planning Journal in 2018 https://academic.oup.com/heapol/article/33/4/611/4868632. ATM conducted the screening process. The initial search generated 1844 papers. No time limit was set for the studies. Screening of the retrieved papers involved three sequential stages. The first stage involved title screening of all the papers. From this process, 83 duplicates were immediately removed. A further 1232 papers were removed for either being non-health related or being from outside SSA. In the context of this study, SSA is, geographically the area of the continent of Africa south of the Sahara. Countries from the Middle East/North Africa region: Algeria, Egypt, Libya, Morocco and Tunisia were therefore excluded. Non-health papers included general country profiles and coverage of reforms in other social sectors such as education, agriculture and housing and politics in general. After the title screening, 529 papers were eligible for the second stage which involved abstract screening. Out of these, 411 were excluded chiefly for not focusing on policy process. These papers were largely descriptive without explaining the drivers of such (non) reforms and fell into three broad categories: (1) those elaborating the importance of policy (2) those highlighting the risks of not implementing a given policy and (3) those showcasing benefits of reforms. Of the 118 papers that were eligible for full article screening, 45 were removed because they either included theory or framework ex post or frameworks announced but none referred to explicitly during analysis. This left a final list of 73 articles for data extraction and analysis. An additional 11 articles were obtained from the reference list of selected papers. A final list of 84 papers was eligible for full analysis. A detailed inclusion and exclusion criteria is shown in table 1. Inclusion and exclusion criteria for relevant studies Adapted from Jones et al (2021). SSA, sub-Saharan Africa. After identifying eligible articles, ATM conducted the data charting. Data charting is a technique for synthesising and interpreting qualitative data by sifting, charting and sorting material according to themes. Themes can be known or pre-established before data extraction (inductive approach) or emerge as data extraction begins and patterns start to form (deductive approach). In this study, we drew themes using both an inductive and deductive approach. Inductively, we drew themes from two papers that examined the concept of political will as an explanatory variable for (non) health reforms. The first paper by Baum et al used eight case studies from Australia to examine the determinants of political will for pro-health equity policies and how political will can be created through analysis of public policy.35 The second paper by Michael Reich synthesises relevant critiques on the application of the concept of political will to understand health reform process, including in LMICs.30 We also examined the main themes from the two supplements that focused on the politics of health reforms namely the Special Issue on Analysing the Politics of Health in LMICs published in the IJHPM in 2021 and the 10 best resources on power in health policy and systems in LMICs published by the Health Policy and Planning Journal in 2018. Through an integrative synthesis of these sources, we identified five relevant themes (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies and (5) elite interests. A data charting tool (extraction tool) was developed in Microsoft Excel capturing essential characteristics such as the title of the paper, year of publication, policy issue under study, theory used, the policy stage, reform drivers and other relevant attributes as shown in detail in table 2. Publication characteristics and reform aspects We conducted a thematic analysis by categorising the contents of each eligible article according to the five themes mentioned above. The first step involved verbatim extraction of text excerpts from the selected articles, which were categorised according to the themes in the data charting tool. The second step involved an iterative process of interpretive data analyses and refining, including an analysis of how a given reform driver played out similarly or diverged across geography and time. Through this iterative process, a sixth theme emerged: the influence of transnational and national policy diffusion as a reform driver. This emerging theme was incorporated into the data extraction tool and all the papers were examined against the emergent theme. Pivot tables were run in Microsoft Excel to collate and summarise the results on publication characteristics and reform aspects. The selection process is shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram in figure 1. The policy studies were drawn from more than 30 different countries from Southern, Central, East and West Africa. Out of the 84 studies included, two countries accounted for more than 40% of the total studies, with South Africa accounting for 22% of the total studies while Ghana accounted for 19%. PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The general profile of the selected papers is shown in table 3. Profile of reviewed studies ARV, Antiretroviral; CBHI, Community-Based Health Insurance; NHI, National Health Insurance; PBF, Perfomance-Based Financing; PMTCT, Prevention of Mother To Child Transmission; VMMC, Voluntary Medical Male Circumcision. The next sections present how the drivers for health reforms identified earlier influenced (non) health reforms in SSA: (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) transnational and national policy diffusion. Health policy reform efforts face resistance because they commonly place concentrated new costs on well-organised, powerful groups while seeking to make new benefits available to non-organised and powerless groups.30 In Ghana, the transition