Jeremy Shiffman

Doing health policy analysis: methodological and conceptual reflections and challenges

The case for undertaking policy analysis has been made by a number of scholars and practitioners. However, there has been much less attention given to how to do policy analysis, what research designs, theories or methods best inform policy analysis. This paper begins by looking at the health policy environment, and some of the challenges to researching this highly complex phenomenon. It focuses on research in middle and low income countries, drawing on some of the frameworks and theories, methodologies and designs that can be used in health policy analysis, giving examples from recent studies. The implications of case studies and of temporality in research design are explored. Attention is drawn to the roles of the policy researcher and the importance of reflexivity and researcher positionality in the research process. The final section explores ways of advancing the field of health policy analysis with recommendations on theory, methodology and researcher reflexivity.

Generation of Political Priority for Global Health Initiatives: A Framework and Case Study of Maternal Mortality

Why do some global health initiatives receive priority from international and national political leaders whereas others receive little attention? To analyse this question we propose a framework consisting of four categories: the strength of the actors involved in the initiative, the power of the ideas they use to portray the issue, the nature of the political contexts in which they operate, and characteristics of the issue itself. We apply this framework to the case of a global initiative to reduce maternal mortality, which was launched in 1987. We undertook archival research and interviewed people connected with the initiative, using a process-tracing method that is commonly employed in qualitative research. We report that despite two decades of effort the initiative remains in an early phase of development, hampered by difficulties in all these categories. However, the initiatives 20th year, 2007, presents opportunities to build political momentum. To generate political priority, advocates will need to address several challenges, including the creation of effective institutions to guide the initiative and the development of a public positioning of the issue to convince political leaders to act. We use the framework and case study to suggest areas for future research on the determinants of political priority for global health initiatives, which is a subject that has attracted much speculation but little scholarship.

Early childhood development coming of age: science through the life course

Early childhood development programmes vary in coordination and quality, with inadequate and inequitable access, especially for children younger than 3 years. New estimates, based on proxy measures of stunting and poverty, indicate that 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of not reaching their developmental potential. There is therefore an urgent need to increase multisectoral coverage of quality programming that incorporates health, nutrition, security and safety, responsive caregiving, and early learning. Equitable early childhood policies and programmes are crucial for meeting Sustainable Development Goals, and for children to develop the intellectual skills, creativity, and wellbeing required to become healthy and productive adults. In this paper, the first in a three part Series on early childhood development, we examine recent scientific progress and global commitments to early childhood development. Research, programmes, and policies have advanced substantially since 2000, with new neuroscientific evidence linking early adversity and nurturing care with brain development and function throughout the life course.

The emergence of global attention to health systems strengthening

After a period of proliferation of disease-specific initiatives, over the past decade and especially since 2005 many organizations involved in global health have come to direct attention and resources to the issue of health systems strengthening. We explore how and why such attention emerged. A qualitative methodology, process-tracing, was used to construct a case history and analyse the factors shaping and inhibiting global political attention for health systems strengthening. We find that the critical factors behind the recent burst of attention include fears among global health actors that health systems problems threaten the achievement of the health-related Millennium Development Goals, concern about the adverse effects of global health initiatives on national health systems, and the realization among global health initiatives that weak health systems present bottlenecks to the achievement of their organizational objectives. While a variety of actors now embrace health systems strengthening, they do not constitute a cohesive policy community. Moreover, the concept of health systems strengthening remains vague and there is a weak evidence base for informing policies and programmes for strengthening health systems. There are several reasons to question the sustainability of the agenda. Among these are the global financial crisis, the history of pendulum swings in global health and the instrumental embrace of the issue by some actors.

A social explanation for the rise and fall of global health issues

This paper proposes an explanation concerning why some global health issues such as HIV/AIDS attract significant attention from international and national leaders, while other issues that also represent a high mortality and morbidity burden, such as pneumonia and malnutrition, remain neglected. The rise, persistence and decline of a global health issue may best be explained by the way in which its policy community--the network of individuals and organizations concerned with the problem--comes to understand and portray the issue and establishes institutions that can sustain this portrayal. This explanation emphasizes the power of ideas and challenges interpretations of issue ascendance and decline that place primary emphasis on material, objective factors such as mortality and morbidity levels and the existence of cost-effective interventions. This explanation has implications for our understanding of strategic public health communication. If ideas in the form of issue portrayals are central, strategic communication is far from a secondary public health activity: it is at the heart of what global health policy communities do.

Issue attention in global health: the case of newborn survival.

