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Background: The involvement of mental health service users and their caregivers in health system policy and planning, service monitoring and research can contribute to mental health system strengthening, but as yet there have been very few efforts to do so in low- and middle-income countries (LMICs).Methods: This systematic review examined the evidence and experience of service user and caregiver involvement in mental health system strengthening, as well as models of best practice for evaluation of capacity-building activities that facilitate their greater participation. Both the peer-reviewed and the grey literature were included in the review, which were identified through database searches (MEDLINE, Embase, PsycINFO, Web of Knowledge, Web of Science, Scopus, CINAHL, LILACS, SciELO, Google Scholar and Cochrane), as well as hand-searching of reference lists and the internet, and a snowballing process of contacting experts active in the area. This review included any kind of study design that described or evaluated service user, family or caregiver (though not community) involvement in LMICs (including service users with intellectual disabilities, dementia, or child and adolescent mental health problems) and that were relevant to mental health system strengthening across five categories. Data were extracted and summarised as a narrative review.Results: Twenty papers matched the inclusion criteria. Overall, the review found that although there were examples of service user and caregiver involvement in mental health system strengthening in numerous countries, there was a lack of high-quality research and a weak evidence base for the work that was being conducted across countries. However, there was some emerging research on the development of policies and strategies, including advocacy work, and to a lesser extent the development of services, service monitoring and evaluation, with most service user involvement having taken place within advocacy and service delivery. Research was scarce within the other health system strengthening areas.Conclusions: Further research on service user and caregiver involvement in mental health system strengthening in LMICs is recommended, in particular research that includes more rigorous evaluation. A series of specific recommendations are provided based on the review. [ABSTRACT FROM AUTHOR]

Background: European societies are ageing rapidly and thus health promotion for older people (HP4OP) is becoming an increasingly relevant issue. Crucial here is not only the clinical aspect of health promotion but also its organisational and institutional dimension. The latter has been relatively neglected in research on HP4OP. This issue is addressed in this study, constituting a part of the EU project ProHealth65+, engaging ten member countries. This paper is based on two intertwining research goals: (1) exploring which institutions/organisations are performing HP4OP activities in selected European countries (including sectors involved, performed roles of these institutions, organisation of those activities); (2) developing an institutional approach to HP4OP. Thus, the paper provides a description of the analytical tools for further research in this area.Methods: The mentioned aims were addressed through the mutual use of two complementary methods: (a) a literature review of scientific and grey literature; and (b) questionnaire survey with selected expert respondents from 10 European countries. The expert respondents, selected by the project's collaborating partners, were asked to fill in a custom designed questionnaire concerning HP4OP institutional aspects.Results: The literature review provided an overview of the organisational arrangements in different HP4OP initiatives. It also enabled the development of functional institutional definitions of health promotion, health promotion activities and interventions, as well as an institutional definition adequate to the health promotion context. The distinctions between sectors were also clarified. The elaborated questionnaires provided in-depth information on countries specifically indicating the key sectors involved in HP4OP in those selected countries. These are: health care, regional/local authorities, NGO's/voluntary institutions. The questionnaire and literature review both resulted in the indication of a significant level of cross-sectorial cooperation in HP4OP.Conclusions: The inclusion of the institutional analysis within the study of HP4OP provides a valuable opportunity to analyse, in a systematic way, good practices in this respect, also in terms of institutional arrangements. A failure to address this aspect in policymaking might potentially cause organisational failure even in evidence-based programmes. This paper frames the perception of this problem. [ABSTRACT FROM AUTHOR]

Background: In the last decade, the health status of Afghans has improved drastically. However, the health financing system in Afghanistan remains fragile due to high out-of-pocket spending and reliance on donor funding. To address the country's health financing challenges, the Ministry of Public Health investigated health insurance as a mechanism to mobilize resources for health. This paper presents stakeholders' opinions on seven preconditions of implementing this approach, as their understanding and buy-in to such an approach will determine its success.Methods: Key informant interviews and focus group discussions were conducted with stakeholders. The interviews focused on perceptions of the seven preconditions of introducing health insurance, and adapting a framework developed by the International Labor Organization. Content analysis was conducted after interviews and discussions were transcribed and coded.Results: Almost all of the stakeholders from government agencies, the private sector, and development partners are interested in introducing health insurance in Afghanistan, and they were aware of the challenges of the country's health financing system. Stakeholders acknowledged that health insurance could be an instrument to address these challenges. However, stakeholders differed in their beliefs about how and when to initiate a health insurance scheme. In addition to increasing insecurity in the country, they saw a lack of clear legal guidance, low quality of healthcare services, poor awareness among the population, limited technical capacity, and challenges to willingness to pay as the major barriers to establishing a successful nationwide health insurance scheme.Conclusions: The identified barriers prevent Afghanistan from establishing health insurance in the short term. Afghanistan must progressively address these major impediments in order to build a health insurance system. [ABSTRACT FROM AUTHOR]

Background: Cancer centers are pressured to deliver high-quality services that can be measured and improved, which has led to an increase of assessments in many countries. A critical area of quality improvement is to improve patient outcome. An overview of existing assessments can help stakeholders (e.g., healthcare professionals, managers and policy makers) improve the quality of cancer research and care and lead to patient benefits. This paper presents key aspects of assessments undertaken by European cancer centers, such as: are assessments mandatory or voluntary? Do they focus on evaluating research, care or both? And are they international or national?Methods: A survey was sent to 33 cancer centers in 28 European Union member states. Participants were asked to score the specifics for each assessment that they listed.Results: Based on the responses from 19 cancer centers from 18 member states, we found 109 assessments. The numbers have steadily increased from 1990's till 2015. Although, a majority of assessments are on patient-care aspects (n = 45), it is unclear how many of those include assessing patient benefits. Only few assessments cover basic research. There is an increasing trend towards mixed assessments (i.e., combining research and patient-care aspects)Conclusions: The need for assessments in cancer centers is increasing. To improve efforts in the quality of research and patient care and to prevent new assessments that "reinvent the wheel", it is advised to start comparative research into the assessments that are likely to bring patient benefits and improve patient outcome. Do assessments provide consistent and reliable information that create added value for all key stakeholders? [ABSTRACT FROM AUTHOR]

