Supporting policy dialogue for health
planning and health financing
E. Robert, D. Porignon, D. Rajan, V. Ridde
1
Brisbane, October 25th 2017
A realist intervention theory of
the Universal Health Coverage Partnership
Objectives of the presentation
1. To present the
intervention theory
as the first output of
the research
2. To reflect on the
value of the
intervention theory
and the research
process
Context
• Universal health coverage (UHC) as a blueprint to strengthen health systems in developing countries
• Policy dialogue as a promising governance tool: process targeting both the technical and policy aspects of the
problem being discussed, involving evidence and sensitive policy discussions, in which a wide range of stakeholders participate, with a concrete objective, such as the
development of a plan or strategy
• UHC-Partnership to support policy dialogue for health planning and health financing in about 30 countries
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• Typical soft intervention: how to account for outcomes in different settings with major contextual influences?
Method
For the realist evaluation • Objective: to better
understand if the UHC-Partnership can
contribute to
strengthen policy
dialogue, how and in what contexts
• Multiple case study
(Togo, Liberia, Burkina Faso, Niger, DRC, Cape Verde)
• Qualitative research
For the intervention theory
• 1st round:
– Documentation
– Formal discussions with implementers
• 2nd round :
– Observations– Interviews with key informants – Literature review
• 3rd round :
– Discussions with implementers 4Fed by knowledge Fed by knowledge Inclusive and participator y Inclusive and participator y Led by MoH Led by MoH S tr e n g th e n in g o f g o v e rn a n ce t o w a rd s U n iv e rs a l H e a lt h C o v e ra g e S tr e n g th e n in g o f g o v e rn a n ce t o w a rd s U n iv e rs a l H e a lt h C o v e ra g e S u p p o rt t o i n st it u ti o n a lis a ti o n o f p o lic y d ia lo g u e f o r h e a lt h p la n n in g a n d fi n a n ci n g S u p p o rt t o i n st it u ti o n a lis a ti o n o f p o lic y d ia lo g u e f o r h e a lt h p la n n in g a n d fi n a n ci n g Approac h (SOFT) Approac h (SOFT) On-going support On-going support Training Training C a p a ci ty b u ild in g o f M o H C a p a ci ty b u ild in g o f M o H Knowledge and resources production Knowledge and resources production Components of support (HARD) Components of support (HARD) Fl e x ib ili ty Fl e x ib ili ty Pr o a ct iv e n e ss Pr o a ct iv e n e ss Ad hoc technical expertise Ad hoc technical expertise Policy dialogue Policy dialogue Goal Goal Results Results MAKE IT HAPPEN MAKE IT HAPPEN MAKE IT HAPPEN MAKE IT HAPPEN Outcom es Outcom es Fo rm u la ti o n o f ro b u st a n d co m p re h e n si v e h e a lt h p o lic ie s, s tr a te g ie s a n d p la n s Fo rm u la ti o n o f ro b u st a n d co m p re h e n si v e h e a lt h p o lic ie s, s tr a te g ie s a n d p la n s A lig n m e n t o f st a ke h o ld e rs A lig n m e n t o f st a ke h o ld e rs S tr e n g th e n e d le a d e rs h ip o f M o H S tr e n g th e n e d le a d e rs h ip o f M o H T R IG G E R S T R IG G E R S R e sp o n si v e n e ss R e sp o n si v e n e ss S u p p o rt t o p o lic y d ia lo g u e S u p p o rt t o p o lic y d ia lo g u e MoH ownership of the process MoH ownership of the process Mutual understanding of values, agendas, and needs of stakeholders Mutual understanding of values, agendas, and needs of stakeholders Stakeholders’ buy-in of decisions Stakeholders’ buy-in of decisions Mécanismes Mécanismes Trust in a structured and transparent process Trust in a structured and transparent process
UHC-P realist intervention theory
5C o n t r i b u t i o n C o n t r i b u t i o n M (?) M (?) M (?) M (?)
The researchers’ perspective (1)
For the research team
• Provides a common understanding of the intervention
• Becomes a framework to look at national experiences • Exposes the two level
analysis of the research
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• Challenges:
The IT does not depicts reality. It is a way to look at reality.
How to move away from this “typical” representation? Social sciences and anthropology researchers
The researchers’ perspective (2)
For commissioners & implementers
• A way to send out messages :
o Ensure a common understanding of the intervention
o Demonstrate the
complexity of the analysis o Illustrate the multiple
causal pathways and far-reaching and long term expected outcomes
The implementers’ perspective
(Feedback from the field)
The process
• Allowed for
clarifications about both the intervention and their role
• Provoked discussions and triggers a reflective process among implementers on their role • Raised awareness about the research process
The intervention theory
• Provided - in a structured and synthesized manner - an illustration of their role • Gave a sense to action
• Why?
– No time to step back when in the job
– Loss of sight of the objectives
– Possible confusion on role in the UHC-P vs. traditional role / way of doing thing (technical support to MoH)8
The commissioner’s perspective
• Complex intervention on policy dialogue at
country level
• The "million lives saved" syndrome
• The bureaucratic
approach of donors to evaluation
• The attribution nightmare • Confirm the perceptions
of policy-makers
• Demonstrate actual
outcomes of the
intervention:
WHO's role and
mandate as an
institution
• The real life of the
process over time
• Identification of the
mechanisms
Several ways at looking at policy
dialogue & UHC-Partnership
Normative
evaluation SOM (EU) Research on policy dialogue
Realist research
Mandat
e Results/Objectives Results/objectives Perceptions of policy dialogue in the field
Context & mechanisms
Added
value Valued by donors/stake holders Responds to donor requirement s Set the scene of policy dialogue in SSA Flexible Key actionable factors Limits Mechanistic attribution "Governed by numbers" No expertise in health systems « A côté de la plaque » Not about the UHC-P No attribution Does it work? Too sensitive to contexts?10
Lessons learnt
• The intervention theory as an efficient tool to:
– Reflect on the intervention
– Structure the research process
• Building the intervention theory as a necessary step to :
– Ensure a shared understanding among researchers, implementers and commissioners about the research object, the intervention, and the research process
• Challenges of collaboration: symbolic vs. instrumental use of research findings?
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Emilie Robert is a postdoctoral researcher at the Research Institute of McGill University Health Centre (Montreal,
Canada). She holds a scholarship from the Canadian Institute of Health Research.
Contact: emilie.robert2@mail.mcgill.ca Twitter: @emilie_robert_
Valéry Ridde is a professor at the School of Public Health at Montreal University (Canada).
Contact: valery.ridde@umontreal.ca Twitter: @ValeryRidde
Denis Porignon is a health policy specialist at the
Department of Health Systems Governance and Financing at WHO (Geneva, Switzerland).
Contact: porignond@who.int Twitter: @DenisPorignon
Dheepa Rajan is a health policy specialist at the
Department of Health Systems Governance and Financing at WHO (Geneva, Switzerland).
Contact: rajand@who.int Twitter: @Dheepa_Rajan