How health policy decisions are made: ‘people are beginning to make demands on government’
Our interviewees identified a number of aspects of the ways health policy decisions were made that influenced scale-up in the three settings: government willingness to collaborate with development partners and their implementers; government responsiveness to civil society; whether health policy decisions were based on evidence; turnaround of government officials; and bureaucratic government institutions.
Government willingness to collaborate with development partners and implementers
Interviewees suggested the governments in the three settings were open in principle to collaborating with development partners and implementers, and hence responded positively to innovations that align with their national plans, priorities and political thinking. Interviewees observed the Ethiopian government’s willingness to work with development partners and implementers that supported its aims within health sector programmes: ‘…the government has keen interest to work with any partners and to collaborate with them…to improve MNH in the country…’ said one, from a civil society organisation. Similarly, many northeast Nigerian states welcomed external partners bringing funding for MNH and other health programmes; Gombe, for example, was described as having an ‘open door policy’ to such programmes. Interviewees expressed high expectations about the Uttar Pradesh state administration that came into power in 2012, with the young and energetic new state First Minister’s openness to new ideas and working with development partners and their implementers. Despite these signs, the state government was said to be living in the shadow of the prior regime which was less open to collaboration: ‘…the government sector is still paralysed with apathy, lethargy, lack of ideas…’ said an interviewee from a civil society organisation.
Government responsiveness to civil society
According to our interviewees, government responsiveness to civil society also influenced externally funded implementers’ efforts to catalyse innovation scale-up since most implementers were civil society organisations, and across the three settings the situation was changing. The Uttar Pradesh state administration was responsive to civil society, which, an academic interviewee felt was beginning to be viewed as a ‘force of change’. Interviewees in Nigeria noted that stronger democracy meant an increasingly active civil society had influenced the allocation of resources; for example, CSOs advocated successfully for free maternal and child healthcare, leading to a bill being passed: ‘As democracy becomes entrenched, people are beginning to make demands on government and as people make demands, government wants to show results…’ said an interviewee from a multilateral organisation. In both Nigeria and Uttar Pradesh our respondents pointed to organised networks of CSOs working together to influence policy decisions and in many cases they had been successful. In Ethiopia where civil society was less established, CSOs were also described as having some influence on government; one interviewee suggested: ‘civil society organisations can show strategic directions to policy implementation…they can also convince [the Ministry of Health] with evidence about their innovations to be taken up and delivered at scale…’.
Evidence-based decision making
Our respondents suggested that the extent to which governments based policy decisions on evidence was an important consideration for scale-up. In practice when externally funded implementers had presented evidence demonstrating the effectiveness of their innovations this had tended to have limited influence on government thinking. A Nigerian interviewee in national government captured the problem of politics shaping decision making: ‘The ideal situation is that evidence from research, pilots, or practice should influence government’s decision to shape policy. [But] in a country like Nigeria…people want to score cheap goals for political reasons’. Similarly, in Uttar Pradesh, a civil society interviewee reflected: ‘…policies aren’t always based on evidence - sometimes huge decisions are made within an hour!’ In all three settings, ministers of health and state chief ministers tended to dominate decisions: ‘whims of the power centres’ as an academic interviewee in India put it. Nigerian state governors and other high ranking officials were reported as being motivated by ‘political capital’, as a national government interviewee reflected: ‘When an individual is appointed or elected into political offices his associates see it as an opportunity to influence things and get favours. And because he wants to please his ring of friends and associates that makes decision making not quite representative’.
Turnaround of government officials
Turnaround of officials at all levels undermined efforts to catalyse scale-up as reshuffling and attrition was constant across the three settings - ‘fickleness in the entire system’ as an Indian civil society interviewee observed. This made securing government agreement transitory; new officials were often unwilling to accept their predecessors’ decisions to scale-up innovations. One key informant noted: ‘…once your idea has got the desired approval the person may have changed’. In Uttar Pradesh and Ethiopia our interviewees reflected on the limited time a new leader or official had in which to learn their job. Poor institutional memory retained by the system when individuals leave, and outgoing parties’ unwillingness to share knowledge with new administrations, were related factors.