Background: The Global Forum 2015 panel session dialogue entitled "From evidence to policy - thinking outside the box" was held on 26 August 2015 in the Philippines to debate why evidence was not fully translated into policy and practice and what could be done to increase its uptake. This paper reports the reasons and possible actions for increasing the uptake of evidence, and highlights the actions partners could take to increase the use of evidence in the African Region.Discussion: The Global Forum 2015 debate attributed African Region's low uptake of evidence to the big gap in incentives and interests between research for health researchers and public health policy-makers; limited appreciation on the side of researchers that public health decisions are based on multiple and complex considerations; perception among users that research evidence is not relevant to local contexts; absence of knowledge translation platforms; sub-optimal collaboration and engagement between industry and research institutions; lack of involvement of civil society organizations; lack of engagement of communities in the research process; failure to engage the media; limited awareness and debate in national and local parliaments on the importance of investing in research and innovation; and dearth of research and innovation parks in the African Region.Conclusion: The actions needed in the Region to increase the uptake of evidence in policy and practice include strengthening NHRS governance; bridging the motivation gap between researchers and health policy-makers; restoring trust between researchers and decision-makers; ensuring close and continuous intellectual intercourse among researchers, ministry of health policy-makers and technocrats during the life course of research projects or programmes; proactive collaboration between academia and industry; regular briefings of civil society, media, relevant parliamentary committees and development partners; development of vibrant knowledge translation platforms; development of action plans for implementing research recommendations, preferably in the context of the Sustainable Development Goals; and encouragement of competition on NHRS strengthening and research output and uptake among the countries using a barometer or scorecard to review their performance at various regional ministerial forums and taking into account the lessons learned from the MDG period. [ABSTRACT FROM AUTHOR]

Background: Policy-making is a dynamic process involving the interplay of various factors. Power and its role are some of its core components. Though power exerts a profound role in policy-making, empirical evidence suggests that health policy analysis has paid only limited attention to the role of power, particularly in policy dialogues.Methods: This exploratory study, which used qualitative methods, had the main aim of learning about and understanding policy dialogues in five African countries and how power influences such processes. Data were collected using key informant interviews. An interview guide was developed with standardised questions and probes on the policy dialogues in each country. This paper utilises these data plus document review to understand how power was manifested during the policy dialogues. Reference is made to the Arts and Tatenhove conceptual framework on power dimensions to understand how power featured during the policy dialogues in African health contexts. Arts and Tatenhove conceptualise power in policy-making in relational, dispositional and structural layers.Results: Our study found that power was applied positively during the dialogues to prioritise agendas, fast-track processes, reorganise positions, focus attention on certain items and foster involvement of the community. Power was applied negatively during the dialogues, for example when position was used to control and shape dialogues, which limited innovation, and when knowledge power was used to influence decisions and the direction of the dialogues. Transitive power was used to challenge the government to think of implementation issues often forgotten during policy-making processes. Dispositional power was the most complex form of power expressed both overtly and covertly. Structural power was manifested socially, culturally, politically, legally and economically.Conclusions: This study shows that we need to be cognisant of the role of power during policy dialogues and put mechanisms in place to manage its influence. There is need for more research to determine how to channel power influence policy-making processes positively, for example through interactive policy dialogues. [ABSTRACT FROM AUTHOR]

Background: Countries in the World Health Organization African Region have witnessed an increase in global health initiatives in the recent past. Although these have provided opportunities for expanding coverage of health interventions; their poor alignment with the countries' priorities and weak coordination, are among the challenges that have affected their impact. A well-coordinated health policy dialogue provides an opportunity to address these challenges, but calls for common understanding among stakeholders of what policy dialogue entails. This paper seeks to assess stakeholders' understanding and perceived importance of health policy dialogue and of policy dialogue coordination.Methods: This was a cross-sectional descriptive study using qualitative methods. Interviews were conducted with 90 key informants from the national and sub-national levels in Lusophone Cabo Verde, Francophone Chad, Guinea and Togo, and Anglophone Liberia using an open-ended interview guide. The interviews were transcribed verbatim, coded and then put through inductive thematic content analysis using QRS software Version 10.Results: There were variations in the definition of policy dialogue that were not necessarily linked to the linguistic leaning of respondents' countries or whether the dialogue took place at the national or sub-national level. The definitions were grouped into five categories based on whether they had an outcome, operational, process, forum or platform, or interactive and evidence-sharing orientation. The stakeholders highlighted multiple benefits of policy dialogue including ensuring stakeholder participation, improving stakeholder harmonisation and alignment, supporting implementation of health policies, fostering continued institutional learning, providing a guiding framework and facilitating stakeholder analysis.Conclusion: Policy dialogue offers the opportunity to improve stakeholder participation in policy development and promote aid effectiveness. However, conceptual clarity is needed to ensure pursuance of common objectives. While it is clear that stakeholder involvement is an important component of policy dialogue, numbers must be manageable for meaningful dialogue. Ownership and coordination of the policy dialogue are important aspects of the process, and building the institutional capacity of the ministry of health requires a comprehensive approach as opposed to strengthening selected departments within it. Likewise, capacity for policy dialogue needs to be built at the sub-national level, alongside improving the bottom-up approach in policy processes. [ABSTRACT FROM AUTHOR]

Background: The UK National Health Service Health Checks programme aims to reduce avoidable cardiovascular deaths, disability and health inequalities in England. However, due to the reported lower uptake of screening in specific black and minority ethnic communities who are recognised as being more at risk of cardiovascular disease, there are concerns that NHS Health Checks may increase inequalities in health. This study aimed to examine the feasibility and acceptability of community outreach NHS Health Checks targeted at the Afro-Caribbean community.Methods: This paper reports findings from an ethnographic study including direct observation of four outreach events in four different community venues in inner-city Bristol, England and follow up semi-structured interviews with attendees (n = 16) and staff (n = 4). Interviews and field notes were transcribed, anonymized and analysed thematically using a process of constant comparison.Results: Analysis revealed the value of community assets (community engagement workers, churches, and community centres) to publicise the event and engage community members. People were motivated to attend for preventative reasons, often prompted by familial experience of cardiovascular disease. Attendees valued outreach NHS Health Checks, reinforcing or prompting some to make healthy lifestyle changes. The NHS Health Check provided an opportunity for attendees to raise other health concerns with health staff and to discuss their test results with peers. For some participants, the communication of test results, risk and lifestyle information was confusing and unwelcome. The findings additionally highlight the need to ensure community venues are fit for purpose in terms of assuring confidentiality.Conclusions: Outreach events provide evidence of how local health partnerships (family practice staff and health trainers) and community assets, including informal networks, can enhance the delivery of outreach NHS Health Checks and in promoting the health of targeted communities. To deliver NHS Health Checks effectively, the location and timing of events needs to be carefully considered and staff need to be provided with the appropriate training to ensure patients are supported and enabled to make lifestyle changes. [ABSTRACT FROM AUTHOR]

