Susan F Murray

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.

Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality.

This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.

Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review

BackgroundDemand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system.MethodsThe protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis.ResultsThirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems.ConclusionsDemand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.

Postpartum maternal morbidity requiring hospital admission in Lusaka, Zambia – a descriptive study

BackgroundInformation on the extent of postpartum maternal morbidity in developing countries is extremely limited. In many settings, data from hospital-based studies is hard to interpret because of the small proportion of women that have access to medical care. However, in those areas with good uptake of health care, the measurement of the type and incidence of complications severe enough to require hospitalisation may provide useful baseline information on the acute and severe morbidity that women experience in the early weeks following childbirth. An analysis of health services data from Lusaka, Zambia, is presented.MethodsSix-month retrospective review of hospital registers and 4-week cross-sectional study with prospective identification of postpartum admissions.ResultsBoth parts of the study identified puerperal sepsis and malaria as, respectively, the leading direct and indirect causes of postpartum morbidity requiring hospital admission. Puerperal sepsis accounted for 34.8% of 365 postpartum admissions in the 6-month period. Malaria and pneumonia together accounted for one-fifth of all postpartum admissions (14.5% & 6% respectively). At least 1.7% of the postpartum population in Lusaka will require hospital-level care for a maternal morbidity.ConclusionsIn developing country urban settings with high public health care usage, meticulous review of hospital registers can provide baseline information on the burden of moderate-to-severe postpartum morbidity.

Factors Affecting the Duration of Exclusive Breastfeeding Among HIV-Infected and -Uninfected Women in Lusaka, Zambia

Exclusive breastfeeding (EBF) is optimal for infant health and is associated with decreased risk of mother-to-child HIV transmission compared with mixed feeding of breast milk and other foods. To investigate why many women stop EBF before the recommended 6 months, maternal and infant health and infant-feeding data were collected from 177 HIV-infected and 177-uninfected Zambian women regularly from 34 weeks gestation to 16 weeks postpartum. Despite strong support for good breastfeeding practice, only 37% of women were still EBF at week 16. Factors significantly associated with shorter duration of EBF were primiparity, maternal systemic illness, and infant length at 6 weeks. The results suggest that the association of EBF with lower rates of mother-to-child HIV transmission may not be causal but may be secondary to the reduced duration of EBF associated with poor maternal or infant health. Programs supporting EBF should include support for maternal health.

Factors Associated With Postpartum Physical and Mental Morbidity Among Women With Known HIV Status in Lusaka, Zambia

Abstract The objective of our study was to investigate factors associated with postpartum physical and mental morbidity among women in Lusaka, Zambia with particular reference to known HIV status. Our study was part of the Breastfeeding and Postpartum Health (BFPH) longitudinal cohort study conducted between June 2001 and July 2003. Women were recruited at 34 weeks gestation and followed up to 16 weeks postpartum. Data on maternal health were collected at 3, 7, 10, and 14 days and at 3, 4, 5, 6, 9, 12, and 16 weeks postpartum. Maternal mental health data were collected from April 2002 onwards at recruitment and at seven days and six weeks postpartum. Data on physical morbidity were collected for 429 women (218 HIV-negative, 211 HIV-positive) and data on mental morbidity were collected for 272 women (134 HIV-negative, 138 HIV-positive). Multivariate logistic regression was used to examine factors associated with postpartum physical or mental morbidity. Postpartum physical morbidity was associated with HIV status, parity ≥5 and age < 20 years. Neither antenatal nor postpartum mental morbidity, as indicated by a self-reporting questionnaire 20-item (SRQ-20) score ≥7, were associated with HIV status or with postpartum physical morbidity in this population. Larger comparative studies are required to corroborate or contest these findings.

