From: Politics–evidence conflict in national health policy making in Africa: a scoping review
Author/year | Purpose/aim | Methods and setting | Nature of conflict | Policy type(s) | Consequences of conflict on policy | Conclusion |
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(Abubakar et al., 2021) | Assess the pros and cons of evidence generation and decision-making, discuss potential impacts and derive lessons for Nigeria, sub-Saharan Africa, and beyond | Qualitative/Nigeria | Challenges with the coproduction model included lack of transparency, bureaucratic barriers and a narrow focus on the direct health impacts of the disease rather than considering the broader social and economic effects of response measures | COVID-19 response guidelines | The guidelines helped in achieving its goal of slowing down the spread of the virus However, COVID-19 has inflicted significant social and economic hardships on many Nigerian households and individuals, complicating efforts to address the country’s broader health challenges amidst economic contraction | A multidisciplinary approach, integrating epidemiological, social science and economic analyses, along with evidence coproduction with policy-makers, is key to addressing the dual social and public health challenges of the COVID-19 pandemic in Nigeria and beyond |
(Agyepong et al., 2021) | To explore why and how collaborations and fragmentations occur during national policy and programme agenda setting | Qualitative/Ghana and Sierra Leone | 1.Country and global level factors 2.Power imbalances attached to funding 3.Disruptions in the flow of funds 4. Lack of political commitment and prioritization | Health Policies UHC HS HP | Accountability and trust issues collapse the synergy in the entire process of policy-making | Synergies and fragmentations are prevalent in policy agenda setting, formulation and implementation Fragmentations are detrimental to achieving policy goals Country actors require commitment, technical expertise and leadership to tilt the power balance towards Prioritization and political commitment of country actors |
(Alhelou et al., 2022) | Explore the opportunities and challenges countries have experienced and identify gaps to advance policy-making on menstrual hygiene and health | Qualitative/India, Kenya, Senegal and the United States | Policy drivers identified include: 1.Strong leadership and political will 2. Employing evidence-based approaches 3. Non-dependency/self-sufficiency 4. Prioritization of basic needs 5. Acknowledging weaknesses in the system and resolving them | Menstrual hygiene and health policies | Policies are being implemented smoothly but with some systemic challenges | African countries can initiate, formulate and implement policies to solve complex health problems with political will and minimal external interference |
(Akhnif et al., 2020) | Document the developmental process of a consolidated health financing strategy in Morocco | Qualitative/ Morocco | Success factors: 1.High political commitment 2. All actors adopted a common path of action | Health financing policy | Collaborative nature of the process favoured consensus building and collective ownership of the policy | The policy document was produced through collaboration among actors The process was devoid of the usual top-down approach and was more participatory in nature |
(Amukugo et al., 2021) | Analyse Namibia’s policies on NCD prevention Assess the government’s readiness to adopt a sugar-sweetened beverage tax policy | Qualitative/Namibia | The lack of interest on the part of government | No progress towards the enactment of the sugar-sweetened beverage policy |  | Although there is the endorsement of the sugar-sweetened beverage (SSB) policy, there are no steps to its adoption due to lack of convincing data on its impact This makes advocacy difficult and policy actors are latent |
(Blystad et al., 2019) | Examined the relationship between the abortion law, policy and access to safe abortion services | Qualitative/Zambia, Tanzania and Ethiopia | Ambiguity of the language used in the laws and policies Complexities between the laws, policy and actual access to health services | Abortion law Safe Abortion policy |  |  |
(Colvin et al., 2021) | Explore the barriers to and opportunities for improvement of, effective TB infection prevention and control | Qualitative/South Africa | Barriers include fragmentation of institutional responsibility and accountability for TB-IPC Inability of advocates to present TB-IPC as an urgent policy problem Barriers to policy innovation from lack of evidence to justify new policy | TB Infection Prevention and Control |  | TB-IPC is a chronic and complex health system challenge and requires both policy- and behavioural-level interventions. There is the need to effectively deal with the upstream barriers to policy formulation and implementation |
(Croke, 2020) | Identified the success factors of model primary healthcare programmes in Ethiopia | Qualitative/Ethiopia | Political will, Characteristics of political leaders A clear strategic plan of action informed by several policy experiments over a period | Primary healthcare programme | Tremendous success of the model programme informing its replication at the national level | Government models of federalism and policy to involve the population in service delivery models, to ensure political stability and development yielded the desired results |