Background Extant research suggests that there is a strong social component to Evidence-Based Medicine (EBM) adoption due to the fact that professional networks amongst physicians are strongly associated with their attitudes towards EBM. Despite this evidence, it is still unknown whether individual attitudes to use scientific evidence in clinical decision-making influence the position that physicians hold in their professional network. This paper explores how physicians' attitudes towards EBM is related to the network position they occupy within healthcare organizations. Methods Data pertain to a sample of Italian physicians, whose professional network relationships, demographics and work-profile characteristics were collected. A social network analysis was performed to capture the structural importance of physicians in the collaboration network by the means of a core-periphery analysis and the computation of network centrality indicators. Then, regression analysis was used to test the association between the network position of individual clinicians and their attitudes towards EBM. Results Findings documented that the overall network structure is made up of a dense cohesive core of physicians and of less connected clinicians who occupy the periphery. A negative association between the physicians' attitudes towards EBM and the coreness they exhibited in the professional network was also found. Network centrality indicators confirmed these results documenting a negative association between physicians' propensity to use EBM and their structural importance in the professional network. Conclusions Attitudes that physicians show towards EBM are related to the part (core or periphery) of the professional networks to which they belong as well as to their structural importance. By identifying virtuous attitudes and behaviors of professionals within their organizations, policymakers and executives may avoid marginalization and stimulate integration and continuity of care, both within and across the boundaries of healthcare providers. [ABSTRACT FROM AUTHOR]

Background: Patient advisory councils are a way for healthcare organizations to promote patient engagement. Despite mandates to implement patient advisory councils through programs like the Patient-Centered Medical Home (PCMH), there is a paucity of data measuring the impact of patients functioning in advisory roles. Our objective is to investigate whether patient engagement in patient advisory councils is linked to improvements in clinical quality, patient safety or patient satisfaction.Methods: We searched PubMed, SCOPUS, CINAHL and Google Scholar for English language publications between November 2002 to August 2015, using a combination of "patient advisor" and "care outcomes" search terms. Article selection utilized dual screening facilitated by DistillerSR software, with group discussion to resolve discordance. Observational studies, randomized controlled trials, and case studies were included that described patients serving in an advisory role where primary outcomes were mentioned. Reference lists of included studies and grey literature searches were conducted. Qualitative thematic analysis was performed to synthesize results.Results: Database searching yielded 639 articles total after removing duplicates, with 129 articles meeting full text inclusion criteria. 32 articles were identified for final review, 16 of which were case studies. Advisory roles included patient advisory councils, ad-hoc patient committees, community advisory councils, experience-based co-design, and other. Four practice-based studies from one research group, involving community advisors in the design of public health interventions, found improved clinical outcomes. No prospective experimental studies assessed the impact of patient advisors on patient safety or patient satisfaction. One cluster-randomized RCT showed that patient advisors helped health care planning efforts identify priorities more aligned with the PCMH. Ten case studies reported anecdotal benefit to individual patient advisors.Conclusion: Five included studies demonstrate promising methods for evaluating patient engagement in healthcare delivery and describe impacts on clinical outcomes and priority setting. Based on the case studies found, patient advisors tend to contribute to patient-facing services that may affect clinical care but are not easily evaluated. As clinics and hospitals implement patient advisory councils, rigorous evaluation of their programs is needed to support the expansion of system-level patient engagement.Trial Registration: This systematic review was registered in the PROSPERO database of the University of York Centre for Reviews and Dissemination (ID: 2015: CRD42015030020 ). [ABSTRACT FROM AUTHOR]

Background: During the last years, randomized designs have been promoted as the cornerstone of evidence-based policymaking. Also in the field of community participation, Random Control Trials (RCTs) have been the dominant design, used for instance to examine the contribution of community participation to health improvement. We aim at clarifying why RCTs and related (quasi-) experimental designs may not be the most appropriate approach to evaluate such complex programmes.Results: We argue that the current methodological debate could be more fruitful if it would start from the position that the choice of designs should fit the nature of the program and research questions rather than be driven by methodological preferences. We present how realist evaluation, a theory-driven approach to research and evaluation, is a relevant methodology that could be used to assess whether and how community participation works. Using the realist evaluation approach to examine the relationship between participation and action of women groups and antenatal outcomes would enable evaluators to examine in detail the underlying mechanisms which influence actual practices and outcomes, as well as the context conditions required to make it work.Conclusions: Realist research in fact allows opening the black boxes of "community" and "participation" in order to examine the role they play in ensuring cost-effective, sustainable interventions. This approach yields important information for policy makers and programme managers considering how such programs could be implemented in their own setting. [ABSTRACT FROM AUTHOR]

Background: Policy dialogue, a collaborative governance mechanism, has raised interest among international stakeholders. They see it as a means to strengthen health systems governance and to participate in the development of health policies that support universal health coverage. In this context, WHO has set up the Universal Health Coverage Partnership. This Partnership aims to support health ministries in establishing inclusive, participatory, and evidence-informed policy dialogue. The general purpose of our study is to understand how and in what contexts the Partnership may support policy dialogue and with what outcomes. More specifically, our study aims to answer two questions: 1) How and in what contexts may the Partnership initiate and nurture policy dialogue? 2) How do collaboration dynamics unfold within policy dialogue supported by the Partnership?  METHODS: We conducted a multiple-case study realist evaluation based on Emerson's integrative framework for collaborative governance to investigate the role of the Partnership in policy dialogue on three policy issues in six sub-Saharan African countries: health financing (Burkina Faso and Democratic Republic of Congo), health planning (Cabo Verde, Niger, and Togo), and aid coordination for health (Liberia). We interviewed 121 key informants, analyzed policy documents, and observed policy dialogue events.Results: The Partnership may facilitate the initiation of policy dialogue when: 1) stakeholders feel uncertain about health sector issues and acknowledge their interdependence in responding to such issues, and 2) policy dialogue coincides with their needs and interests. In this context, policy dialogue enables stakeholders to build a shared understanding of issues and of the need for action and encourages collective leadership. However, ministries' weak ownership of policy dialogue and stakeholders' lack of confidence in their capacity for joint action hinder their engagement and curb the institutionalization of policy dialogue.Conclusions: Development aid actors wishing to support policy dialogue must do so over the long term so that collaborative governance becomes routine and a culture of collaboration has time to grow. Public administrations should develop collaborative governance mechanisms that are transparent and intelligible in order to facilitate stakeholder engagement. [ABSTRACT FROM AUTHOR]