Introduction In many low-income countries newborn babies face diffi cult odds in living past the fi rst month of life. About 3·8 million deaths occur every year in babies younger than 28 days—of which 99% are in the developing world—and deaths in the fi rst month of life account for 42% of deaths in children younger than 5 years. Before 2000, few organisations paid much attention to neonatal mortality. Since that year, several organisations have come to address the problem, including foundations, UN agencies, bilateral development agencies, governments of low-income countries, and non-governmental organ isa tions (NGOs). This wave of attention is surprising: there was no sudden increase in the number of babies dying or swift spread of a virus that alarmed citizens of rich countries. The emergence of attention to newborn survival in a short period of time presents an interesting study in how global health issues attract priority. In this paper, I examine the processes and factors behind the emergence of attention. I also identify challenges that proponents of newborn survival could face in advancing priority. In doing so, I aim to contribute to inquiry concerning how and why some global health issues attract attention, and what this means for the sustainability of priority. In 2007, Stephanie Smith and I presented a framework of four categories that sought to promote inquiry on the determinants of issue attention in global health. I use this framework to organise the examination of newborn survival. First, actor power refers to the collective power of the network of individuals and organisations mobilising around an issue, such as UN agencies, donors, NGOs, and governments. Second, ideas concern how these actors portray the issue. Any issue can be framed in several ways, and some framings could be more conducive to attraction of political support than others. Third, issue characteristics pertain to inherent features of the issue. Problems that are easily measured, cause substantial harm, and have simple evidence-based solutions available are more likely to gain political support than are ones that do not have these features. Last, political context refers to features of the environment that individuals and organisations confront as they seek to advance attention for an issue. These features include other actors who do not yet work on the issue but might be inclined to participate in support or opposition. They also include policy windows: moments in time when global conditions align favourably for an issue. For instance, the Millennium Development Goals (MDGs) have helped to open policy windows for the several health problems included in the goals. I used a case study methodology, triangulating several sources of information to keep bias to a minimum, including interviews, documents, and published reports. In 2008 and 2009 I did 33 interviews, each lasting about 1·25 h, with three groups of individuals: those centrally involved in global eff orts to address newborn survival; those in a position to observe and off er authoritative inform ation about the eff ectiveness of these eff orts; and those critical of these eff orts. Interview (I) numbers are listed in parentheses throughout the text. I identifi ed these individuals through publicly available documents, commentaries, and consultation with individuals working in global health. All interviews were recorded and tran scribed. Respondents came from countries of low and high income, and all had worked with a national government, private foundation, UN agency, donor agency, university, or NGO. Rather than follow a set of structured questions, I sought through open-ended questions to elicit the unique knowledge that each informant held about global eff orts to address newborn survival. Additionally, I undertook archival research on the history of global newborn survival eff orts, gathering and reviewing 120 documents from the archives of several agencies that had participated in eff orts to address newborn survival. Beyond this, I consulted published reports on newborn survival that I had obtained through several Medline searches. I organised the data into the four categories—actor power, ideas, issue characteristics, and political context— which served as a heuristic device to group material, present the history of eff orts to promote newborn survival, and identify themes and factors concerning determinants of issue attention in global health. Several individuals participating in global eff orts for newborn survival checked the draft for factual accuracy. National experiences are critical dimensions of the history of new born survival, and shape and are shaped by global eff orts. For instance, newborn survival eff orts in India have aff ected and have been aff ected by global strategies. With funding from the Saving Newborn Lives pro gramme of Save the Children USA, case studies are being done on political atten tion for newborn survival in Bangla desh, Bolivia, Malawi, and Nepal. The focus of this paper, however, is confi ned to attention by global health actors.

The state of political priority for safe motherhood in India

Approximately one‐quarter of all maternal deaths occur in India, far more than in any other nation on earth. Until 2005, maternal mortality reduction was not a priority in the country. In that year, the cause emerged on the national political agenda in a meaningful way for the first time. An unpredictable confluence of events concerning problem definition, policy alternative generation and politics led to this outcome. By 2005, evidence had accumulated that maternal mortality in India was stagnating and that existing initiatives were not addressing the problem effectively. Also in that year, national government officials and donors came to a consensus on a strategy to address the problem. In addition, a new government with social equity aims came to power in 2004, and in 2005, it began a national initiative to expand healthcare access to the poor in rural areas. The convergence of these developments pushed the issue on to the national agenda. This paper draws on public policy theory to analyse the Indian experience and to develop guidance for safe motherhood policy communities in other high maternal mortality countries seeking to make this cause a political priority.

Knowledge, Moral Claims and the Exercise of Power in Global Health

A number of individuals and organizations have considerable influence over the selection of global health priorities and strategies. For some that influence derives from control over financial resources. For others it comes from expertise and claims to moral authority-what can be termed, respectively, epistemic and normative power. In contrast to financial power, we commonly take for granted that epistemic and normative forms of power are legitimate. I argue that we should not; rather we should investigate the origins of these forms of power, and consider under what circumstances they are justly derived.

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.

Has aid for AIDS raised all health funding boats

Global health analysts have debated whether donor prioritization of HIV/AIDS control has lifted all boats, raising attention and funding levels for health issues aside from HIV/AIDS. We investigate this question, considering donor funding for 4 historically prominent health agendas-HIV/AIDS, health systems strengthening, population and reproductive health, and infectious disease control-over the decade 1998-2007. We employ funding data from the Development Assistance Committee of the Organization for Economic Cooperation and Development, which tracks donor aid. The data indicate that HIV/AIDS may have helped to increase funding for the control of other infectious diseases; however, there is no firm evidence that other health issues beyond the control of infectious diseases have benefited. Between 1998 and 2007, funding for HIV/AIDS control rose from just 5.5% to nearly half of all aid for health. Over the same period, funding for health systems strengthening declined from 62.3% to 23.9% of total health aid and that for population and reproductive health declined from 26.4% to 12.3%. Also, even as total aid for health tripled during this decade, aid for health systems strengthening largely stagnated. Overall, the data indicate little support for the contention that donor funding for HIV/AIDS has lifted all boats.