(Dalglish et al., 2017) | Examine processes of health policy development in a case study of Niger | Qualitative/Niger | Government policy-makers showed adeptness in negotiating with donors and weighing conflicting factors but lacked the capacity and resources to formally evaluate and document programmes, limiting their ability to draw reliable lessons from them | Community case management of childhood illness (iCCM) policy | Government actors employed logical and ethical reasoning in making decisions that were subsequently identified as crucial to the success of iCCM | Access to codified knowledge empowers participants in policy discussions, yet it constitutes only one facet of knowledge utilized in the policy process, potentially not the most significant |
(Ditlopo et al., 2013) | Examine and identify the implementation and success factors of financial incentives among nurses | Qualitative case study/South Africa | Weaknesses identified include incomplete and inaccurate data on specialized nurses. Poor management of time and resources, improper coordination and communication. Rush in implementation, lack of consultation with health facility managers and poor orientation for implementors | Occupation-specific dispensation (OSD) policy; a financial incentive policy for health works in the public sector | Suboptimal implementation of the policy | Successful implementation of financial incentives requires adequate planning and management to maintain the morale of staff and reduce their grievances |
(Ditlopo et al., 2014) | Analyse the dynamics, strengths and weaknesses of nurses to participate national health workforce policies | Qualitative/South Africa | Poor awareness creation among policy beneficiaries Lack of consensus among policy actors No representation of the policy beneficiaries in policy-making process Lack of consensus over which nursing group represents nurses in policy-making | Policy regarding nursing practice, scope of practice framework for nursing qualifications and renumeration policy | Negative effect on how nurse’s views and inputs were regarded and included into the policy | There is the need for strong leadership, improved health policy capacity and skills of nurses to contribute effectively to health policy |
(Etiaba et al., 2023) | The study analyses government collaboration in implementing maternal, neonatal and child health (MNCH) programmes, derived from an integrated strategy. It aims to identify principles applicable to multilevel governance, especially in low-income countries | Qualitative case study/ Nigeria | Memoranda of Understanding were signed collaboratively but remained unimplemented. State did not meet programme goals due to a disconnect in the national governance structure, despite contextual differences | Maternal, neonatal and child health (MNCH) policies | Misaligned governance structures constrained implementation | Resource-limited countries need ongoing advocacy and tailored models for distributed leadership across government levels. Stakeholders must understand available collaboration drivers and system context requirements |
(Gavriilidis & Ă–stergren, 2012) | Analyse the ATM policy | Quantitative/South Africa | Facilitators: importance of the policy to communities, employment, education promotion, entrepreneurship and resource mobilization at the periphery Barriers: centralised conception, planning and implementation, lack of local adaptations, authoritative legislation | African Traditional Medicine Policy | Â | There is the need for deliberate community representation in policy-making, through conception, design to implementation. This participatory approach improves |
(Haaland et al., 2020) | Address gaps between knowledge, policy and practice Explore processes involved in translating policy into practice | Qualitative/Zambia | Issues of morality are key barriers to the policy implementation | Regulate and ensure safe abortion services | Healthcare facilities do not make safe abortion services available to women who seek them especially in rural areas | The discourse on safe abortion is even during policy meetings due to the dominant moral regime in Zambia |
(Holcombe & Gebru, 2022) | Describe the actors and processes involved in the policy process | Qualitative/Ethiopia | Drivers of the process: Government’s receptiveness, the pressure from civil society, health professionals and other NGOs | Safe abortion policy to promote the access to safe legal abortion services to prevent maternal mortality | Policy process was smooth and fast | The policy was internally driven with minimal external influence. There was a strong collaboration between government and civil society, and this is the major driver of the success achieved |