Background: Research shows that the most typical response to client violence has been to implement policies that safeguard social workers at their workplaces. This article examined, through a document analysis, the international norms for the protection of social workers. The goal of the document analysis was to inform policy development in South Africa against client violence.Methods: The researchers found, selected, analysed, and synthesised 17 international policies, frameworks, protocols, guidelines, and legislative frameworks using the applied thematic analysis (ATA) approach. The data was analysed at three levels, and open coding yielded 18 codes.Results: The codes were refined into three main themes and subthemes related to protecting social workers from client violence: (1) employers inspired a culture of safety and security within the work-environment, (2) social workers prioritised their safety by using their clinical skills, and (3) actively implementing initiatives to ensure the safety of social workers.Conclusions: The research highlighted social work safety while providing services at an office, visiting sites, or traveling. Examining these practicalities provided valuable data that can inform policy development processes in different countries. [ABSTRACT FROM AUTHOR]

Background: Policymakers such as English healthcare commissioners are encouraged to adopt 'evidence-based policy-making', with 'evidence' defined by researchers as academic research. To learn how academic research can influence policy, researchers need to know more about commissioning, commissioners' information seeking behaviour and the role of research in their decisions.Methods: In case studies of four commissioning organisations, we interviewed 52 people including clinical and managerial commissioners, observed 14 commissioning meetings and collected documentation e.g. meeting minutes and reports. Using constant comparison, data were coded, summarised and analysed to facilitate cross case comparison.Results: The 'art of commissioning' entails juggling competing agendas, priorities, power relationships, demands and personal inclinations to build a persuasive, compelling case. Policymakers sought information to identify options, navigate ways through, justify decisions and convince others to approve and/or follow the suggested course. 'Evidence-based policy-making' usually meant pragmatic selection of 'evidence' such as best practice guidance, clinicians' and users' views of services and innovations from elsewhere. Inconclusive or negative research was unhelpful in developing policymaking plans and did not inform disinvestment decisions. Information was exchanged through conversations and stories, which were fast, flexible and suited the rapidly changing world of policymaking. Local data often trumped national or research-based evidence. Local evaluations were more useful than academic research.Discussion: Commissioners are highly pragmatic and will only use information that helps them create a compelling case for action.Therefore, researchers need to start producing more useful information.Conclusions: To influence policymakers' decisions, researchers need to 1) learn more about local policymakers' priorities 2) develop relationships of mutual benefit 3) use verbal instead of writtencommunication 4) work with intermediaries such as public health consultants and 5) co-produce local evaluations. [ABSTRACT FROM AUTHOR]

Background: Significant knowledge gaps exist in the functioning of institutional designs and organisational practices in purchasing within free healthcare schemes in low resource countries. The study provides evidence of the governance requirements to scale up strategic purchasing in free healthcare policies in Nigeria and other low-resource settings facing similar approaches.Methods: The study was conducted at the Ministry of Health and in two health districts in Enugu State, Nigeria, using a qualitative case study design. Semi-structured interviews were conducted with 44 key health system actors (16 policymakers, 16 providers and 12 health facility committee leaders) purposively selected from the Ministry of Health and the two health districts. Data collection and analysis were guided by Siddiqi and colleagues' health system governance framework. Data were analysed using a framework approach.Results: The key findings show that supportive governance practices in purchasing included systems to verify questionable provider claims, pay providers directly for services, compel providers to procure drugs centrally and track transfer of funds to providers. However, strategic vision was undermined by institutional conflicts, absence of purchaser-provider split and lack of selective contracting of providers. Benefit design was not based on stakeholder involvement. Rule of law was limited by delays in provider payment. Benefits and obligations to users were not transparent. The criteria and procedure for resource allocation were unclear. Some target beneficiaries seemed excluded from the scheme. Effectiveness and efficiency was constrained by poor adherence to purchasing rules. Accountability of purchasers and providers to users was weak. Intelligence and information is constrained by paper-based system. Rationing of free services by providers and users' non-adherence to primary gate-keeping role hindered ethics.Conclusion: Weak governance of purchasing function limits potential of FMCHP to contribute towards universal health coverage. Appropriate governance model for strengthening strategic purchasing in the FMCHP and possibly free healthcare interventions in other low-resource countries must pay attention to the creation of an autonomous purchasing agency, clear framework for selective contracting, stakeholder involvement, transparent benefit design, need-based resource allocation, efficient provider payment methods, stronger roles for citizens, enforcement of gatekeeping rules and use of data for decision-making. [ABSTRACT FROM AUTHOR]

Background: Competing priorities in health systems necessitate difficult choices on which health actions and investments to fund: decisions that are complex, value-based, and highly political. In light of the centrality of universal health coverage (UHC) in driving current health policy, we sought to examine the value interests that influence agenda setting in the country's health financing space. Given the plurality of Kenya's health policy levers, we aimed to examine how the perspectives of stakeholders involved in policy decision-making and implementation shape discussions on health financing within the UHC framework.Methods: A series of in-depth key informant interviews were conducted at national and county level (n = 13) between April and May 2018. Final thematic analysis using the Framework Method was conducted to identify similarities and differences amongst stakeholders on the challenges hindering Kenya's achievement of UHC in terms of its the optimisation of health service coverage; expansion of the population that benefits from essential healthcare services; and the minimisation of out-of-pocket costs associated with health-seeking behaviour.Results: Our findings indicate that the perceived lack of strategic leadership from Kenya's national government has led to a lack of agreement on stakeholders' interpretation of what is to be understood by UHC, its contextual values and priorities. We observe material differences between and within policy networks on the country's priorities for population coverage, healthcare service provision, and cost-sharing under the UHC dispensation. In spite of this, we note that progressive universalism is considered as the preferred approach towards UHC in Kenya, with most interviewees prioritising an equity-based approach that prioritises better access to healthcare services and financial risk protection. However, the conflicting priorities of key stakeholders risk derailing progress towards the expansion of access to health services and financial risk protection.Conclusions: This study adds to existing knowledge of UHC in Kenya by contextualising the competing and evolving priorities that should be taken into consideration as the country strategises over its UHC process. We suggest that clear policy action is required from national government and county governments in order to develop a logical and consistent approach towards UHC in Kenya. [ABSTRACT FROM AUTHOR]