Bureaucratic government institutions
Bureaucratic institutions were also reported as a barrier to scale-up. Complex, lengthy government approval processes undermined or delayed decision making and slowed or stalled the implementation of innovations at scale. A key informant in India observed: ‘Right from the NRHM [National Rural Health Mission] directorate to the planning commission there are tedious processes to get approvals, once approvals are made there are bureaucratic delays…’. Indeed, some procedures became progressively complex; a corruption scandal surrounding the use of NRHM (now known as the National Health Mission) monies prompted the incoming Uttar Pradesh Government to route financing through the Treasury to strengthen checks and balances. Ethiopian procurement and contracting rules were also depicted as constraining the adoption of new commodities or innovative practices: ‘They can’t do things in certain ways because the government rules are very rigid and constraining…’ said a representative of a donor agency.
Prioritising and funding maternal and newborn health: ‘the stars seem aligned’
Interviewees suggested that the willingness and ability of governments in the three contexts to scale MNH innovations closely reflected the prioritisation of MNH in federal and state policies. Our data reveal a number of factors connected to policy prioritisation: the existence of national policy frameworks; the availability of economic resources; global and development partners’ influence; and the influence of professional associations, traditional leaders and media.
National policy frameworks
The high priority given to MNH in Uttar Pradesh and Ethiopia was enshrined in policy frameworks which our interviewees described as enabling MNH innovation scale-up. The federal government of India’s NRHM was a positive policy environment bringing with it substantial funding for state governments’ rural primary healthcare programmes, including MNH programmes. The new Uttar Pradesh state administration in combination with the NRHM was seen by interviewees as an important policy window for externally funded implementers to put forward innovations that align with the state’s aims: ‘The stars seem aligned in terms of the [policy] environment!’ one interviewee from a donor organisation exclaimed, while another, from a multilateral agency, reflected: ‘It’s important that institutions capitalise on this mood’. Ethiopia’s prioritisation of rural primary healthcare was embodied in its national flagship programme – the Health Extension Program (HEP) and national health plans including the Health Sector Development Program IV 2010/11-2014/15. The Ethiopian Government was described as receptive to externally funded MNH interventions that align closely with national plans and priorities, as a civil society organisation representative explained: ‘…government policies and programmes are very supportive to our programme…this is an encouraging issue for this organisation to expand its interventions…’. In contrast, rural primary healthcare, including MNH, struggled for policy attention in Nigeria: ‘What’s now happening is there’s erosion of primary healthcare,’ said a state government interviewee. The problem stemmed less from Nigerian economic resources, and more from how resources were allocated. Health was not on the executive list in the 1999 Constitution; at the time of the interviews it was not considered a priority sector and competed annually for funding: ‘There’s a lot of politicking and jostling for a piece of the cake…you struggle for monies to come to maternal and newborn health,’ a researcher said. State health departments therefore had limited finances to divert to scaling external programmes.
Economic resources and global and development partners’ influence
India’s economic growth together with the NRHM substantially increased Uttar Pradesh’s resources for rural healthcare including MNH. Reductions in external aid receipts changed relationships between donors and the state government, with the former increasingly adopting technical assistance rather than funding roles which gave them less influence on state policies, and made it crucial for externally funded programmes to closely align with Uttar Pradesh’s priorities. A government interviewee suggested: ‘…ideas that are working within the government framework have greater potential to be scaled-up. Working in oblivion doesn’t help…’. In Ethiopia, domestic resources were more limited: ‘A big barrier to scale is resources and continuity of resources’ as one donor representative noted. While the Ethiopian Government maintained strong control over its policy priorities, substantial external aid was required to support its health programmes and global priorities such as the Millennium Development Goals (MDGs) had shaped Ethiopia’s health programmes. Interviewees also reported that the publication of the 2011 Demographic and Health Survey revealed disappointing improvements in neonatal and maternal mortality against MDG targets which reinvigorated the Government’s efforts in MNH, and externally funded implementers saw this as an opportunity to promote their MNH innovations. An interviewee from the government observed that at the time of the interviews: ‘We are still lagging behind the MDG targets…there will be no change in priority until the MDGs are met in the coming three years - MNH will continue to be our top priority…’. In northeast Nigeria, while state governments commonly support programmes in principle, they were not always backed by financial resources: ‘…a lot of rhetoric – they don’t put their money where their mouth is…,’ noted an academic researcher. One reason for state governments’ limited financial support for rural healthcare was donor attention on this issue: ‘everything is seen as if it has to be donor-funded,’ said a multilateral agency representative. As a consequence, resources were vulnerable to shifting global priorities; HIV, for example, competed with MNH for funding and attention.