from the pay for service arrangement or ‘cash and carry system’ to a National Health Insurance (NHI) in the early 2000s received popular support because the working middle class wanted to be relieved of the burden to cater for their own health and that of extended families36 37 and parliamentarians desired to offload the constituents’ incessant demand for money to cater for personal health needs.22 Contrary, the middle class in South Africa showed apathy towards advocating for the NHI policy because they benefited from a labour structure that provided them with private sector health.38 At institutional or bureaucratic level, reforms with fiscal implications were slowed down or derailed due to divergent frames between the Ministry of Health (MOH) and the Ministry of Finance (MOF) as in the case of South Africa.39 40 Through its power to set the macroeconomic agenda and control the government budget, the MOF’s lack of support technically vetoed the NHI off the policy agenda. In contrast, in Uganda the coalition of MOF and other ministries facilitated the NHI’s ascension and maintenance on the policy agenda41; a coalition that similarly favoured the development of the AIDS Trust fund.42 However, the Social Health Insurance (SHI) was resisted because it was viewed as threat to the authority and influence of the existing insurance management entity.41 The other reform driver relates to the extent to which the private sector perceives the costs and benefits arising from reforms. Private sector interests, particularly market protectionism dampened SHI and NHI oriented reforms in Ghana,43 Uganda,41 Zimbabwe24 and South Africa.39 Reform propsects are also dampened if they are perceived as a threat to non-material benefits such as professional status which explained nurses’ resistance to community health worker programmes in Zambia44 and Burkina Faso.45 Studies have also found that reforms with public health benefits but with commercial costs and fiscal implications are subject to corporate resistance and under-prioritisation by governments particularly those aimed at controlling the production and use of tobacco,46 47 alcohol48 and sugar.49 While these examples portray the distribution of benefits and costs as the basis of interest group competition that derails reforms, there are examples to the contrary. In Ghana, the framing of Anti-Microbial Resistance (AMR) not as a health problem but a multisectorial threat enabled stakeholder cohesion that helped to set and sustain the AMR agenda under the OneHealth Approach.50 Power is defined as the ability or capacity to ‘do something or act in a particular way’ and to ‘direct or influence the behaviour of others or the course of events’. Koduah et al43 combined Mintzberg’s power concept, arenas of conflict of Grindle and Thomas28 and Sterman’s concept of policy resistance (2006) to examine the rise and fall of primary care maternal services from Ghana’s capitation policy.43 During the agenda setting and policy formulation stages; predominantly technical policy actors within the bureaucratic arena used their expertise and authority for consensus to influence the capitation basket. However, the political momentum was dampened during implementation when providers used their knowledge, skills, authority, social and professional identity to resist the policy changes. McCollum et al conducted an analysis of power within priority-setting for health following devolution in Kenya using Gaventa’s power cube and Veneklasen’s expressions of power.51 ‘Power over’—which involves direct decision-making power over other actors—was by far the most common expression of power as for the case of Ghana’s capitation policy. As a result of concentrated power and closed spaces for meaningful citizen participation, priority setting reforms in Kenya were manipulated in favour of elite preferences. In a study conducted in South Africa, Schneider et al showed that power over was a necessary condition for effective implementation of a maternal and child health initiative52; aided by self-efficacy (power to) and agency (power within). Usher38 used Power Resources Theory to demonstrate that the lack of support from the working class derailed support for the NHI in South Africa.38 Studies have also found that African Presidents have highly personalised power to decide what becomes or ceases to be policy. Studies have also shown the power of global actors in influencing reforms. A study on malaria control in seven countries showed how the concentration of technical and financial resources in few donors provides them the power to distort local priority needs,53 a similar finding from a study on Perfommace-Based Financing (PBF) in Sierra Leonne.54 Crises also provides a window of opportunity for external agencies to wield additional levers of power. In Zimbabwe, the World Bank wielded financial and ideational power to steer Results Based Financing (RBF) post the socioeconomic crisis of the late 2000s55 as the case of the United Kingdom’s Department for International Development (DFID) in South Sudan.56 In addition, crises enhance the attention of global actors towards previously marginalised issues, particularly if such a crisis is perceived as a global health security as the case with health system strengthening efforts in Guinea post the Ebola crisis.57 However, studies from countries such as Malawi and Zimbabwe have also shown that the influence of external agencies is moderated or resisted due to historical, cultural and political considerations at the implementation stage.53 55 58 The power of global actors is also constrained by the own rules that espouse adherence to the ideals of local ownership59 and lack of local ownership has been shown to derail reforms.60 Although power is often analysed from a top-down approach, application of Lipsky’s Street Level bureaucracy have found that health workers possess