Background: There are increasing calls for developing robust processes of community-based accountability as key components of health system strengthening. However, implementation of these processes have shown mixed results over time and geography. The Community Action for Health (CAH) project was introduced as part of India's National Rural Health Mission (now National Health Mission) to strengthen community-based accountability through community monitoring and planning. In this study we trace the implementation process of this project from its piloting, implementation and abrupt termination in the South Indian state of Tamil Nadu.Methods: We framed CAH as an innovation introduced into the health system. We use the framework on integration of innovations in complex systems developed by Atun and others. We used qualitative approaches to study the implementation. We conducted interviews among a range of individuals who were directly involved in the implementation, focusing on the policy making organizational level.Results: We uncover what we have termed "dissonances" and "disconnects" at the state level among individuals with key responsibility of implementation. By dissonances we refer to the diversity of perspective on the concept of community-based accountability and its perceived role. By disconnects we refer to the lack of spaces and processes for "sense-making" in a largely hierarchically functioning system. These constructs we believe contributes significantly to making sense of the initial uptake and the subsequent abrupt termination of the project.Conclusions: This study contributes to the overall field of policy implementation, especially the phase between the emergence on the policy agenda and its incorporation into the day to day functioning of a system. It focuses on the implementation of contested interventions like community-based accountability, in Low- and Middle-income country settings undergoing transitions in governance. It highlights the importance of "problematization" a dimension not included in most currently popular frameworks to study the uptake and spread of innovations in the health system. It points not only to the importance of diverse perspectives present among individuals at different positions in the organization, but equally importantly the need for spaces and process of collective sense-making to ensure that a contested policy intervention is integrated into a complex system. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses topics including the World Health Organization in African Region, the policy dialogue in low income countries and the resources required in policy development.

Background: Most previous studies on healthcare service utilization in low-income countries have not used a multilevel study design to address the importance of community-level women's autonomy. We assessed whether women's autonomy, measured at both individual and community levels, is associated with maternal healthcare service utilization in Ethiopia.Methods: We analyzed data from the 2005 and 2011 Ethiopia Demographic and Health Surveys (N = 6058 and 7043, respectively) for measuring women's decision-making power and permissive gender norms associated with wife beating. We used Spearman's correlation and the chi-squared test for bivariate analyses and constructed generalized estimating equation logistic regression models to analyze the associations between women's autonomy indicators and maternal healthcare service utilization with control for other socioeconomic characteristics.Results: Our multivariate analysis showed that women living in communities with a higher percentage of opposing attitudes toward wife beating were more likely to use all three types of maternal healthcare services in 2011 (adjusted odds ratios = 1.21, 1.23, and 1.18 for four or more antenatal care visits, health facility delivery, and postnatal care visits, respectively). In 2005, the adjusted odds ratios were 1.16 and 1.17 for four or more antenatal care visits and health facility delivery, respectively. In 2011, the percentage of women in the community with high decision-making power was positively associated with the likelihood of four or more antenatal care visits (adjusted odds ratio = 1.14). The association of individual-level autonomy on maternal healthcare service utilization was less profound after we controlled for other individual-level and community-level characteristics.Conclusions: Our study shows that women's autonomy was positively associated with maternal healthcare service utilization in Ethiopia. We suggest addressing woman empowerment in national policies and programs would be the optimal solution. [ABSTRACT FROM AUTHOR]

Background: This study presents a descriptive synthesis of Kurdistan Region of Iraq's (KRI) primary care system, which is undergoing comprehensive primary care reforms within the context of a cross-cutting structural economic adjustment program and protracted security, humanitarian, economic and political crises.Methods: The descriptive analysis used a framework operationalizing Starfield's classic primary care model for health services research. A scoping review was performed using relevant sources, and expert consultations were conducted for completing and validating data.Results: The descriptive analysis presents a complex narrative of a primary care system undergoing classical developmental processes of transitioning middle-income countries. The system is simultaneously under tremendous pressure to adapt to the continuously changing, complex and resource-intensive needs of sub-populations exhibiting varying morbidity patterns, within the context of protracted security, humanitarian, economic, and political crises. Despite exhibiting significant resilience in the face of the ongoing crises, the continued influx of IDPs and Syrian refugees, coupled with extremely limited resources and weak governance at policy, organizational and clinical levels threaten the sustainability of KRI's public primary care system. Diverse trajectories to the strengthening and development of primary care are underway by local and international actors, notably the World Bank, RAND Corporation, UN organizations and USAID, focusing on varying imperatives related to the protracted humanitarian and economic crises.Conclusions: The convergence, interaction and outcomes of the diverse initiatives and policy approaches in relation to the development of KRI's primary care system are complex and highly uncertain. A common vision of primary care is required to align resources, initiatives and policies, and to enable synergy between all local and international actors involved in the developmental and humanitarian response. Further research that integrates the knowledge synthesized in this article, and enables actors in KRI to learn from their own experiences and efforts, along with those of other jurisdictions, would be invaluable towards the ongoing development of primary care. [ABSTRACT FROM AUTHOR]

