Conditional cash transfer policies in maternal health service utilization in Nepal: Analysis of safe delivery incentive program (Aama Surakshya Karyakram) using Kingdon's multiple streams framework

Various factors limit access to and utilization of health services even when provided at subsidized cost. This results in poor utilization of services that contributes to further economic impoverishment and health care disparity. Many countries are experimenting with various approaches to tackle the poor utilization of health care services including demand‐side financing policy. This paper explains the policymaking process during the formulation of safe delivery incentive program, a conditional cash transfer program in Nepal using Kindgon's multiple streams framework. Analysis of earlier policies and programs around safe motherhood concludes that high transportation cost was a major cause for poor utilization of institutional obstetric care, despite being provided at free of cost. Health was recognized as fundamental constitutional right in 2007. This assured societal support and political commitments for protecting health constitutionally. Furthermore, there was commitment from external development partners (EDPs) for investment in maternal health. Together, these problem, policy, and politics opened Kingdon's “windows of opportunity” for formulation of conditional cash transfer policy. This paper presents evolution of Aama Surakshya Karyakram and uses Kingdon's multiple streams framework to explain how problem, policy, and politics streams converged together to allow this program to be introduced in Nepal.     

Implementing the integration of component services for reproductive health

In the wake of the 1994 International Conference on Population and Development in Cairo, considerable activity has occurred both in national policymaking for reproductive health and in research on the implementation of the Cairo Program of Action. This report considers how effectively a key component of the Cairo agenda--integration of the management of sexually transmitted infections, including human immunodeficiency virus, with maternal and child health-family planning services--has been implemented. Quantitative and qualitative data are used to illuminate the difficulties faced by implementers of reproductive health programs in Ghana, Kenya, South Africa, and Zambia. In these countries, clear evidence is found of a critical need to reexamine the continuing focus on family planning services and the nature of the processes by which managers implement reproductive health policies. Implications of findings for policy and program direction are discussed.     

Involving older people in research: methodological issues

The policy imperative to increase public participation in health and social care research, planning and service delivery raises significant questions about optimum approaches, methods and the extent to which this policy can influence change in practice. This paper highlights the key policy literature on user involvement and participatory research methods to establish the context for a partnership research project exploring perceptions of risk in relation to falls from the perspectives of older people, carers, and health and social care professionals. The paper reports the methods used in developing user involvement in the research at a number of levels, including project management, and a consumer panel working alongside the research team and influencing the dissemination in local falls prevention strategies. The authors draw out the issues related to the context and method of involvement, and discuss the impact on research quality and local service development in health and social care.     

SUPPORT Tools for evidence-informed health Policymaking (STP) 1: What is evidence-informed policymaking?

This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers. In this article, we discuss the following three questions: What is evidence? What is the role of research evidence in informing health policy decisions? What is evidence-informed policymaking?Evidence-informed health policymaking is an approach to policy decisions that aims to ensure that decision making is well-informed by the best available research evidence. It is characterised by the systematic and transparent access to, and appraisal of, evidence as an input into the policymaking process. The overall process of policymaking is not assumed to be systematic and transparent. However, within the overall process of policymaking, systematic processes are used to ensure that relevant research is identified, appraised and used appropriately. These processes are transparent in order to ensure that others can examine what research evidence was used to inform policy decisions, as well as the judgements made about the evidence and its implications. Evidence-informed policymaking helps policymakers gain an understanding of these processes.     

Developing Policies Responsive to Barriers to Health Care Among Rural Residents: WhatDo We Need to Know?

A substantial body of research has been devoted to the subject of access to health care services for rural residents, much with the intention of shaping government policies to remove barriers or equalize the distribution of health care services. A number of programs and policies hove grown out of or been affected by access research, yet despite identifiable successes of the policy research process, barriers to health care services still exist in rural areas. This article attempts to stimulate discussion about ways that rural health researchers can build on past research on access to care. A framework for posing access questions is proposed, suggesting that access research focus on the following areas: factors that drive differences in utilization, availability, and acceptability; consumer satisfaction and an understanding of why rural consumer satisfaction has been found to be high; factors that impede access that are mutable; and services that can be shown to improve outcomes.     