considerable discretionary power over the services, benefits and sanctions received by their clients on a daily basis. Such practices—often driven by personal values and necessitated by the realities of daily work demands—effectively become public policy, rather than the intentions or objectives of documents and statements developed at a central level.61–67 Although discretionary power is often viewed as active defiance to national policy that is fraught with negative consequences, studies have shown that it can be associated with desirable outcomes as health workers devise positive coping behaviours to deal with the imperative of service delivery within severely constrained environments62 63 67 or as a managerial innovation within a decision space.68 Whether an issue would impact on staying in or winning government influences reforms35. This is based on an assumption that the ambition to gain power drives electoral competitors to pledge action on voters’ demands.36 In the aftermath of a democratic transition in Ghana in the early 1990s, the cash and carry system that was deeply despised by many Ghanaians became an attractive ground on which the opposition could challenge the ruling party36 69 and the repeal and replacement of the system with an NHI emerged as a cornerstone of its electoral campaign pledges.22 37 On electoral victory in 2000, the then newly elected president swiftly introduced the NHI to show the electorate that their party had fulfilled an election pledge, in the process bolstering the electoral chances for the next plebiscite. After the initial adoption of the NHI, political parties continued to propose technical changes with an electoral appeal,70 although the technical merits of such reforms were trumped by partisan politics, which culminated in non-implementation.71 Partisan politics, including competition for credit and counter-blaming for policy failures, have continued to characterise healthcare policies in Ghana, a phenomenon that was laid bare during the COVID-19 pandemic.72 In Uganda, user fees were hastily removed just before the 2001 presidential elections to bolster re-election chances41 and electorally appealing projects which could be easily showcased during election campaigns were prioritised for maternal health policies73 as in the case of priority setting reforms in Kenya.51 74 In Ethiopia, the massive expansion of PHC in the mid 2000s was partly driven by the government’s desire to win back opposition voters.75 Political declarations also provide a window of opportunity for reforms. The launch of the Free Health Care Initiative by the then president of Sierra Leone in 2000 was a key driver for the PBF reforms,54 while the Cameronian president’s electoral promise to fight against corruption favoured similar reforms.76 Studies have also shown that electoral competition generates incentives for incumbents to pursue vote-maximising policies that favour the basic health conditions of the rural population which constitutes the largest segment of voters.77 We found that political ideologies significantly influenced health reforms, particularly those with widespread redistributive effects. In the 1980s, a socialist political orientation facilitated the adoption of a well-elaborated PHC strategy in Zimbabwe that was influenced by the desire to dismantle the colonial legacy of racially driven health inequities24; a similar path taken by South Africa during the postpartheid era.40 In Ethiopia, the decision to embark on widesperead PHC reforms was rooted in the ruling coalition’s developmental state strategy with a rural bias.31 Studies have also shown the influence of market economy ideologies. The neoliberal agenda of the 1980s–1990s had adverse effects in Ghana,36 Zimbabwe24 and Uganda.78 In South Africa, the SHI lost momentum when the country adopted the neoliberal-laden Growth, Employment and Redistribution (GEAR) 40 which favoured efficiencies and control of public sector expenditure.38 39 Political ideologies also intersect with social values. In Ghana, the NHI received popular support because it resonated with certain established societal values, norms and customs anchored on societal cohesion and mutual solidarity.79 In Zimbabwe, the Results Bsed Financing (RBF) model was initially resisted because of the perceived contradiction with the entrenched values of professionalism and labour market harmonisation.55 Social values also influence how scientific and epidemiological evidence can be used to inform or back policy. In Malawi, despite overwhelming evidence on the epidemiological and social burden of abortion in the country and generation of political will for action, abortion law reforms could not be effected due to religiously based opposition from the Christian and Muslim community.58 In Ghana, more political attention was directed towards breast cancer although there was evidence of more epidemiological and social burden for cervical cancer.80 This was because Ghanaian women’s organisations successfully drew attention to breast cancer by connecting it to powerful societal values associated with the breast such as breast feeding and motherhood while the social construction of cervical cancer as a disease caused by a sexually transmitted infection and poor genital hygiene dampened public appeal.Studies have also shown that political figures can selectively use or modify data to boost reforms that appeal to their own values and interests. In South Africa, the Minister of Health piled pressure on the committee working on health financing options to adapt its conclusions towards the Minister’s preferred insurance option39 while in Uganda political figures imposed ambitious targets for ending preventable maternal deaths to court political legitimacy.73 In Zimbabwe, the initial scale up RBF preceded sharing of the impact since there was no demand for robust evidence from the MOH