Enhancing governance and strengthening advocacy for policy change of large Collective Impact initiatives.
ABSTRACT: Nutrition issues are increasingly being addressed through global partnerships and multi-sectoral initiatives. Ensuring effective governance of these initiatives is instrumental for achieving large-scale impact. The Collective Impact (CI) approach is an insightful framework that can be used to guide and assess the effectiveness of this governance. Despite the utility and widespread use of this approach, two gaps are identified: a limited understanding of the implications of expansion for an initiative operating under the conditions of CI and a lack of attention to advocacy for policy change in CI initiatives. In this paper, a case study was undertaken in which the CI lens was applied to the advocacy efforts of Alive & Thrive (A&T), UNICEF and partners. The initiative expanded into a regional movement and achieved meaningful policy changes in infant and young child feeding policies in seven countries in Southeast Asia. These efforts are examined in order to address the two gaps identified in the CI approach. The objectives of the paper are (a) to examine the governance of this initiative and the process of expansion from a national to a regional, multilayered initiative, with attention to challenges, adaptations, and key elements, and (b) to compare advocacy in the A&T-UNICEF initiative and in typical CI initiatives and gain insight into how the practice of advocacy for policy change can be strengthened in CI initiatives.
Project description:Evaluating the impact of advocacy for policy change presents many challenges. Recent advances in the field of evaluation, such as contribution analysis (CA), offer guidance on how to make credible claims regarding such impact. The purposes of this article are (a) to detail the application of CA to assess the contribution of an advocacy initiative to improve infant and young child feeding policies and (b) to present the emergent theory of change and contribution story of how progress was achieved. An evaluation applying developmental evaluation and CA was conducted on the Alive & Thrive (A&T)-UNICEF initiative in seven Southeast Asian countries to document the extent to which policy objectives were achieved and identify key drivers of policy change. A contribution story was developed based on these experiences. The advocacy approach, which involved a four-part process, contributed directly to (a) set the agenda of various actors and (b) create a strategic group; and indirectly to (a) set and maintain the issue on the agenda at all stages of the policy cycle, (b) support the government to carry out a set of critical tasks, and (c) extend commitment. All of this helped to achieve progress towards policy change. External influences were at play. The flexibility of A&T allowed key actors to utilize the positive external influences and address some of the negative ones through developing responsive strategies mitigating their effects. The emerging contribution story supports that A&T-UNICEF initiative contributed to the progress achieved in the participating countries.
Project description:BACKGROUND: Oftentimes, cancer advocates in Africa look at the developed nations in North America and Europe for guidance on cancer advocacy. However, lessons learnt from developed nations do not necessarily apply to the situational context of Africa. Without a doubt, successful cancer advocates in Africa can best serve as learning sources and role models for advocacy in Africa. This paper describes the results of an environmental scan of advocacy organizations in Africa. METHODS: A cross-sectional study design was employed for this project. Using a structured survey data collection form, participants submitted their responses either by online submission (Google docs) or by electronic mail to firstname.lastname@example.org. RESULTS: A total of 39 African advocates representing 17 countries participated in the project. The majority of participants have been advocates for more than five years; and mostly advocate for both males and females and individuals between the ages of 30 and 39. The most common cancers focused on by the advocacy organizations include breast, prostate, liver, cervix, stomach, bladder, pediatric, colorectal and neck. The information provided by participants offer clear guidelines on establishing and maintaining an advocacy program in Africa despite the various challenges faced by these organizations. CONCLUSION: Whilst this paper only highlights a subset of advocacy initiatives on the Continent, there is an opportunity for a more inclusive dialogue for advocates to share ideas with each other, connect with other advocates, learn about other innovative advocacy programs, and join the global war against cancer. To this end, the biennial International Workshop on Cancer Advocacy for African Countries (CAAC) during the next AORTIC International Cancer conference, offers an opportunity to further Africa's cancer advocacy initiatives.