"Developing good taste in evidence": facilitators of and hindrances to evidence-informed health policymaking in state government

CONTEXT: Policymaking is a highly complex process that is often difficult to predict or influence. Most of the scholarship examining the role of research evidence in policymaking has focused narrowly on characteristics of the evidence and the interactions between scientists and government officials. The real-life context in which policymakers are situated and make decisions also is crucial to the development of evidence-informed policy. METHODS: This qualitative study expands on other studies of research utilization at the state level through interviews with twenty-eight state legislators and administrators about their real-life experiences incorporating evidence into policymaking. The interviews were coded inductively into the following categories: (1) the important or controversial issue or problem being addressed, (2) the information that was used, (3) facilitators, and (4) hindrances. FINDINGS: Hindrances to evidence-informed policymaking included institutional features; characteristics of the evidence supply, such as research quantity, quality, accessibility, and usability; and competing sources of influence, such as interest groups. The policymakers identified a number of facilitators to the use of evidence, including linking research to concrete impacts, costs, and benefits; reframing policy issues to fit the research; training to use evidence-based skills; and developing research venues and collaborative relationships in order to generate relevant evidence. CONCLUSIONS: Certain hindrances to the incorporation of research into policy, like limited budgets, are systemic and not readily altered. However, some of the barriers and facilitators of evidence-informed health policymaking are amenable to change. Policymakers could benefit from evidence-based skills training to help them identify and evaluate high-quality information. Researchers and policymakers thus could collaborate to develop networks for generating and sharing relevant evidence for policy.     

Low-income Canadians' experiences with health-related services: implications for health care reform

This study investigated the use of health-related services by low-income Canadians living in two large cities, Edmonton and Toronto. Interview data collected from low-income people, service providers and managers, advocacy group representatives, and senior-level public servants were analyzed using thematic content analysis. Findings indicate that, in addition to health care policies and programs, a broad range of policies, programs, and services relating to income security, recreation, and housing influence the ability of low-income Canadians to attain, maintain, and enhance their health. Furthermore, the manner in which health-related services are delivered plays a key role in low-income people's service-use decisions. We conclude the paper with a discussion of the health and social policy implications of the findings, which are particularly relevant within the context of recent health care reform discussions in Canada.     

Changing Definitions of Women's Health: Implications for Health Care and Policy

Objectives: To present an overview of how and why normative conceptions of women's health are changing and to discuss some implications of definitional shifts in the context of the changing U.S. health care system. Method: The paper describes the historical development of views of women's health and health care, contrasts the biomedical and biopsychosocial perspectives on women's health, and presents some evidence of challenges and opportunities for change in health care and policy. Results: While women's health has generally been equated with reproductive functions, expanded definitions focus on health through the life span and in the context of women's multiple roles and diverse social circumstances. This expanded view highlights the limitations of health services and policy based on narrower conceptions and program mandates and the need for strategies for integrated, continuous care. There is evidence of change in women's health care, including in Title V programs. Conclusions: New understandings of women's health are particularly relevant to maternal and child health programs, which are positioned to provide model approaches for improving women's health care.     

SUPPORT Tools for evidence-informed Policymaking in health 11: Finding and using evidence about local conditions

Background

Little is known about the process of knowledge translation in low- and middle-income countries. We studied policymaking processes in Mozambique, South Africa and Zimbabwe to understand the factors affecting the use of research evidence in national policy development, with a particular focus on the findings from randomized control trials (RCTs). We examined two cases: the use of magnesium sulphate (MgSO₄) in the treatment of eclampsia in pregnancy (a clinical case); and the use of insecticide treated bed nets and indoor residual household spraying for malaria vector control (a public health case).

Methods

We used a qualitative case-study methodology to explore the policy making process. We carried out key informants interviews with a range of research and policy stakeholders in each country, reviewed documents and developed timelines of key events. Using an iterative approach, we undertook a thematic analysis of the data.

Findings

Prior experience of particular interventions, local champions, stakeholders and international networks, and the involvement of researchers in policy development were important in knowledge translation for both case studies. Key differences across the two case studies included the nature of the evidence, with clear evidence of efficacy for MgSO₄ and ongoing debate regarding the efficacy of bed nets compared with spraying; local researcher involvement in international evidence production, which was stronger for MgSO₄ than for malaria vector control; and a long-standing culture of evidence-based health care within obstetrics. Other differences were the importance of bureaucratic processes for clinical regulatory approval of MgSO₄, and regional networks and political interests for malaria control. In contrast to treatment policies for eclampsia, a diverse group of stakeholders with varied interests, differing in their use and interpretation of evidence, was involved in malaria policy decisions in the three countries.

