Ruairi Brugha

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.

What can be done about the private health sector in low-income countries?

A very large private health sector exists in low-income countries. It consists of a great variety of providers and is used by a wide cross-section of the population. There are substantial concerns about the quality of care given, especially at the more informal end of the range of providers. This is particularly true for diseases of public health importance such as tuberculosis, malaria, and sexually transmitted infections. How can the activities of the private sector in these countries be influenced so that they help to meet national health objectives? Although the evidence base is not good, there is a fair amount of information on the types of intervention that are most successful in directly influencing the behaviour of providers and on what might be the necessary conditions for success. There is much less evidence, however, of effective approaches to interventions on the demand side and policies that involve strengthening the purchasing and regulatory roles of governments.

The Global Fund: managing great expectations.

The Global Fund to fight AIDS, Tuberculosis, and Malaria was created to increase funds to combat these three devastating diseases. We report interim findings, based on interviews with 137 national-level respondents that track early implementation processes in four African countries. Country coordinating mechanisms (CCMs) are country-level partnerships, which were formed quickly to develop and submit grant proposals to the Global Fund. CCM members were often ineffective at representing their constituencies and encountered obstacles in participating in CCM processes. Delay in dissemination of guidelines from the Global Fund led to uncertainty among members about the function of these new partnerships. Respondents expressed most concern about the limited capacity of fund recipients--government and non-government--to meet Global Fund conditions for performance-based disbursement. Delays in payment of funds to implementing agencies have frustrated rapid financing of disease control interventions. The Global Fund is one of several new global initiatives superimposed on existing country systems to finance the control of HIV/AIDS. New and existing donors need to coordinate assistance to developing countries by bringing together funding, planning, management, and reporting systems if global goals for disease control are to be achieved.

GAVI, the first steps: lessons for the Global Fund.

The Global Alliance for Vaccines and Immunization (GAVI) is seen as a model for the new Global Fund to Fight AIDS, Tuberculosis and Malaria, to be launched early in 2002. We did an assessment in four African countries to report the experiences of ministries of health and their partners in applying to GAVI for funds to strengthen health systems and for new vaccines. Countries welcomed the introduction of hepatitis B vaccine, safe injection equipment, and the financial support to strengthen immunisation programmes. All reported that the pace of the application process was too rapid. District visits revealed low staffing levels, insufficient transport and fuel, poorly functioning cold chains, and infrequent supervision. Information systems were unreliable, which will be an obstacle to GAVI when monitoring and rewarding improvements in immunisation coverage. Also, the high cost of expensive new vaccines will be difficult to sustain if GAVI funding stops at the end of its 5 year commitment. Our study suggests that applications for support and planning for AIDS, tuberculosis, and malaria control under the new Global Fund, will be more complex and demanding on already over-stretched ministries of health. Further, the rapid onset of activities, coupled with uncertainty about the time-scale of donor commitment, could be problematic. A limited and carefully assessed set of initial activities, focusing on where and how to strengthen existing country systems, is more likely to be successful and could provide useful models for scaling-up to larger programmes in different contexts.

A community outbreak of food-borne small round-structured virus gastroenteritis caused by a contaminated water supply.

In August 1994, 30 of 135 (23%) bakery plant employees and over 100 people from South Wales and Bristol in the United Kingdom, were affected by an outbreak of gastroenteritis. Epidemiological studies of employees and three community clusters found illness in employees to be associated with drinking cold water at the bakery (relative risk 3.3, 95%, CI 1.6-7.0), and in community cases with eating custard slices (relative risk 19.8, 95%, CI 2.9-135.1) from a variety of stores supplied by one particular bakery. Small round-structured viruses (SRSV) were identified in stool specimens from 4 employees and 7 community cases. Analysis of the polymerase and capsid regions of the SRSV genome by reverse transcription-polymerase chain reaction (RT-PCR) demonstrated viruses of both genogroups (1 and 2) each with several different nucleotide sequences. The heterogeneity of the viruses identified in the outbreak suggests that dried custard mix may have been inadvertently reconstituted with contaminated water. The incident shows how secondary food contamination can cause wide-scale community gastroenteritis outbreaks, and demonstrates the ability of molecular techniques to support classical epidemiological methods in outbreak investigations.

A clinical algorithm for the diagnosis of malaria: results of an evaluation in an area of low endemicity

We conducted a study of 1945 children and 2885 adults who presented with fever to a hospital outpatients clinic in an urban area of India order to develop and evaluate a clinical algorithm for the diagnosis of malaria. Only 139 (7%) children and 349 (12%) adults had microscopically confirmed malaria. None of the symptoms or signs elicited from the respondents were good predictors of clinical malaria. Simple scores were derived through combining clinical features which were associated with slide positivity or were judged by clinicians to be important. The best‐performing algorithms were a score of 4 clinical features in children (sensitivity 60.0% and specificity 61.2%) and a score of 5 in adults (sensitivity 54.6% and specificity 57.5%). The clinical features differed and algorithm performances were poorer than in previous studies in highly endemic areas. The conclusion is that malaria diagnosis in areas of low endemicity requires microscopy to be accurate.

Private health care in developing countries.

Private healthcare provision is growing in low and middle income countries. 1 2 The poor, as well as the rich, often seek health care from private providers, including for conditions of public health importance such as malaria, tuberculosis, and sexually transmitted infections. 3 4 5 The reasons cited by users include better and more flexible access, shorter waiting, greater confidentiality, and greater sensitivity to user needs. 1 6 International policymakers are currently recommending greater use of private providers 7 8 9 on the grounds that they offer consumers greater choice; increase competition in the healthcare market; and remove state responsibility for service provision, thereby encouraging its role as regulator and guarantor. We should, however, be concerned. When examined, the quality of care offered by many private providers is poor. 1 2 10 Furthermore, poor people spend a greater proportion of their income on health care (private or public) than do the rich, often using less qualified or totally untrained private providers. We have recommended three objectives in relation to the private provision of care for conditions of public health importance: widening access, improving quality, and ensuring non-exploitative prices.11 None of these will be simple to achieve; and multifaceted interventions, involving policymakers, providers, and …

Scaling up HIV/AIDS evaluation

The HIV/AIDS pandemic shows little signs of abating with an estimated 38 million infections by the end of 2004 and 3 million deaths. Yet an effective expanded prevention and treatment response could avert as many as 29 million infections and 10 million deaths by 2020 in sub-Saharan Africa alone. The level of external funding for HIV/AIDS is on the right trajectory to achieve the goal of reversing the epidemic by 2015 through radically scaling up prevention treatment and care: US

Antiretroviral treatment in developing countries: the peril of neglecting private providers

1 billion since 2000 to the World Banks multicountry AIDS program (MAP) US

Integrating reproductive health services in a reforming health sector: the case of Tanzania.

1.7 billion approved by the Global Fund to fight AIDS TB and malaria (2002-05); and the US Congress appropriation of US