due to the urgent need for funding while there was perceived bias towards positive evaluative results on the part of funders.55 Studies have also found that evidence is unlikely to induce reforms unless it resonates with the prevailing political philosophy as the case with population health policies in Ethiopia.81 Personal beliefs have also been shown to shape advocacy work. Application of Sabatier and Jenkins’ advocacy coalition framework on maternal health in Nigeria82 and access to HIV/AIDS treatment in South Africa83 showed that resonance of the core belief (personal philosophy) that health is an individual right motivated the formation of coalitions that pushed for reforms in those areas. Besides influencing advocacy coalitions, core beliefs have an important influence on policy choices. Reforms that threaten the core beliefs of policy makers and the public such as religion, culture and morality are generally subjected to doubt, defiance and resistance as in the case of male circumcision in Uganda and Malawi84 85 and abortion in Ethiopia, Tanzania and Uganda.86–88 Core beliefs also reinforce political ideologies which significantly influence policy reforms through discursive practices that are shaped by history, including challenging dominant narratives and the pre-eminence of transnational actors. The framing of the cholera epidemic in Zimbabwe as a global health security necessitating some external intervention threatened the core belief that Zimbabwe was a sovereign country free from outside interference.89 As a result, the government mounted a vicious counter narrative that framed Cholera as a calculated racist terrorist attack by the former colonial power Britain and its allies as part of a grand strategy to recolonise Zimbabwe, tapping into the collective colonial memory when the British engaged in pathogen terrorism during the liberation struggle. This bioterror-colonial interdiscursivity resurfaced during the COVID-19 pandemic.90 Similarly, the racial and geographical profiling of AIDS as a disease that disproportionately affected black people explains President Thabo Mbeki’s denialist approach to the science of HIV/AIDS and the magnitude of the problem in South Africa since such ‘Black profiling’ was perceived to reimport the core belief of White supremacy that was perpetuated during the apartheid era.91 92 Elites consist of minority individuals or organised groups who wield substantial capacity to influence policy by virtue of possessing, such characteristics as power, wealth, skill, deference and monopoly to vital information.93 In this paper, we found one study that explicitly applied elite theory to analyse how actors’ interests and power influenced maternal health policies in Uganda between 2000 and 2015.73 In that study, Mukuru et al conceptualise elite interests as varying from self-interest (maximise personal benefits), to pragmatism (less powerful elites adjusting to accommodate the interests of the dominant elites) and public interest/altruism (genuine pursuit for public welfare). We found this characterisation to be useful in analysing elite behaviour in general, therefore it was applied to other studies that we reviewed although they did not explicitly apply elite theory. In Uganda, elites holding dominant power were mainly motivated by self interest such as the desire to secure electoral votes, establish personal legacies, maintain political appointments and accruing personal benefits from donor funds.73 On the other hand, elites with altruistic motives often lacked the power and clout to shape reform. Consequently, resulting policies often appeared to be skewed towards elites’ personal political and economic interests, rather than maternal mortality reduction. In Ghana, breast cancer was given more prominence because it affects elite women from higher socioeconomic groups who have access to political structures, while cervical cancer more frequently affects women of lower socioeconomic status.80 A study on priority setting under devolution in Kenya found that that elites often have unwielding influence on policy because they make decisions behind closed doors; akin to elite capture51 which aligns with the findings from Zimbabwe for the implementation of good governance for medicines (GGM) initiative94 and the abolishment of user fees in Uganda.41 Elites have also been found to be instrumental in public positioning of issues and construction of social problems (framing) to garner political support for reforms. In Malawi, doctors possessing first-hand knowledge of unsafe abortion persistently argued that the government must address unsafe abortion as part of its effort to reduce maternal mortality while lawyers framed access to abortion services as a human right that required a supportive legislative environment.58 Studies have also found that individual elites draw substantial power from their political and personal ties to push for desired reforms. In Ethiopia, the then Minister of Health Dr Tedros Adhanom Ghebreyesus managed to push for PHC expansion and other health financing reforms partly due to his close relationship with the then Prime Minister Meles Zenawi75; similar acquaintances that facilitated the establishment of the AIDS trust fund in Uganda.42 Elites from international organisations also draw from similar proximity to power structures. In Uganda, some health development partners took advantage of their access to policy elites to influence maternal health policies, including conditioning grants towards areas aligned with their own interests.73 Personal characteristics of the policy elites also influence their leverage on reforms. In Zambia, the tactical ability and charismatic characterof the second Minister of Health was noted as instrumental in driving hospital reforms, a move that was also seen as part of his personal agenda to pro-up his own political profile40 while