Project description:Introduction:Advocacy and service-learning increasingly are being incorporated into medical education and residency training. The Jefferson Service Training in Advocacy for Residents and Students (JeffSTARS) curriculum is an educational program for Thomas Jefferson University and Nemours trainees. The JeffSTARS Advocacy and Community Partnership Elective is one of two core components of the larger curriculum. Methods:The elective is a monthlong rotation that provides trainees in their senior year of medical school or residency training the opportunity to learn about health advocacy in depth. Trainees develop a basic understanding of social determinants of health, learn about health policy, participate in legislative office visits, and work directly with community agencies on a mutually agreeable project. The elective provides advocacy training to self-selected trainees from area medical schools and residency programs to develop a cadre of physicians empowered to advocate for child health. Results:JeffSTARS has advanced the field of child health advocacy locally by forging new partnerships and building a network of experts, agencies, and academic institutions. After this experience, trainees realize that their health expertise is very valuable to health advocacy and policy development. JeffSTARS is recognized nationally as one of a growing number of advocacy training programs for students and residents, with trainees presenting selected projects at national meetings. Discussion:Teaching advocacy has raised awareness about social determinants of health, community resources, and the medical home. One of the many benefits of the elective has been to strengthen the skills and expertise of trainees and faculty members alike.
Project description:POLICY POINTS: Many barriers hamper advocacy for health equity, including the contemporary economic zeitgeist, the biomedical health perspective, and difficulties cooperating across policy sectors on the issue. Effective advocacy should include persistent efforts to raise awareness and understanding of the social determinants of health. Education on the social determinants as part of medical training should be encouraged, including professional training within disadvantaged communities. Advocacy organizations have a central role in advocating for health equity given the challenges bridging the worlds of civil society, research, and policy.Health inequalities are systematic differences in health among social groups that are caused by unequal exposure to-and distributions of-the social determinants of health (SDH). They are persistent between and within countries despite action to reduce them. Advocacy is a means of promoting policies that improve health equity, but the literature on how to do so effectively is dispersed. The aim of this review is to synthesize the evidence in the academic and gray literature and to provide a body of knowledge for advocates to draw on to inform their efforts.This article is a systematic review of the academic literature and a fixed-length systematic search of the gray literature. After applying our inclusion criteria, we analyzed our findings according to our predefined dimensions of advocacy for health equity. Last, we synthesized our findings and made a critical appraisal of the literature.The policy world is complex, and scientific evidence is unlikely to be conclusive in making decisions. Timely qualitative, interdisciplinary, and mixed-methods research may be valuable in advocacy efforts. The potential impact of evidence can be increased by "packaging" it as part of knowledge transfer and translation. Increased contact between researchers and policymakers could improve the uptake of research in policy processes. Researchers can play a role in advocacy efforts, although health professionals and disadvantaged people, who have direct contact with or experience of hardship, can be particularly persuasive in advocacy efforts. Different types of advocacy messages can accompany evidence, but messages should be tailored to advocacy target. Several barriers hamper advocacy efforts. The most frequently cited in the academic literature are the current political and economic zeitgeist and related public opinion, which tend to blame disadvantaged people for their ill health, even though biomedical approaches to health and political short-termism also act as barriers. These barriers could be tackled through long-term actions to raise public awareness and understanding of the SDH and through training of health professionals in advocacy. Advocates need to take advantage of "windows of opportunity," which open and close quickly, and demonstrate expertise and credibility.This article brings together for the first time evidence from the academic and the gray literature and provides a building block for efforts to advocate for health equity. Evidence regarding many of the dimensions is scant, and additional research is merited, particularly concerning the applicability of findings outside the English-speaking world. Advocacy organizations have a central role in advocating for health equity, given the challenges bridging the worlds of civil society, research, and policy.