Conclusion

Translating research knowledge into policy is a complex and context sensitive process. Researchers aiming to enhance knowledge translation need to be aware of factors influencing the demand for different types of research; interact and work closely with key policy stakeholders, networks and local champions; and acknowledge the roles of important interest groups.     

An evidence integration triangle for aligning science with policy and practice

Over-reliance on decontextualized, standardized implementation of efficacy evidence has contributed to slow integration of evidence-based interventions into health policy and practice. This article describes an "evidence integration triangle" (EIT) to guide translation, implementation, prevention efforts, comparative effectiveness research, funding, and policymaking. The EIT emphasizes interactions among three related components needed for effective evidence implementation: (1) practical evidence-based interventions; (2) pragmatic, longitudinal measures of progress; and (3) participatory implementation processes. At the center of the EIT is active engagement of key stakeholders and scientific evidence and attention to the context in which a program is implemented. The EIT model is a straightforward framework to guide practice, research, and policy toward greater effectiveness and is designed to be applicable across multiple levels-from individual-focused and patient-provider interventions, to health systems and policy-level change initiatives.     

Health policy in the Baltic countries since the beginning of the 1990s

The objective of this article is to compare the development of health policies in three Baltic countries, Estonia, Latvia and Lithuania in the period from 1992 to 2004 and reflect on whether key dimensions of these policies are developing in parallel, diverging or even converging in some respects. The paper identifies the similarity in the overall goals and compares the policy content in primary health care, the hospital sector and financing. We conclude that health policy in Estonia, Latvia and Lithuania has been progressing in parallel towards a Western European social insurance funding model, developing a primary care system anchored on a general practitioner service and lessening the hospital orientation of the pre-1990s system. There is evidence of both convergence and divergence across the three countries and of progress in the direction of EU15 in key health policy and outcome characteristics. These patterns are explained partly by differing starting points and partly by political and economic factors over the 1992-2004 period.     

The Promise of Community-Based Participatory Research for Health Equity: A Conceptual Model for Bridging Evidence With Policy

Insufficient attention has been paid to how research can be leveraged to promote health policy or how locality-based research strategies, in particular community-based participatory research (CBPR), influences health policy to eliminate racial and ethnic health inequities. To address this gap, we highlighted the efforts of 2 CBPR partnerships in California to explore how these initiatives made substantial contributions to policymaking for health equity. We presented a new conceptual model and 2 case studies to illustrate the connections among CBPR contexts and processes, policymaking processes and strategies, and outcomes. We extended the critical role of civic engagement by those communities that were most burdened by health inequities by focusing on their political participation as research brokers in bridging evidence and policymaking.Landmark studies have helped keep race and ethnic health inequalities on the national political agenda for more than 3 decades. These studies have included the Secretary’s Task Force on Black and Minority Health,1 Unequal Treatment,2 and Examining the Health Disparities Research Plan.3 Despite the continued research evidence of disproportionate adverse health impacts on racial/ethnic minorities,4 insufficient attention has been paid to the role of governmental action or inaction on these health disparity outcomes. How research can be leveraged to promote health equity policy, or the role of locality-based research strategies, in particular community-based participatory research (CBPR), is less understood. Two major challenges inhibit our knowledge about the link between research and policy change: (1) the gap between scientific evidence and policy action based on evidence, and (2) the difficulty of mobilizing civic engagement for policymaking in the United States.We sought to help fill these gaps by exploring 2 locality-based CBPR initiatives that have effected policy change to promote health equity. After brief overviews of the social justice basis for CBPR and health equity, the literature on CBPR policymaking for health equity, and the issues underlying the research to policy gap, we presented a new conceptual model for better understanding of the pathways and connections between CBPR contexts and processes, policymaking strategies, and policy outcomes. We summarized our case studies and then used detailed findings to illustrate the model’s utility for showcasing how CBPR might contribute, along with other efforts, to local and regional policy change. We concluded by comparing our findings with those of earlier research, and highlighted how further refinement of the conceptual model might assist CBPR partnerships in promoting health equity policy.     

