Policy Forum Examines the Complexities of Health Policymaking in Developing Countries
April 10, 2017
How can you ensure sustainable domestic financing for health programs that prioritize access to the marginalized? How do you navigate power struggles at the decentralized level to effectively implement health programs? How do you keep policy reforms moving forward when stakeholders are at odds?
These were among the challenging policy—and political—issues discussed at the forum on “The Art of Policymaking: Advancing Health Policy in Dynamic and Complex Environments,” hosted by the Health Policy Plus (HP+) project. The policy forum featured directors from four HP+ country programs and marked the start of the project’s Technical Leadership Exchange, in which teams from nearly 15 countries gathered to learn from each other’s experiences and chart future strategic directions.
The forum’s theme centered on how health policy can help lay the foundation for strong, resilient health systems that help end preventable child and maternal deaths, achieve an AIDS-free generation, ensure access to voluntary family planning (FP), and protect communities from infectious diseases. Policies set priorities, obligate action to achieve goals, help guide resource allocation decisions, protect clients’ rights, and provide the basis for monitoring accountability.
Yet, as Dr. Suneeta Sharma, HP+ Project Director, highlighted, the policy process is complex. Policymaking takes place in ever-changing contexts and can be highly contested. It often involves an array of stakeholders with asymmetric power and differing viewpoints. According to Sharma, “Technical evidence can and should help steer policy discussions, but often the underlying political economy of the country, the power dynamics, political will, and other factors influence policy decisions.”
After Dr. Sharma’s remarks, Ron MacInnis, HP+ Senior Technical Advisor, welcomed the panelists from Guatemala, Pakistan, Kenya, and Jamaica and charged each with sharing a particular policy challenge and how they worked with in-country partners to address it.
In Guatemala, which graduated from USAID family planning assistance, advocates secured 15 percent of the alcohol tax for family planning and reproductive health (FP/RH) through adoption of the 2004 Beverage Tax Law Decree. From 2006 – 2016, the tax has generated US$56.7 million for FP/RH programs. But, as Herminia Reyes, country director for HP+ Guatemala—known locally as Health and Education Policy Plus, explained, “Finally, we had the money. The problem was solved? No.”
Each year, members of Guatemala’s Congress have tried to “capture” the tax for other purposes or set up legislative restrictions on how the funding can be used. Advocacy by civil society champions, such as the National Alliance of Organizations for Reproductive Health of Indigenous Women, and multisectoral watchdog groups like the Reproductive Health Observatory, has been essential in ensuring accountability for allocating alcohol tax revenues to FP/RH as required by law. These groups have also advocated for supplementary laws, decrees, and regulations over the years, including a 2015 decree that allows procurement of contraceptives through international organizations. Reyes noted that civil society is ready with “open eyes” every year to protect hard-fought wins to sustain high-quality FP/RH programs.
Pakistan and Kenya are both undergoing devolution to bring social services closer to communities, which creates both challenges and opportunities for the financing and governance of health programs. In Sindh Province in Pakistan, two departments are responsible for FP/RH programs: the Population Welfare Department, which is a smaller department that focuses on population issues, and the Department of Health, which is larger, better financed, and plays a role in implementing FP/RH programs. In addition to needing strengthened capacity to take up responsibilities once managed at the federal level, there is a need for better coordination across the departments. In particular, there is limited capacity to do health policy and budgeting work.
Rahal Saeed, HP+ country director for Pakistan, described how a lot of policy work is “informal.” It involves relationship-building, troubleshooting, and, she noted (not entirely in jest), “apologizing to people.” By being responsive and providing assistance when and where needed, HP+ has gained buy-in from senior provincial leaders. As a result, Sindh is the first province to have developed and adopted a costed implementation plan to operationalize the country’s commitment to FP2020. HP+ support has emphasized continuous communication between the departments, coordination of activities, shared measurement, and planning for functional integration at the district and sub-district level.
In Kenya, the devolution of health system is requiring counties to take greater ownership of their health and HIV programs. HP+, with the Ministry of Health, Ministry of Planning, and Kenya School of Government, is assisting 26 priority counties to enact program-based budgeting (PBB) as required by the Kenya Public Finance Management Act, 2012. PBB aims to align local budgeting to program targets and outputs, annual operation plans, and county integrated development plans. A key challenge is that while health was devolved, many county officials still viewed HIV funding as a national-level function.
According to Stephen Muchiri, HP+ country director for Kenya, “we had to produce evidence: evidence on the disease burden and evidence on who is financing HIV and AIDS” to convince governors to invest in HIV. Following, PBB training, policy discussions, and advocacy county HIV budget allocations have increased from zero to US$4 million from FY2015/16 to FY 2017/18. A next step is to look at how the increased funding will be applied.
In the Caribbean, a seminal moment occurred a few years ago when a respected religious leader from Jamaica testified during a Belize court case in favor of anti-sodomy laws. The religious leader, who had been seen as an ally and expert in the HIV response, contended that such laws were needed because same-sex relationships were driving the HIV epidemic. In the aftermath, HIV program proponents and advocates for lesbian, gay, bisexual, and transgender rights faced backlash while public conversation was consumed with debates over acceptable cultural norms.
According to Sandra McLeish, country director for HP+ Jamaica, what seemed like a setback became an opportunity to spark conversations about HIV issues in churches, schools, and communities. HP+ and its predecessors strengthened the leadership, advocacy, and treatment literacy capacity of people living with HIV and key populations. The project facilitated a participatory, iterative process to create a 17-module curriculum building on the Positive Health, Dignity, and Prevention (PHDP) Operational Guidelines developed by the Global Network of People Living HIV and UNAIDS. McLeish explained, “We built the ship as we sailed it” and communities developed the PHDP components most relevant to them. This stakeholder-led approach has been key to gaining traction.
Grassroots leaders have become champions for rights- and evidence-based policy approaches to HIV. After nearly four years of engagement, people living with HIV are not just members of HIV treatment teams, but occupy other spaces in the national HIV response. A third of Jamaica’s representatives on the Country Coordinating Mechanism for the Global Fund are from the positive community. PHDP principles are included Jamaica’s test-and-start plan, reflecting ownership by both civil society and the government. As McLeish stated, “At the end of the day, the work we do is really all about people.”
The policy forum was attended by about 60 participants in-person and online. During the Q&A session, attendees and panelists discussed issues such as fiscal space for health, how to make policies operational, and the importance of both data and tenacity throughout the process. In sum, the four country examples represented four different regions and issues, but raised common challenges—including the power of civil society and the need for sustainable financing and strengthened government collaboration. The examples also provide a window into the complexity and time commitment for making policy change happen.