Project description:OBJECTIVE:This study was conducted to explore how and whether, the strategic grants made by the Rockefeller Foundation (RF) in different sectors of health systems in the inception phase were able to 'connect the dots' for 'generating a momentum for Universal Health Coverage (UHC)' in the country. DESIGN:Cross-sectional descriptive study, using document review and qualitative methods. SETTING:Bangladesh, 17 UHC-related projects funded by the RF Transforming Health Systems (THS) initiative during 2010-2013. DATA:Available reports of the completed and on-going UHC projects, policy documents of the government relevant to UHC, key-informant interviews and feedback from grant recipients and relevant stakeholders in the policy and practice. OUTCOME MEASURES:Key policy initiatives undertaken for implementing UHC activities by the government post grants disbursement. RESULTS:The RF THS grants simultaneously targeted and connected the academia, the public and non-profit development sectors and news media for awareness-building and advocacy on UHC, develop relevant policies and capacity for implementation including evidence generation. This strategy helped relevant stakeholders to come together to discuss and debate the core concepts, scopes and modalities of UHC in an attempt to reach a consensus. Additionally, experiences gained from implementation of the pilot projects helped in identifying possible entry points for initiating UHC activities in a low resource setting like Bangladesh. CONCLUSIONS:During early years of UHC-related activities in Bangladesh, strategic investments of the RF THS initiative played a catalytic role in sensitising and mobilising different constituencies for concerted activities and undertaking necessary first steps. Learnings from this strategy may be of help to countries under similar conditions of 'low resource, apparent commitment, but poor governance,' on their journey towards UHC.
Project description:BACKGROUND: Education in health policy and advocacy is recognized as an important component of health professional training. To date, curricula have only been assessed at the medical school level. OBJECTIVE: We sought to address the gap in these curricula for residents and other health professionals in primary care. INNOVATION: We created a health policy and advocacy curriculum for the VA Connecticut Healthcare System, Center of Excellence in Primary Care Education, an interprofessional, ambulatory-based, training program that includes internal medicine residents, nurse practitioner fellows, health psychology fellows, and pharmacy residents. The policy module focuses on health care finance and delivery, and the advocacy module emphasizes negotiation skills and opinion-based writing. Trainee attitudes were surveyed before and after the course, and using the Wilcoxon signed rank test, relative change was determined. Knowledge acquisition was evaluated with precourse and postcourse examinations using a paired sample t test. RESULTS: From July 2011 through June 2013, 16 trainees completed the course. In the postcourse survey, trainees demonstrated improved comfort with understanding health law and the American health care system (Likert mean increased from 2.1 to 3.0, P = .01), as well as with associated advocacy skills (Likert mean increased from 2.0 to 2.9, P = .04). Knowledge-based test scores also showed significant improvement (increasing from 55% to 78% correct, P ≤ .001). CONCLUSIONS: Our curriculum integrating core health policy knowledge with advocacy skills represents a novel approach in postgraduate health professional education and resulted in sustained improvement in knowledge and comfort with health policy and advocacy.
Project description:<h4>Background</h4>Ghana has achieved significant progress in breastfeeding practices in the past two decades. Further progress is, however, limited by insufficient government funding and declining donor support for breastfeeding programs. The current study pretested feasibility of the <i>Becoming Breastfeeding Friendly (BBF) toolbox</i> in Ghana, to assess the existing enabling environment and gaps for scaling-up effective actions.<h4>Methods</h4>Between June 2016 and April 2017, a 15-person expert country committee drawn from government and non-government agencies was established to implement the BBF toolbox. The committee used the BBF index (BBFI), comprising of 54 benchmarks and eight gears of the Breastfeeding Gear Model (advocacy; political will; legislation and policy; funding and resources; training and program delivery; promotion; research and evaluation; and coordination, goals and monitoring). Available evidence (document reviews, and key informant interviews) was used to arrive at consensus-scoring of benchmarks. Benchmark scores ranged between 0 (no progress) and 3 (major progress). Scores for each gear were averaged to estimate the Gear Total Score (GTS), ranging from 0 (least) to 3.0 (strong). GTS's were aggregated as a weighted average to estimate the BBFI which ranged from 0 (weak) to 3.0 (outstanding). Gaps in policy and program implementation and recommendations were proposed for decision-making.<h4>Results</h4>The BBFI score was 2.0, indicating a moderate scaling-up environment for breastfeeding in Ghana. Four gears recorded strong gear strength: advocacy (2.3); political will (2.3); legislation and policy (2.3); and coordination, goals and monitoring (2.7). The remaining four gears had moderate gear strength: funding and resources (1.3); training and program delivery (1.9); promotion (2.0); and research and evaluation (1.3). Key policy and program gaps identified by the committee included sub-optimal coordination across partners, inadequate coverage and quality of services, insufficient government funding, sub-optimal enforcement of policies, and inadequate monitoring of existing initiatives. Prioritized recommendations from the process were: 1) strengthen advocacy and empower breastfeeding champions, 2) strengthen breastfeeding regulations, including maternity protection, 3) strengthen capacity for providing breastfeeding services, and 4) expand and sustain breastfeeding awareness initiatives.<h4>Conclusions</h4>The moderate environment for scaling-up breastfeeding in Ghana can be further strengthened by addressing identified gaps in policy and programs.