Cancer registry policies in the United States and geographic information systems applications in comprehensive cancer control

OBJECTIVES: Through a long history of cancer policies, public health has a foundation for cancer research and data to use in applying technological advancements for U.S. cancer control efforts. Geographic information systems (GIS) are one technology enabling the visualization of cancer risk patterns associated with incidence, mortality, and accessibility to care. METHODS: U.S. Comprehensive Cancer Control (CCC) program directors were interviewed from 49 of 50 states to assess use and function of GIS tools for mapping data related to cancer control policies and practices. Interviews were coded to obtain frequencies of response associated with content domains mapped using GIS tools and the perceived relative advantages. RESULTS: Significant relationships were found between the mapping of behavioral risk factors, health care services, transportation access, and policy advantages identified by program managers. The mapping of cancer incidence, mortality, and staging, transportation access, and multiple layers of content were found to have significant associations with perceived research advantages. CONCLUSIONS: U.S. CCC program managers recognize several important advantages relating to health policy and research for use of GIS tools in cancer control efforts. The application of GIS in U.S. cancer control efforts is employed unevenly, suggesting the need for innovative policies to support accessibility.     

German health interview and examination survey for adults (DEGS) - design, objectives and implementation of the first data collection wave

Background

Use of evidence in health policymaking plays an important role, especially in resource-constrained settings where informed decisions on resource allocation are paramount. Several knowledge translation (KT) models have been developed, but few have been applied to health policymaking in low income countries. If KT models are expected to explain evidence uptake and implementation, or lack of it, they must be contextualized and take into account the specificity of low income countries for example, the strong influence of donors. The main objective of this research is to elaborate a Middle Range Theory (MRT) of KT in Uganda that can also serve as a reference for other low- and middle income countries.

Methods

This two-step study employed qualitative approaches to examine the principal barriers and facilitating factors to KT. Step 1 involved a literature review and identification of common themes. The results informed the development of the initial MRT, which details the facilitating factors and barriers to KT at the different stages of research and policy development. In Step 2, these were further refined through key informant interviews with policymakers and researchers in Uganda. Deductive content and thematic analysis was carried out to assess the degree of convergence with the elements of the initial MRT and to identify other emerging issues.

Results

Review of the literature revealed that the most common emerging facilitating factors could be grouped under institutional strengthening for KT, research characteristics, dissemination, partnerships and political context. The analysis of interviews, however, showed that policymakers and researchers ranked institutional strengthening for KT, research characteristics and partnerships as the most important. New factors emphasized by respondents were the use of mainstreamed structures within MoH to coordinate and disseminate research, the separation of roles between researchers and policymakers, and the role of the community and civil society in KT.

Conclusions

This study refined an initial MRT on KT in policymaking in the health sector in Uganda that was based on a literature review. It provides a framework that can be used in empirical research of the process of KT on specific policy issues.     

Introduction of new vaccines for immunization in pregnancy – Programmatic,regulatory, safety and ethical considerations

Immunizing pregnant women is a promising strategy to reduce infectious disease-related morbidity and mortality in pregnant women and their infants. Important pre-requisites for the successful introduction of new vaccines for immunization in pregnancy include political commitment and adequate financial resources: trained, committed and sufficient numbers of healthcare workers to deliver the vaccines; close integration of immunization programs with antenatal care and Maternal and Child Health services; adequate access to antenatal care by pregnant women in the country (especially in low and middle-income countries (LMIC)); and a high proportion of births occurring in health facilities (to ensure maternal and neonatal follow-up can be done). The framework needed to advance a vaccine program from product licensure to successful country-level implementation includes establishing and organizing evidence for anticipated vaccine program impact, developing supportive policies, and translating policies into local action. International and national coordination efforts, proactive planning from conception to implementation of the programs (including country-level policy making, planning, and implementation, regulatory guidance, pharmacovigilance) and country-specific and cultural factors must be taken into account during the vaccines introduction.     

Lessons drawn from research utilization in the maternal iodine supplementation policy development in Thailand

ABSTRACT: In this paper, the authors share their experience on evidence utilization in the development of Thailand's maternal iodine supplementation policy in 2009-2010. Observations and reflections on their experience of engaging with research for policymaking are illustrated. The case study indicates that rapid approaches in conducting research, namely a targeted literature review and cross-sectional survey of professionals' opinions and current practices were efficient in achieving the timeliness of evidence provision. In addition pro-activity, trust and interaction between researchers and policymakers enhanced the research-policy integration. The Thai experience may be useful for other developing countries which pursue evidence-informed policymaking, despite differences in the health system context.     