Health sector reform and rise of caesarean birth in Chile

64 Vol 349 • January 4, 1997 takes as its control group a similar number of similarly stratified non-participant veterans of the armed forces (ie, men who did not participate in the CROSSROADS series). Most people in both participant and non-participant cohorts were navy veterans. The use of the term participant does not in fact coincide with the term on-site participation, as cited by the report from the Federal Register, but with the operational period as defined in the same source (ie, July 1, 1946, to Aug 31, 1946). The report notes: “To maintain clarity of cohort definition, this study does not include so-called ‘postCROSSROADS’ participants, those military personnel who arrived in the designated area after the formal cutoff date of the operation but within the 6month period 1 September 1946 through 28 February 1947.” Thus, men who participated in Operation CROSSROADS in the clean-up and decontamination periods could well have been listed among the controls. Despite these and other limitations, the study did detect a 4·6% increased mortality among the navy veterans of Operations CROSSROADS. The database created by the study over 10 years would provide an excellent comparison—especially of the long-term, latent effects—with that held by the UK’s National Radiological Protection Board of more than 20 000 veterans of British tests in Australia and the Pacific. However, this UK database is due to be dismantled in March, 1997, “for lack of funds” according to the board.

Social Service Professional or Market Expert? Maternity Care Relations under Neoliberal Healthcare Reform

Recent developments in the organization and practice of healthcare, driven by the introduction of (quasi-) markets and privatization, are altering traditional forms of professionalism found in high- and middle-income countries. Yet there remains debate about whether these neoliberal trends are universal or country specific, and whether they have any effect (positive or negative) on health service delivery. This article develops a comparative analysis that focuses on changes in maternity service systems in four countries in Northern Europe and the Americas with primarily publicly financed healthcare systems: the UK, Finland, Chile and Canada. The article begins with a discussion of the continuum of professional forms found in the post-Second World War period and their relationship to different kinds of welfare states. It then focuses on the impact of recent neoliberal reforms on the ideological projects of the medical and allied health professions in the four case examples. The results show that variation across time and place is mainly the result of structural/economic factors and that various forms of professional discourses are the result of the public/private ways that healthcare systems are organized. The article concludes with suggestions for further comparative sociological research.

Future directions for health policy analysis: a tribute to the work of Professor Gill Walt

This edition of Health Policy and Planning comprises a set of seven papers that focus on the field of health policy analysis. Such analysis shares an understanding that policy making is a process of continuing interaction among institutions (the structures and rules which shape how decisions are made), interests (groups and individuals who stand to gain or lose from change) and ideas (including arguments and evidence) (John 1998). This area of multi-disciplinary inquiry is, in higher income countries, a recognized academic field of practical relevance, but in low and middle income settings it remains an underdeveloped area of work. Yet, in the year we celebrate the 30-year anniversary of the Alma Ata Declaration on Primary Health Care, it is clear that better understanding of the challenges to health policy implementation and renewed action to achieve the Millennium Development Goals are vital in these settings. Health policy analysis is important to both tasks. It can help explain why certain health issues receive political attention, and others do not, such as by enabling identification of which stakeholders may support or resist policy reforms, and why. It can also identify the perverse and unintended consequences of policy decisions, as well as the obstacles that undermine policy implementation and so jeopardize national and global goals for improved health. In these ways, policy analysis supports more realistic expectations about the timeframes and nature of policy reform, can assist in enabling successful policy development and implementation, and can support the use of technical evidence in these processes (Buse et al. 2007). The papers presented here derive from a workshop held in London in May 2007 which brought together 25 practicing health policy analysts from around the world. The workshop sought to take stock of the current state of health policy analysis inquiry in low and middle income countries (LMICs). Participants reflected not just on the content of this body of work but also, and equally importantly, on how this work is undertaken. The workshop specifically allowed an exchange of ideas about the use of theoretical and conceptual frameworks, and methods and approaches, in investigating and understanding policy processes; and it sought to identify how such analysis could be strengthened in the future. The workshop and this set of papers pay tribute to the work of Gill Walt, a co-founder of this journal, Professor Emeritus in Health Policy at the London School of Hygiene and Tropical Medicine, and a key intellectual influence in the field of health policy analysis. Gill established Health Policy and Planning with Patrick Vaughan in 1986 and has played an important role in the journal’s subsequent development. The hallmarks of their approach to health policy are reflected in the very first editorial [1(1): 3–4, 1986], which established that the journal would:

Improving Emergency Obstetric Care in a Context of Very High Maternal Mortality: The Nepal Safer Motherhood Project 1997–2004