Project description:OBJECTIVE:Community-based initiatives have enormous potential to facilitate the attainment of universal health coverage (UHC) and health system development. Yet key gaps exist and threaten its sustainability in many low-income and middle-income countries. This study is first of its kind (following the launch of the Sustainable Developments Goal [SDG]) and aimed to holistically explore the challenges to achieving UHC through the community-based health planning and service (CHPS) initiative in Ghana. DESIGN:A qualitative study design was adopted to explore the phenomenon. Face-to-face indepth interviews were conducted from April 2017 until February 2018 through purposive and snowball sampling techniques. Data were analysed using inductive and deductive thematic analysis approach. SETTING:Data were gathered at the national level, in addition to the regional, district and subdistrict/local levels of four regions of Ghana. Sampled regions were Central Region, Greater Accra Region, Upper East Region and Volta Region. PARTICIPANTS:In total, 67 participants were interviewed: national level (5), regional levels (11), district levels (9) and local levels (42). Interviewees were mainly stakeholders-people whose actions or inactions actively or passively influence the decision-making, management and implementation of CHPS, including policy makers, managers of CHPS compound and health centres, politicians, academics, health professionals, technocrats, and community health management committee members. RESULTS:Based on our findings, inadequate understanding of CHPS concept, major contextual changes with stalled policy change to meet growing health demands, and changes in political landscape and leadership with changed priorities threaten CHPS sustainability. CONCLUSION:UHC is a political choice which can only be achieved through sustainable and coherent efforts. Along countries' pathways to reach UHC, coordinated involvement of all stakeholders, from community members to international partners, is essential. To achieve UHC within the time frame of SDGs, Ghana has no choice but to improve its national health governance to strengthen the capacity of existing CHPS.
Project description:Policy making, translation and implementation in politically and administratively decentralized systems can be challenging. Beyond the mere sub-national acceptance of national initiatives, adherence to policy implementation processes is often poor, particularly in low and middle-income countries. In this study, we explore the implementation fidelity of integrated PHC governance policy in Nigeria's decentralized governance system and its implications on closing implementation gaps with respect to other top-down health policies and initiatives.Having engaged policy makers, we identified 9 core components of the policy (Governance, Legislation, Minimum Service Package, Repositioning, Systems Development, Operational Guidelines, Human Resources, Funding Structure, and Office Establishment). We evaluated the level and pattern of implementation at state level as compared to the national guidelines using a scorecard approach.Contrary to national government's assessment of level of compliance, we found that sub-national governments exercised significant discretion with respect to the implementation of core components of the policy. Whereas 35 and 32% of states fully met national criteria for the structural domains of "Office Establishment" and Legislation" respectively, no state was fully compliant to "Human Resource Management" and "Funding" requirements, which are more indicative of functionality. The pattern of implementation suggests that, rather than implementing to improve outcomes, state governments may be more interested in executing low hanging fruits in order to access national incentives.Our study highlights the importance of evaluating implementation fidelity in providing evidence of implementation gaps towards improving policy execution, particularly in decentralized health systems. This approach will help national policy makers identify more effective ways of supporting lower tiers of governance towards improvement of health systems and outcomes.