Policies for disease prevention in Germany in the European context: a comparative analysis

BACKGROUND: In Europe important differences exist concerning policies for the prevention of common diseases. In most cases these cannot be explained by the underlying epidemiology. However, successful policies should have a measurable effect on disease epidemiology. There has been little research comparing the effect of national preventive policies on disease-specific mortality. OBJECTIVES: To describe the mortality trends for three health problems representing the three levels of prevention in Germany and in selected European countries, which are of interest for the disease under question. To relate epidemiological trends to preventive policies at the national level and at the level of the European Union (EU). METHODS: Comparison of age-standardized mortality rates for road traffic accidents, cervical cancer and diabetes mellitus in the period 1970-2002, using routine data. Analysis of disease-specific prevention policies in countries that deviate from the general trend in the EU, with a special focus on developments in Germany. RESULTS: The development of mortality rates during the last 30 years for road traffic accidents, cervical cancer and diabetes mellitus varied substantially across Europe. Although the evidence linking specific public policies to epidemiological trends is sparse and often limited to ecological studies, a number of epidemiological changes can be plausibly linked to specific policies in the countries concerned. CONCLUSION: Successful preventive policies exist for all health problems reviewed. The current status of implementation of these policies can only be interpreted in the historical and political context of the countries concerned. The role of epidemiology to guide health policy decisions is under-utilized, as is the regulatory framework for disease and injury prevention at the level of the EU. Less formal policy measures such as European clinical guidelines are equally scarce. More rigorous comparative health services research is needed to formulate evidence-based policies for disease prevention.     

Holding health providers in developing countries accountable to consumers: a synthesis of relevant scholarship

Health care providers in low-income countries often treat consumers poorly. Many providers do not consider it their responsibility to listen carefully to consumer preferences, to facilitate access to care, to offer detailed information, or to treat patients with respect. A lack of provider accountability to health consumers may have adverse effects on the quality of health care they provide, and ultimately on health outcomes. This paper synthesizes relevant research on health provision in low-, middle- and high-income countries with the aim of identifying factors that shape health provider accountability to consumers, and discerning promising interventions to enhance responsiveness. Drawing on this scholarship, we develop a framework that classifies factors into two categories: those concerning the health system and those that pertain to social influences. Among the health systems factors that may shape provider accountability are oversight mechanisms, revenue sources, and the nature of competition in the health sector-all influences that may lead providers to be accountable to entities other than consumers, such as governments and donors. Among the social factors we explore are consumer power, especially information levels, and provider beliefs surrounding accountability. Evidence on factors and interventions shaping health provider accountability is thin. For this reason, it is not possible to draw firm conclusions on what works to enhance accountability. This being said, research does suggest four mechanisms that may improve provider responsiveness: 1. Creating official community participation mechanisms in the context of health service decentralization; 2. Enhancing the quality of health information that consumers receive; 3. Establishing community groups that empower consumers to take action; 4. Including non-governmental organizations in efforts to expand access to care. This synthesis reviews evidence on these and other interventions, and points to future research needs to build knowledge on how to enhance health provider accountability to consumers.     

A generative response to palliative service capacity in Canada

PURPOSE: This paper situates a large-scale learning and service development capacity-building initiative for hospice palliative care services within the current Canadian policy context for use by international readers. DESIGN/METHODOLOGY/APPROACH: In 2000 a national initiative using action research as its design was crafted to support continuing professional development and knowledge management in primary-health care environments. FINDINGS: The Canadian health policy context is complex and requires innovative solutions to achieve desired changes in response to emerging population health demands for quality end-of-life care. Employment of educational and social science constructs, including complexity theory, communities of practice, transformative learning theory, and workplace learning methods, has proven helpful in supporting the creation of national capacity for hospice palliative care. RESEARCH LIMITATIONS/IMPLICATIONS: There is a significant contribution for social scientists to make in aiding a better understanding of the complexity in health systems. At the same time, an aging population in industrial countries demands more active engagement of legal and bioethical scholars in a range of emerging policy and legislative questions about quality end-of-life care. Educational research is also required to understand better and reform curricula to prepare an emerging generation of health science practitioners for the demands of an aging population. PRACTICAL IMPLICATIONS: Changing health service delivery environments demand rethinking of the knowledge and skills leaders require to influence desired change. A broader understanding of where and how learning takes place is essential for enhancing the quality of patient care. ORIGINALITY/VALUE: The Pallium Project represents a generative response to facilitating learning and building longer-term system capacity. The journey of project development to date illustrates some important lessons that can be adopted from hospice palliative care to inform other primary-health care initiatives, including, potentially, mental health, cardiology, diabetes, geriatrics, where productive change can result from productively linking specialists and primary-care colleagues.