Background: We analyzed and compared primary health care (PHC) policies in British Columbia, Alberta and Saskatchewan to understand how they inform the design and implementation of team-based primary health care service delivery. The goal was to develop policy imperatives that can advance team-based PHC in Canada.Methods: We conducted comparative case studies (n = 3). The policy analysis included: Context review: We reviewed relevant information (2007 to 2014) from databases and websites. Policy review and comparative analysis: We compared and contrasted publically available PHC policies. Key informant interviews: Key informants (n = 30) validated narratives prepared from the comparative analysis by offering contextual information on potential policy imperatives. Advisory group and roundtable: An expert advisory group guided this work and a key stakeholder roundtable event guided prioritization of policy imperatives.Results: The concept of team-based PHC varies widely across and within the three provinces. We noted policy gaps related to team configuration, leadership, scope of practice, role clarity and financing of team-based care; few policies speak explicitly to monitoring and evaluation of team-based PHC. We prioritized four policy imperatives: (1) alignment of goals and policies at different system levels; (2) investment of resources for system change; (3) compensation models for all members of the team; and (4) accountability through collaborative practice metrics.Conclusions: Policies supporting team-based PHC have been slow to emerge, lacking a systematic and coordinated approach. Greater alignment with specific consideration of financing, reimbursement, implementation mechanisms and performance monitoring could accelerate systemic transformation by removing some well-known barriers to team-based care. [ABSTRACT FROM AUTHOR]

Background: Heightened fiscal constraints, increases in the chronic disease burden and in consumer expectations are among several factors contributing to the global interest in evidence-informed health policy. The present article builds on previous work that explored how the Australian Federal Government applied five instruments of policy, or policy levers, to implement a series of reforms under the Australian National Mental Health Strategy (NMHS). The present article draws on theoretical insights from political science to analyse the relative successes and failures of these levers, as portrayed in formal government evaluations of the NMHS.Methods: Documentary analysis of six evaluation documents corresponding to three National Mental Health Plans was undertaken. Both the content and approach of these government-funded, independently conducted evaluations were appraised.Results: An overall improvement was apparent in the development and application of policy levers over time. However, this finding should be interpreted with caution due to variations in evaluation approach according to Plan and policy lever. Tabulated summaries of the success and failure of each policy initiative, ordered by lever type, are provided to establish a resource that could be consulted for future policy-making.Conclusions: This analysis highlights the complexities of health service reform and underscores the limitations of narrowly focused empirical approaches. A theoretical framework is provided that could inform the evaluation and targeted selection of appropriate policy levers in mental health. [ABSTRACT FROM AUTHOR]

Background: Policy making, translation and implementation in politically and administratively decentralized systems can be challenging. Beyond the mere sub-national acceptance of national initiatives, adherence to policy implementation processes is often poor, particularly in low and middle-income countries. In this study, we explore the implementation fidelity of integrated PHC governance policy in Nigeria's decentralized governance system and its implications on closing implementation gaps with respect to other top-down health policies and initiatives.Methods: Having engaged policy makers, we identified 9 core components of the policy (Governance, Legislation, Minimum Service Package, Repositioning, Systems Development, Operational Guidelines, Human Resources, Funding Structure, and Office Establishment). We evaluated the level and pattern of implementation at state level as compared to the national guidelines using a scorecard approach.Results: Contrary to national government's assessment of level of compliance, we found that sub-national governments exercised significant discretion with respect to the implementation of core components of the policy. Whereas 35 and 32% of states fully met national criteria for the structural domains of "Office Establishment" and Legislation" respectively, no state was fully compliant to "Human Resource Management" and "Funding" requirements, which are more indicative of functionality. The pattern of implementation suggests that, rather than implementing to improve outcomes, state governments may be more interested in executing low hanging fruits in order to access national incentives.Conclusions: Our study highlights the importance of evaluating implementation fidelity in providing evidence of implementation gaps towards improving policy execution, particularly in decentralized health systems. This approach will help national policy makers identify more effective ways of supporting lower tiers of governance towards improvement of health systems and outcomes. [ABSTRACT FROM AUTHOR]

Background: Numerous health policy makers/researchers are concerned about the limitations of research being applied to support informed decision/policy making and the implementation of practical solutions. The aim of the Chaguo Letu project (which means our choice in Swahili) was to determine how local decision makers could apply a multimethod approach to make strategic decisions to effectively implement a Cervical Self-Sampling Program in Kenya.Methods: A multimethod approach, involving participatory action research, scenario based planning, and phenomenology, was applied in conjunction with two tools to identify relevant factors (negative or positive) that could impact Cervical Self-Sampling Program implementation. A total of 107 stakeholders participated in interviews, focus groups, workshops, and informal interactions. Content analysis, an affinity exercise, and impact analysis were used to analyze data and develop robust strategic directions and supporting implementation strategies.Results: A total of 57 factors thought to impact the implementation of the Cervical Self-Sampling Program were identified and grouped into 13 thematic categories. These themes were instrumental in developing 10 strategic directions and 22 implementation strategies deemed necessary to implement a technically viable, politically supported, affordable, logistically feasible, socially acceptable, and transformative Program.Conclusions: This study made three conclusions: 1) there is political will and a desire to improve cervical screening across Kenya, but in a period of dynamic change resources are constrained; 2) implementing the Program in urban/rural settings is logistically feasible, but the majority of Kenyan women could not afford screening without some form of a subsidy, and 3) self-sampling is perceived to be much more socially acceptable than the current Pap screening process. The Chaguo Letu study went beyond the traditional strategy development process of determining "what" needs to do done by describing in detail "how" the Program should be implemented to be relevant and accessible to all Kenyan women at risk of cervical cancer. This work could potentially facilitate communities of practice and knowledge sharing when addressing other types of health decisions in other low resource settings beyond Kenya. [ABSTRACT FROM AUTHOR]

Background: The South African (SA) public health system has employed an Essential Medicines List (EML) with Standard Treatment Guidelines (STGs) in the public sector since 1996. To date no studies have reported on the process of selection of essential medicines for SA EMLs and how this may have changed over time. This study reports on the decision making process for the selection of essential medicines for SA EMLs, over the years, as described by various members of the National Essential Medicines List Committee (NEMLC) and their task teams.Methods: Qualitative in-depth interviews, guided by an interview questionnaire, were conducted with 11 members of the SA NEMLC and their task teams (both past and present members) during the period January - April 2015. Interviews were recorded and transcribed verbatim. Transcripts were then coded by the first author and verified by the second author before being reconciled and input into NVIVO, a qualitative software, to facilitate analysis of the data.Results: The interviews conducted suggest that the NEMLC process of medicine selection has been refined over the years. This together with the EML review process is now essentially predominantly an evidence based process where quality, safety and efficacy of a medicine is considered first followed by cost considerations which includes pharmacoeconomic evaluations, and pricing of medicines.Conclusions: This is the first study in SA to report on how decisions are taken to include or exclude medicines on SA national EMLs and provides insight into the SA EML medicine selection, review and monitoring processes over time. The results show that the NEMLC has undergone tremendous transformation over the years. Whilst the membership of the committee largely remains unchanged, the committee has developed its policies and processes over the years. However there is still a need to strengthen the monitoring and evaluation aspects of the SA EML policy process. [ABSTRACT FROM AUTHOR]

