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Additional file 1. Data extraction sheet. The extraction of relevant information from the 11 articles included in the review based on the characteristics of the intervention they report on and the study design adopted.

Background: Widespread evidence on implementation indicates that health policies once adopted are not implemented as envisioned and do not always achieve the intended outcomes. The challenges associated with policy implementation gaps have been widely attributed to several factors, ranging from problematic policies to lack of governance and resources. Yet developing countries continue to experience these problems in their bid to translate policy into outcomes, including reduced health care and health inequity. This study seeks to understand the complexity associated with health policy implementation and why implementation gaps remain a challenge for low-and-middle income countries. Methods: A thematic synthesis of findings from three PhD studies, each focusing on national health policies across three African countries (Malawi, Ghana and Botswana) was undertaken to provide insight into the complex processes and factors influencing implementation outcomes. We developed ?descriptive themes? and ?analytical themes? to elucidate and explain key factors leading to policy implementation gaps guided by theoretical and empirical literature. Through an iterative process of data extraction, core themes from the studies were thematically analysed to highlight the contributing factors leading to implementation gaps. Results and discussion: These three cases provided experience of the system-wide complexity associated with implementing national health policies that seek to promote health care equity. We identified overarching factors contributing towards implementation gaps and policy failures across the three countries which include issues of: collaboration, discretionary powers, resources, governance and socio-cultural appropriateness. These factors are not exclusive but interlinked, illustrating a complex interaction among actors with the processes and context of implementation. The results of our analysis also showed that health policy implementation occurs in a highly dynamic and complex environment that is constantly being shaped and influenced, in unpredictable ways by external and internal factors to the system with people and relationships at the core of these factors. Conclusion: We concluded that implementing health policies is a complex phenomenon that triggers unintended consequences, and that intangible factors are often ignored by policymakers, yet have critical impact on policy processes and outcomes. Therefore, policymakers need to rethink the process of implementing health policies, engaging actors and addressing the multiple factors confronting actors when putting policies into practice.

Additional file 1. Data extraction sheet. The extraction of relevant information from the 11 articles included in the review based on the characteristics of the intervention they report on and the study design adopted.

In den vergangenen drei Jahrzehnten gab es eine rasche Zunahme der Zahl der Nicht-Regierungs-Organisationen (NGOs) in allen Bereichen der Entwicklung. Diese Studie untersucht die Wirksamkeit von NGOs bei der Bereitstellung von antiretroviralen Therapie Dienstleistungen in Malawi. Er vergleicht die Qualität und Kosteneffizienz von NGOs, Regierungen und den for-Profit-Sektor. Daten über die ART-Programm Ergebnisse wurden von der HIV und AIDS-Einheit gesammelt, in dem Gesundheitsministerium. Mortality Ergebnisse zeigen, dass der Staatssektor die schlechteste Sterblichkeit von 17,7 Todesfälle pro 100 Personenjahre hat, der NGOs mit 15.2, gefolgt vom for-profit mit 12.2. Der öffentliche Sektor ist der Kostengünstige mit einem Kosten-Nutzen-Verhältnis von 199.74 US$ pro Person und Jahr gelebt, gefolgt von NGOs (267.00 US$) und dem for-profit (370.98 US$). Die Studie kommt zu dem Schluss, dass die NGO-Sektor kritische Spieler in HIV-und AIDS-Service Delivery in Malawi ist. In the past three decades, there has been a rapid increase in the number of Non-Governmental Organisations (NGOs) operating in all areas of development. This study analyses the effectiveness of NGOs in providing antiretroviral therapy services in Malawi. It compares the quality and cost-effectiveness of NGOs, government and the for-profit sectors. Data on the ART programme outcomes was collected from the HIV and AIDS unit, in the Ministry of Health. Mortality outcomes show that the government sector has the worst mortality rate of 17.7 deaths per 100 person years followed by the NGOs with15.2 and the for-profit with12.2. The government sector is the most cost-effective with a cost-effectiveness ratio of 199.74US$ per person year lived, followed by NGOs (267.00US$) and the for-profit (370.98US$). The study concludes that the NGO sector is critical player in HIV and AIDS service delivery in Malawi.

In den vergangenen drei Jahrzehnten gab es eine rasche Zunahme der Zahl der Nicht-Regierungs-Organisationen (NGOs) in allen Bereichen der Entwicklung. Diese Studie untersucht die Wirksamkeit von NGOs bei der Bereitstellung von antiretroviralen Therapie Dienstleistungen in Malawi. Er vergleicht die Qualität und Kosteneffizienz von NGOs, Regierungen und den for-Profit-Sektor. Daten über die ART-Programm Ergebnisse wurden von der HIV und AIDS-Einheit gesammelt, in dem Gesundheitsministerium. Mortality Ergebnisse zeigen, dass der Staatssektor die schlechteste Sterblichkeit von 17,7 Todesfälle pro 100 Personenjahre hat, der NGOs mit 15.2, gefolgt vom for-profit mit 12.2. Der öffentliche Sektor ist der Kostengünstige mit einem Kosten-Nutzen-Verhältnis von 199.74 US pro Person und Jahr gelebt, gefolgt von NGOs (267.00 US) und dem for-profit (370.98 US). Die Studie kommt zu dem Schluss, dass die NGO- Sektor kritische Spieler in HIV-und AIDS-Service Delivery in Malawi ist.