the then Ethiopian Minister of Health Dr Tedros Adhanom Ghebreyesus is regarded as ‘the prime mover’ for reforms in his country.75 Studies have also identified how political elites can manipulate the policy agenda through partisan appointees who ignore technical considerations to align with the interests of appointing authorities.37 We also found that the characterisation of elites as driven by altruistic motives or self-interests depends on who is ‘losing ‘or ‘winning’ from intended policies, a phenomenon that played it self out when pharmacists pushed for stricter laws to regulate medicine vendors in Uganda.95 Despite these self-interest motives, we found examples where elites were moved by altruistic motives. In South Africa, government officials who came from underprivileged communities found it important and necessary to change poor maternal health conditions of those communities and successfully lobbied for progressive reforms.96 Transnational policy diffusion involves the mechanisms through which remarkably similar policy innovations spread across widely differing nation-states.97 It is a phenomenon characterised by temporal waves, spatial concentration and content commonality in diverse settings.98 Policy diffusion is influenced by) a) the success or failure of policies elsewhere (learning), b) by policies of other jurisdictions with which they compete for resources (competition), (C) c) by the pressure from international organisations or powerful countries (coercion) and d) by the perceived appropriateness of policies (emulation).99 The period from the 2000s is dominated by diffusion of policies aimed at achieving UHC through health financing reforms such as SHI, NHI, Community-Based Health Insurance (CBHI), abolishment of user fees and PBF.22 38 41 55 75 76 78 79 100–103 While the diffusion of SHI, NHI and abolishment of user fees was mainly through the broad ideational movement towards financial protection, we found that emulation and learning fostered the uptake of CBHI and PBF across diverse settings. The acceptability of PBF in Cameron was influenced by encouraging results from Rwanda and the involvement of senior MOH officials in regional meetings where countries that had started PBF reported quicker progress towards Millennium Development Goals.76 This transnational policy diffusion was driven by networks and experts or diffusion entrepreneurs from the World Bank and other technical agencies. In relation to CBHI, Ethiopian officials conducted feasibility studies to Senegal, then considered the leading African example of CBHI75 but the design was strongly influenced by the success of Rwanda’s Mutuelles de Santé which was considered as a ‘pilot site’ by one official. In relation to HIV/AIDS financing, the adoption of the AIDS trust Fund in Uganda was influenced by the success of a similar mechanism in Zimbabwe.42 The influence of transnational networks was not limited to health financing aspects. In Malawi, the generation of political priority for abortion law reforms was influenced by a network of international and local diffusion entrepreneurs who took advantage of global movements and domestic contexts to push for reforms,58 a similar situation with the generation of political attention for breast cancer in Ghana.80 Studies have also found that the diffusion of certain policies is favoured by prevailing ideational paradigms through the active contribution of diffusion entrepreneurs at global level. That was the case with national medicines policies which were visibly promoted by the third WHO Director general Dr Halfdan Mahler after the inclusion of access to essential drugs as a component of PHC.104 Studies have also found Global Health Institutions (GHIs) can strategically coalesce to endorse the legitimacy or illegitimacy of policies in SSA, often in alignment with the dominant position of institutions with perceived global clout. In the 1980s–1990s, GHIs endorsed the World Bank’s stance on the introduction of user fees and aligned with the same institution when it called for their removal in the 2000s.105 Apart from the geospatial diffusion, studies have also found the temporal diffusion of policies within the same country as the case of CBHIs which served as a learning precursor for the NHI in Ghana.36 This temporal diffusion also explains how Ghana’s fee exemption policy for maternal health initiated in 1963 was maintained over the years in a path-dependent manner.106 While policies are dominantly framed as diffusing from norm-setting agencies at global level to SSA following a rigorous evidentiary process, exceptions exist where country level implementation influenced global policy. Pragmatic considerations influenced Malawi to adopt Option B+for Prevention of Mother To Child Transmission for HIV/AIDS ahead of WHO recommendations and guidelines; a policy that rapidly diffused to other countries in the absence of normative (formalised) guidelines from WHO.107 This ‘bottom-up’ diffusion also occurred within a national jurisdiction when provincial implementation of ARV policy in South Africa fostered federal homogeneity, which eventually became national policy.108 Table 4 shows the drivers for reforms and non-health reforms in SSA. Drivers for reforms and non-health reforms in SSA + positive effect (favours implementation of reforms that promote access to health, particularly for marginalised populations). − negative effect (against reforms that promote access to health). +/− it can be either positive or negative depending on the context. SSA, sub-Saharan Africa.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Health Financing Reforms: Implementing health financing reforms, such as National Health Insurance (NHI) or Community-Based Health Insurance (CBHI), can help ensure that maternal health services are affordable and accessible to all women, regardless of their socioeconomic status.