Background: Harmonisation is a key principle of the Paris Declaration. The Universal Health Coverage (UHC) Partnership, an initiative of the European Union, the Government of Luxembourg and the World Health Organization, supported health policy dialogues between 2012 and 2015 in identified countries in the WHO African Region. The UHC Partnership has amongst its key objectives to strengthen national health policy development. In Guinea and Chad, policy dialogue focused on elaborating the national health plan and other key documents. This study is an analytical reflection inspired by realist evaluative approaches to understand whether policy dialogue led to improved harmonisation amongst health actors in Guinea and Chad, and if so, how and why.Methods: Interviews were conducted in Guinea and Chad with key informants at the national and sub-national government levels, civil society, and development partners. A review of relevant policy documents and reports was added to data collection to construct a full picture of the policy dialogue process. Context-mechanism-outcome configurations were used as the realist framework to guide the analysis on how participants' understanding of what policy dialogue was and the way the policy dialogue process unfolded led to improved harmonisation.Results: Improved harmonisation as a result of policy dialogue was perceived to be stronger in Guinea than in Chad. While in both countries the participants held a shared view of what policy dialogue was and what it could achieve, and both policy dialogue processes were considered to be well implemented (i.e., well-facilitated, evidence-based, participatory, and consisted of recurring meetings and activities), certain contextual factors in Chad tempered the view of harmonisation as having improved. These were the pre-existence of dialogic policy processes that had exposed the actors to the potential that policy dialogue could have; a focus on elaborating provincial level strategies, which gave the sense that the process was more bottom-up; and the perception that there were acute resource constraints, which conditioned partners' interactions.Conclusions: Policy dialogue improves harmonisation in terms of fostering information exchange amongst partners; however, it does not appear to influence the operational procedures of the actors. This has implications for aid effectiveness. [ABSTRACT FROM AUTHOR]

Background: Policy processes that yield good outcomes are inherently complex, requiring interactions of stakeholders in problem identification, generation of political will and selection of practical solutions. To make policy processes rational, policy dialogues are increasingly being used as a policy-making tool. Despite their increasing use for policy-making in Africa, evidence is limited on how they have evolved and are being used on the continent or in low and middle income countries elsewhere.Methods: This was an exploratory study using qualitative methods. It utilised data related to policy dialogues for three specific policies and strategies to understand the interplay between policy dialogue and policy-making in Cabo Verde, Chad and Mali. The specific methods used to gather data were key informant interviews and document review. Data were analysed inductively and deductively using thematic content analysis.Results: Participation in the policy dialogues was inclusive, and in some instances bottom-up participatory approaches were used. The respondents felt that the execution of the policy dialogues had been seamless, and the few divergent views expressed often were resolved in a unanimous manner. The policies and strategies developed were seen by all stakeholders as relating to priority issues. Other specific process factors that contributed to the success of the dialogues included the use of innovative approaches, good facilitation, availability of resources for the dialogues, good communication, and consideration of the different opinions. Among the barriers were contextual issues, delays in decision-making and conflicting coordination roles and mandates.Conclusions: Policy dialogues have proved to be an effective tool in health sector management and could be a crucial component of the governance dynamics of the sector. The policy dialogue process needs to be institutionalised for continuity and maintenance of institutional intelligence. Other essential influencing factors include building capacity for coordination and facilitation of policy dialogues, provision of sustainable financing for execution of the dialogues, use of inclusive and bottom-up approaches, and timely provision of reliable evidence. Ensuring continued participation of all the actors necessitates innovation to allow dialogue outside the formal frameworks and spaces that should feed into the formal dialogue processes. [ABSTRACT FROM AUTHOR]

Background: In the last decade participatory approaches have gained prominence in policy-making, becoming the focus of good policy-making processes. Policy dialogue is recognised as an important aspect of policy-making among several interactive and innovative policy-making models applied in different contexts and sectors. Recently there has been emphasis on the quality of policy dialogue in terms of how it should be conducted to attain participation and inclusiveness. However, there is paucity of evidence on how the context influences policy dialogue, particularly participation of stakeholders. Liberia's context, which is characterised as post-war, highly donor dependent and in recovery from the recent catastrophic Ebola outbreak, provides an opportunity to understand the influence of context on policy dialogue.Methods: This was an exploratory study using qualitative methods. Key informant interviews were conducted using an interview guide. A total of 16 interviews were conducted, 12 at the national level and 4 at the sub national level. Data were analysed using inductive thematic content analysis.Results: The respondents felt that the dialogues were a success and involved important stakeholders; however, there were concerns about the improper methodology and facilitation used to conduct them. Opinions among the respondents about the process of generating and selecting the themes for the dialogues were extremely divergent. Both before and during the Ebola outbreak, the context was instrumental in shaping the dialogues according to the issue of focus, requirements for participation and the decisions to be made. Policy dialogues have become a platform for policy discussions and decisions in Liberia. It is a process that is well recognised and appreciated and is highly attributed to the success of the negotiations during the Ebola outbreak.Conclusions: To sustain and strengthen policy dialogues in future, there needs to be proper information sharing through diverse forums and avenues, stakeholders' empowerment and competent facilitation. These will ensure that the process is credible and legitimate. [ABSTRACT FROM AUTHOR]