Influence of powerful country actors
Powerful actors also influenced the introduction of certain MNH interventions in Nigeria. Professional medical associations opposed community health workers dispensing the drug Misoprostol to prevent and treat postpartum haemorrhage: ‘…they have knowledge, power, they think they know what to do…so relinquishing power was a major problem for them,’ said one academic researcher. While traditional rulers had no formal role in government decision making in reality their influence was substantial. Individual rulers often resisted - although sometimes supported - ‘western’ health interventions making it difficult to introduce them in some states. Family planning, which was often conflated with MNH, was particularly controversial since many people believe it contradicts Islamic teaching and hence traditional leaders can oppose it. These problems appear to be intensifying, as an interviewee from a donor organisation clarified: ‘…all the social pressure at this point is to regress to a more conservative, historical set of behaviours. Everything we are talking about involves some degree of modernisation and the cultural current is absolutely against that at this point’. Nevertheless, interviewees noted changes in federal government’s commitment to MNH in the form of new funds, and some state governments introduced free MNH services. One reason was the government’s attitude towards evidence, coupled with strong civil society advocacy and greater media attention on maternal and child mortality-related issues. A 2008 report presented at a public meeting highlighted high maternal mortality rates in Nigeria which attracted officials’ attention, and data on Gombe pressed the state government into acting. As one national government representative remarked: ‘Any responsive government will respond to such pressure to look responsible’.
Development partner harmonisation: ‘government is very good at Balkanising us’
An important barrier to scale-up emerging from our study was poor harmonisation among the many donors and other development partners and externally funded implementers including the multiplicity of smaller local CSOs implementing parts of wider programmes in the three settings. Harmonisation was made difficult by competing interests, priorities and mandates and pressure to attribute outcomes to specific donor funding inputs. Competition among implementers for donor funding with the expectation that they deliver results to ambitious timeframes thwarted programmatic coordination and information sharing. Implementers feared their ideas for innovations would be poached jeopardising their competitive advantage among rivals: ‘…the issue of competition is crazy!’ exclaimed an interviewee from a Nigerian civil society organisation.
Information sharing and coordinated communication with government
Poor harmonisation undermined scale-up in different ways. It weakened government strategic oversight of external programmes making it difficult to coordinate and deploy externally funded innovations at scale resulting in duplication and programmatic gaps. Interviewees described limited information sharing as a missed opportunity to strengthen innovation design by building on learning derived from programmatic experiences, as a civil society interviewee captured: ‘People in India are not combining their expertise…instead of wasting time reinventing the wheel we really need everyone to come together…’. Further, donors and implementers competing for attention made it difficult for government to make informed decisions about scaling-up: ‘…it’s our moral and ethical duty to work together…we have to go beyond our little thing and make sure that we’re asking for common asks that are based on evidence…’ a civil society interviewee from India suggested.
Embracing donor coordination mechanisms
Many interviewees agreed these problems could be mitigated through donors and implementers working through government-led partner coordination mechanisms, including the Technical Working Group in Ethiopia, the Health Partners’ Forum in Uttar Pradesh and Nigeria’s Maternal and Newborn Child Health Core Technical Committee. In Ethiopia interviewees were most positive about their government’s efforts to coordinate donor programmes, with the Technical Working Group emerging as an important vehicle for achieving this: ‘The government is very good at Balkanising [separating] us – there is very little overlap…’ according to one interviewee from a donor agency, while a government interviewee said: ‘All plans are discussed with partners and we put together an action plan - all the bad and good experiences are discussed…’. An interviewee from a multilateral development agency in India, however, complained about limited donor engagement in the Uttar Pradesh mechanism: ‘Though this Health Partners’ Forum has potential it’s underutilised…’. The Nigerian government and key development partners, responding to the International Health Partnership, signed a Compact on Health in 2011 which strengthened commitments to harmonising health programmes under the National Strategic Health Plan. Interviewees reported that this had stimulated better coordination and represented a more conducive environment for scale-up: ‘Donors have a forum where they meet regularly and integration among donors has improved over the years…but there’s still a lot to be done…,’ said one, from a civil society organisation.