2. Policy Agenda Setting and Formulation: Focusing on policy agenda setting and formulation can help prioritize maternal health within the broader health reform agenda. This involves identifying the specific needs and challenges related to maternal health and developing targeted policies and strategies to address them.

3. Power Dynamics and Stakeholder Engagement: Understanding the distribution of power among different actors and engaging key stakeholders, such as policymakers, healthcare providers, and community leaders, can help drive maternal health reforms. This includes empowering women and communities to participate in decision-making processes and ensuring their voices are heard.

4. Political Will and Leadership: Building political will and leadership at all levels of government is crucial for driving maternal health reforms. This involves advocating for maternal health as a priority, mobilizing resources, and creating an enabling environment for implementation.

5. Policy Diffusion and Learning: Learning from successful experiences and best practices in other countries can inform and accelerate maternal health reforms. This includes studying and adapting policies and strategies that have been effective in improving maternal health outcomes in similar contexts.

6. Addressing Social and Cultural Factors: Recognizing and addressing social and cultural factors that influence maternal health, such as gender norms, religious beliefs, and traditional practices, is essential for ensuring equitable access to maternal health services. This may involve community engagement, education, and awareness campaigns.

It is important to note that these recommendations are based on the information provided and may need to be further tailored to specific contexts and challenges within sub-Saharan Africa.

AI Innovations Description

Based on the information provided, here is a recommendation that can be used to develop an innovation to improve access to maternal health:

1. Develop a comprehensive health reform strategy: Instead of relying solely on political will, it is important to develop a comprehensive strategy that takes into account the various drivers of health reforms in sub-Saharan Africa (SSA). This strategy should address the distribution of costs and benefits arising from policy reforms, the form and expression of power among actors, the desire to win or stay in government, political ideologies, elite interests, and policy diffusion.

2. Address the distribution of costs and benefits: Health reform efforts should consider the distribution of costs and benefits to ensure that reforms do not disproportionately burden certain groups while leaving others without access to essential maternal health services. This may involve implementing policies that provide financial protection, such as national health insurance or community-based health insurance, to ensure that all individuals have access to affordable maternal health services.

3. Empower policy elites and stakeholders: It is important to engage and empower policy elites and stakeholders, including government officials, healthcare providers, and community leaders, in the reform process. This can be done through capacity building, training, and creating platforms for dialogue and collaboration. By involving these key actors, reforms are more likely to be informed by local context and needs, and implementation is more likely to be successful.

