Table 3 Application of Kingdon’s model to the case studies

Problem

Political event: In 2013, Lebanon was hosting 1.1 million Syrian refugees, the highest per capita refugee population in the world. These refugees faced a high burden of disease, and the obligation to address their health needs has put substantial pressure on the Lebanese health care system, particularly in terms of access, cost, and quality

Focusing event: In 2015, the issue of medical error gained tremendous attention in Lebanon following public outcry and extensive media coverage of the case of a 5-year-old child who underwent double amputation as a result of a medical error

Local report: According to a report published in 2017, an estimated number of 15,000 patients need palliative care services each year in Lebanon. This number is expected to increase due to a number of factors, such as the aging population and the rise in NCDs; yet, current health system arrangements do not ensure adequate access to palliative care services

This is a broad problem facing society, which became identified as issues that require public attention in a formal priority setting meetings. Primary studies indicate problems with the quality and prescribing of pharmaceutical drugs in Lebanon, which puts patients at risk of serious adverse effects, increases drug resistance, and leads to unnecessary increased costs on patients and the health system

Policy

Evidence demonstrated limited coordination between organizations and agencies providing health services to refugees, which was leading to both duplication and gaps in delivery of those services

Generation of a set of policy alternatives to address the problem (through a briefing note document that was circulated to stakeholders)

Evidence demonstrated while there has been an increase in reporting of medical errors in Lebanon, the associated implications and debates about causes, responsibilities, and accountabilities are ill-informed, and in many cases, not leading to real improvement in patient safety practices

Generation of a set of policy alternatives to address the problem (through a policy brief document that was circulated to stakeholders)

Evidence demonstrated failure of existing paradigm

Generation of a set of policy alternatives to address the problem (through a policy brief document that was circulated to stakeholders)

Evidence demonstrated inadequate measures at the policy, organizational, healthcare professional, and consumer levels to promote quality of pharmaceuticals

Generation of a set of policy alternatives to address the problem (through a policy brief document that was circulated to stakeholders)

Politics

Shift in national mood (including change in political climate, prevailing public opinion, and funder organizations’ agendas) favored immediate action on this issue

Shift in the balance of organized forces (i.e., interest group pressure campaigns through the public, advocates, and the media) coupled by demand and commitment from policymakers stimulated policy change

Policy champions (through well-established NGOs and stakeholder organizations) and ongoing health sector reform plan at that time, which presented an opportunity to shape the policy agenda around this issue

Policy champion (one of the policymakers was working on Codes of Ethics for Medicinal Product Promotion) and shift in the balance of organized forces (i.e., interest group pressure campaigns through media)