The Nepal Safer Motherhood Project (1997–2004) was one of the first large-scale projects to focus on access to emergency obstetric care, covering 15% of Nepal. Six factors for success in reducing maternal mortality are applied to assess the project. There was an average annual increase of 1.3% per year in met need for emergency obstetric care, reaching 14% in public sector facilities in project districts in 2004. Infrastructure and equipment to achieve comprehensive-level care were improved, but sustained functioning, availability of a skilled doctor, blood and anaesthesia, were greater challenges. In three districts, 70% of emergency procedures were managed by nurses, with additional training. However, major shortages of skilled professionals remain. Enhancement of the weak referral system was beyond the project’s scope. Instead, it worked to increase information in the community about danger signs in pregnancy and delivery and taking prompt action. A key initiative was establishing community emergency funds for obstetric complications. Efforts were also made to develop a positive shift in attitudes towards patient-centred care. Supply-side interventions are insufficient for reducing the high level of maternal deaths. In Nepal, this situation is complicated by social norms that leave women undervalued and disempowered, especially those from lower castes and certain ethnic groups, a pattern reflected in use of maternity services. Programming also needs to address the social environment. Résumé Le projet népalais pour une maternité à moindre risque (1997–2004) a été l’un des premiers grands projets à se centrer sur l’accès aux soins obstétricaux d’urgence, couvrant 15% du Népal. Six facteurs de réduction de la mortalité maternelle ont été choisis pour évaluer le projet. La satisfaction des besoins en soins obstétricaux d’urgence a augmenté en moyenne de 1,3% par an, atteignant 14% en 2004 dans les centres publics visés par le projet. L’infrastructure et les équipements se sont améliorés, mais le fonctionnement, la disponibilité d’un médecin qualifié, de sang et d’anesthésie demeuraient problématiques. Dans trois districts, 70% des procédures d’urgence étaient pratiquées par des infirmières ayant suivi une formation complémentaire. Néanmoins, les professionnels qualifiés continuent de manquer cruellement. L’amélioration du système d’aiguillage n’entrait pas dans le champ du projet qui a préféré apprendre à la communauté à reconnaître les signes de danger pendant la grossesse et l’accouchement et à y réagir rapidement. La création de fonds communautaires pour les complications obstétricales constitue une initiative clé. Le projet a également encouragé un changement de comportement en faveur de soins à l’écoute des patientes. Les interventions centrées sur l’offre ne suffisent pas à réduire le niveau élevé de décès maternels. Au Népal, cette situation est compliquée par des normes sociales défavorables aux femmes – particulièrement quant elles appartiennent à des castes inférieures ou à certains groupes ethniques – qui se reflètent dans beaucoup de services de maternité. La programmation doit aussi agir sur l’environnement social. Resumen El proyecto de Maternidad más segura (1997–2004), en Nepal, fue uno de los primeros proyectos de gran escala que se centró en el acceso a los cuidados obstétricos de emergencia, y abarcó el 15% de Nepal. A fin de evaluar el proyecto se aplican seis factores para lograr disminuir la tasa de mortalidad materna. En 2004, hubo un aumento anual promedio de un 1.3% para cubrir la necesidad de cuidados obstétricos de emergencia, y se alcanzó el 14% en establecimientos del sector público, en distritos del proyecto. Se mejoraron la infraestructura y el equipo para lograr el nivel de atención integral, pero resultó más difícil lograr funcionamiento continuo, así como disponibilidad de un médico calificado, sangre y anestesia. En tres distritos, el 70% de los procedimientos de emergencia eran manejados por enfermeras, con capacitación adicional. Sin embargo, aún existe una gran escasez de profesionales calificados. Quedó fuera del alcance del proyecto mejorar el sistema de referencia deficiente. En vez, se trabajó para aumentar la información de la comunidad respecto a los signos de alarma del embarazo y el parto, y la toma de medidas con prontitud. Una iniciativa importante fue establecer fondos comunitarios de emergencia para complicaciones obstétricas. Además, se realizaron esfuerzos por fomentar un cambio positivo en actitudes hacia la atención centrada en la paciente. Las intervenciones relacionadas con los suministros son insuficientes para disminuir el alto índice de muertes maternas. En Nepal, esta situación se complica por las normas sociales que dejan a las mujeres subvaloradas y sin poder, especialmente aquéllas de clases más bajas y determinados grupos étnicos, un patrón reflejado en el uso de los servicios de maternidad. Los programas deben tener en cuenta el ambiente social.