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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

(2)

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

(3)

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

3

• Typical soft intervention: how to account for outcomes in different settings with major contextual influences?

(4)

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 4

(5)

Fed 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

5

C 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 (?)

(6)

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

6

• 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

(7)

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

(8)

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

(9)

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

(10)

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

(11)

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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12

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

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