4. Consider political ideologies and social values: Political ideologies and social values play a significant role in shaping health reforms. It is important to understand and address these ideologies and values when designing and implementing maternal health policies. This may involve framing maternal health issues in a way that resonates with societal values, engaging religious and community leaders in advocacy efforts, and addressing cultural and moral considerations.

5. Promote policy diffusion and learning: Policy diffusion, both within and across countries, can be a powerful driver of health reforms. It is important to promote policy diffusion and learning by sharing best practices, lessons learned, and successful policy innovations. This can be done through regional and international collaborations, conferences, and knowledge-sharing platforms.

By implementing these recommendations, it is possible to develop innovative approaches to improve access to maternal health in sub-Saharan Africa. These approaches should be context-specific, taking into account the unique challenges and opportunities in each country or region.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Strengthen Health Financing: Implement policies and strategies to increase funding for maternal health services, including the allocation of resources specifically for maternal health programs. This could involve increasing government spending on healthcare, exploring innovative financing mechanisms such as health insurance or community-based health financing, and leveraging external funding from international donors.

2. Enhance Policy Agenda Setting and Formulation: Improve the process of setting and formulating policies related to maternal health. This could involve engaging a wide range of stakeholders, including policymakers, healthcare providers, community leaders, and women themselves, to ensure that policies are evidence-based, responsive to local needs, and address the social determinants of maternal health.

3. Empower Women and Communities: Promote women’s empowerment and community engagement in maternal health. This could involve providing education and information on maternal health, promoting women’s rights and gender equality, and involving communities in decision-making processes related to maternal health services.

4. Strengthen Health Systems: Invest in strengthening health systems to ensure that they have the capacity to provide quality maternal health services. This could involve improving infrastructure, training healthcare providers, ensuring the availability of essential medicines and supplies, and implementing effective referral systems.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed using a combination of quantitative and qualitative approaches. Here is a brief outline of a possible methodology:

1. Define the indicators: Identify key indicators that can measure the impact of the recommendations on improving access to maternal health. This could include indicators such as maternal mortality rate, antenatal care coverage, skilled birth attendance, and access to emergency obstetric care.

2. Collect baseline data: Gather data on the current status of maternal health indicators in the target population or region. This could involve conducting surveys, reviewing existing data sources, and engaging with relevant stakeholders to gather qualitative information.

3. Develop a simulation model: Develop a simulation model that can estimate the potential impact of the recommendations on the selected indicators. This could involve using mathematical models, such as regression models or simulation models, to analyze the relationship between the recommendations and the indicators.

4. Input data and run simulations: Input the baseline data into the simulation model and run simulations to estimate the potential impact of the recommendations. This could involve running different scenarios to assess the impact of different levels of implementation or different combinations of recommendations.

5. Analyze results: Analyze the results of the simulations to assess the potential impact of the recommendations on improving access to maternal health. This could involve comparing the simulated outcomes with the baseline data and identifying the potential changes in the selected indicators.

6. Interpret and communicate findings: Interpret the findings of the simulations and communicate the results to relevant stakeholders. This could involve presenting the findings in a clear and accessible manner, highlighting the potential benefits of implementing the recommendations, and identifying any potential challenges or limitations.

It is important to note that this is just a general outline of a methodology and the specific details would depend on the context and available data. It would be necessary to adapt and refine the methodology based on the specific objectives, resources, and constraints of the study.

Author


Dima Health

Identifiers:

DOI: 10.1136/bmjgh-2022-010228

Research Areas:

Cancer, Community Interventions, COVID, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Substance Abuse, Technology and Innovations, Workforce

Study Countries:

Algeria, Burkina Faso, Egypt, Ethiopia, Ghana, Guinea, Kenya, Libya, Malawi, Morocco, Multi-Countries, Rwanda, Senegal, Sierra Leone, South Africa, South Sudan, Sudan, Tanzania, Tunisia, Uganda, Zambia, Zimbabwe

Study Design:

Cross Sectional Study, Exploratory Study, Narrative Study, randomised-control-trial

Study Approach:

Mixed-methods, Qualitative, Systematic Review

Participants Gender:

Male & Female