Background: In most societies the health marketplace is pluralistic in character, with a mix of formal and informal providers. In high-income countries, state regulation of the market helps ensure quality and access and mitigate market failures. In the present study, using Haiti as a case study, we explore what happens to the functioning of the pluralistic health marketplace in severely disrupted environments where the informal sector is able to flourish.Methods: The overall research design was qualitative. Research methods included an extensive documentary and policy analysis, based on peer-reviewed articles, books and "grey" literature--government policy and program reports, unpublished research and evaluations, reviews and reviews from key multilateral and bilateral donors, and non-government organisations, combined with field site visits and in-depth key informant interviews (N = 45).Results: The findings show that state fragility has resulted in a privatised, commoditised and largely unregulated and informal health market. While different market segments can be identified, in reality the boundaries between international/domestic, public/private, for profit/not-for-profit, legal/illegal are hazy and shifting.Discussion: The lack of state capacity to provide an enabling environment, establish, and enforce its regulatory framework has resulted in a highly segmented, heterogeneous and informal health market. The result is deplorable health indices which are far below regional averages and many other low-income countries.Conclusions: Working in fragile states with limited capacity to undertake the core function of securing the health of its population requires new and innovative ways of working. This needs longer time-frames, combining incremental top-down and bottom-up strategies which recognize and work with state and civil society, public and private actors, formal and informal institutions, and progressively facilitate changes in the different market functions of supply, demand, regulation and supporting functions. [ABSTRACT FROM AUTHOR]

Background: Rankings from the World Health Organization (WHO) place the US health care system as one of the least efficient among Organization for Economic Cooperation and Development (OECD) countries. Researchers have questioned this, noting simplistic or inappropriate methodologies, poor measurement choice, and poor control variables. Our objective is to re-visit this question by using newer modeling techniques and a large panel of OECD data.Methods: We primarily use the OECD Health Data for 25 OECD countries. We compare results from stochastic frontier analysis (SFA) and fixed effects models. We estimate total life expectancy as well as life expectancy at age 60. We explore a combination of control variables reflecting health care resources, health behaviors, and economic and environmental factors.Results: The US never ranks higher than fifth out of all 36 models, but is also never the very last ranked country though it was close in several models. The SFA estimation approach produces the most consistent lead country, but the remaining countries did not maintain a steady rank.Discussion: Our study sheds light on the fragility of health system rankings by using a large panel and applying the latest efficiency modeling techniques. The rankings are not robust to different statistical approaches, nor to variable inclusion decisions.Conclusions: Future international comparisons should employ a range of methodologies to generate a more nuanced portrait of health care system efficiency. [ABSTRACT FROM AUTHOR]

Background: Nursing workforce data are scarce in Switzerland, with no active national registry of nurses. The worldwide nursing shortage is also affecting Switzerland, so that evidence-based results of the nurses at work project on career paths and retention are needed as part of the health care system stewardship; nurses at work is a retrospective cohort study of nurses who graduated in Swiss nursing schools in the last 30 years. Results of the pilot study are presented here (process and feasibility). The objectives are (1) to determine the size and structure of the potential target population by approaching two test-cohorts of nursing graduates (1988 and 1998); (2) to test methods of identifying and reaching them 14 and 24 years after graduation; (3) to compute participation rates, and identify recruitment and participation biases. Methods: Graduates' names were retrieved from 26 Swiss nursing schools: 488 nurses from the 1988 cohort and 597 from 1998 were invited to complete a web-based questionnaire. Initial updated addresses (n = 278, seed sample) were found using the Swiss Nursing Association member file. In addition, a snowball method was applied for recruitment, where directly-contacted respondents provided additional names of graduate mates or sent them the invitation. The study was further advertized through the main employers, study partners, and a press release. Results: Participation rate was 26.5% (n = 287), higher for the older cohort of 1988 (29.7%, n = 145) than for 1998 (15.6%, n = 93). Additional nurses (n = 363) not belonging to the test cohorts also answered. All schools were represented among respondents. Only 18 respondents (6%) worked outside nursing or not at all. Among respondents, 94% would 'probably' or 'maybe' agree to participate in the main study. Conclusion: The pilot study demonstrated that targeted nurses could be identified and approached. There is an overwhelming interest in the project from them and from policymakers. Recommendations to increase nurses' participation rate for nurses at work include: (1) to open nurses at work recruitment to all nurses in Switzerland, while recreating cohorts post-hoc for relevant analysis; (2) to define a comprehensive communication strategy with special attention to graduate nurses who are harder to reach. [ABSTRACT FROM AUTHOR]

Background The gap between research and practice or policy is often described as a problem. To identify new barriers of and facilitators to the use of evidence by policymakers, and assess the state of research in this area, we updated a systematic review. Methods Systematic review. We searched online databases including Medline, Embase, SocSci Abstracts, CDS, DARE, Psychlit, Cochrane Library, NHSEED, HTA, PAIS, IBSS (Search dates: July 2000 - September 2012). Studies were included if they were primary research or systematic reviews about factors affecting the use of evidence in policy. Studies were coded to extract data on methods, topic, focus, results and population. Results 145 new studies were identified, of which over half were published after 2010. Thirteen systematic reviews were included. Compared with the original review, a much wider range of policy topics was found. Although still primarily in the health field, studies were also drawn from criminal justice, traffic policy, drug policy, and partnership working. The most frequently reported barriers to evidence uptake were poor access to good quality relevant research, and lack of timely research output. The most frequently reported facilitators were collaboration between researchers and policymakers, and improved relationships and skills. There is an increasing amount of research into new models of knowledge transfer, and evaluations of interventions such as knowledge brokerage. Conclusions Timely access to good quality and relevant research evidence, collaborations with policymakers and relationship- and skills-building with policymakers are reported to be the most important factors in influencing the use of evidence. Although investigations into the use of evidence have spread beyond the health field and into more countries, the main barriers and facilitators remained the same as in the earlier review. Few studies provide clear definitions of policy, evidence or policymaker. Nor are empirical data about policy processes or implementation of policy widely available. It is therefore difficult to describe the role of evidence and other factors influencing policy. Future research and policy priorities should aim to illuminate these concepts and processes, target the factors identified in this review, and consider new methods of overcoming the barriers described. [ABSTRACT FROM AUTHOR]

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

This research on user fee removal in three African countries is located at the interface of public policy analysis and health systems research. Public policy analysis has gradually become a vast and multifaceted area of research consisting of a number of perspectives. But the context of public policies in Sahelian Africa has some specific characteristics. They are largely shaped by international institutions and development agencies, on the basis of very common 'one-size-fits-all' models; the practical norms that govern the actual behaviour of employees are far removed from official norms; public goods and services are co-delivered by a string of different actors and institutions, with little coordination between them; the State is widely regarded by the majority of citizens as untrustworthy. In such a context, setting up and implementing health user fee exemptions in Burkina Faso, Mali and Niger was beset by major problems, lack of coherence and bottlenecks that affect public policy-making and implementation in these countries. [ABSTRACT FROM AUTHOR]