(Hussein et al., 2021) | Describe how the development of a community health policy contributes to attaining UHC and PHC targets in Kenya | Qualitative/Kenya | Drivers: strong government leadership, strong partnership, strong stakeholder engagements Alignment with political priorities Decentralization of the context to identify specific community needs The policy development was guided by research and evidence | Community health strategic plan National health sector strategic plan, | Successful policy development | The various contributing factors to the successful policy development are useful lessons for other similar jurisdictions. However, the successful implementation of the policy will depend the sustained political interest and consistency in financing sources |
(Jacobs & George, 2022) | Youth participation in the formulation of the Adolescent and Youth Health Policy was examined | Qualitative/South Africa | Barriers: donor politics and segmented donor priorities, fragmented among actors on how to embrace diversity and difference and how to handle power relations Drivers: opening of a good policy window, consensus between policy actors, youth participation | Adolescent and Youth Health Policy | Â | The opportunity for youth to participate in the policy development was a great achievement. However, there is the need to ensure proper representation of the youth in all the concerns them. This is a fundamental human right |
(Kagaha & Manderson, 2021) | Explored the role of power operations in setting priorities for maternal healthcare | Qualitative (ethnography and discourse analysis)/Uganda | Moral and legal restrictions Government priorities | Abortion care policy | Â | Â |
(Kielmann et al., 2021) | Assess health systems readiness to implement a new policy in resource constrained settings | Qualitative/South Africa | Facilitators: interventions to address staffing issues were addressed, infrastructure redesign and equipment arrangements | Policy on drug-resistant TB management | The programme was implemented successfully | Healthcare workers were willing to deliberately go the extra mile to do things that would ease the implementation of the policy |
(Koduah et al., 2018) | Understand decision-making processes that influence policy agenda | Qualitative/Ghana | Understanding and agreeing on the context, stakeholder interactions, ideas and framing of issues | Maternal health policies | Effective use of power to convince final decision makers moves the decision into a specified direction | Interconnectedness of policy drivers is such as the context, actors and their powers crucial in the policy process |
(Koon et al., 2020) | Providing social explanation to the president’s decision not to sign a policy | Qualitative/Kenya | Actors’ preferences influenced their judgement. Decisions were not evidence informed but were informed by the values of the actors. There was no understanding of how to finance the policy among actors | National Social Health Insurance law | The president refused to sign the document into law | The Ngilu Bill did not fail, but rather was fragmented into several smaller policy positions, some of which have recently been legislated |
(Kumwenda et al., 2021) | Explored factors that influenced development, adoption and implementation of ART policies | Qualitative/Malawi, Tanzania and South Africa | Weak health systems, suboptimal care Pressures from different stakeholders to accelerate or slow implementation Donor financing facilitated the process but skewed the power balance | Anti-retroviral therapy policies | Donor influence interfered with local innovative solutions to address specific local health system issues | Donors should be more focused on comprehensive health systems strengthening to achieve more effective results |
(Mac-Seing et al., 2022) | Explored policy actors’ perceptions of pro-disability laws, barriers to SRH services for people with disabilities and recommendations for addressing inequities | Qualitative/Uganda | Legislation and policy implementation faced technical and financial challenges, with disability issues lacking prioritization. People with disabilities encountered various barriers accessing SRH services, including physical, attitudinal, communication, and structural obstacles | Sexual and reproductive health (SRH) policy | There is proof of the complex challenges individuals with disabilities encounter when accessing SRH services, alongside the struggles in implementing disability-focused policies in Uganda | Policy actors identified and proposed concrete solutions to mitigate health inequities for people with disabilities |
(Masefield et al., 2021) | Explored how local stakeholders perceive their involvement in shaping the National Health Policy II (NHP II) and Health Sector Strategic Plan II (HSSP II) | Qualitative/Malawi | Tokenistic involvement, stakeholder hierarchy, mutual distrust, preferred stakeholders, no culture of engagement | National Health Plan II (NHP II) and Health Sector Strategic Plan II (HSSP II) | After18 months of policy implementation, stakeholders observe minimal improvement in governance and lack confidence in the government’s ability to achieve Universal Health Coverage (UHC) | Stakeholders expressed that both top-down and bottom-up pressures were lacking, resulting in superficial consultations with local stakeholders. As a consequence, these stakeholders felt powerless to influence health policy-making in a manner that aligns more effectively with the needs of their respective communities More inclusive top-down efforts are needed for effective stakeholder engagement |
(Mauti et al., 2022) | Assess how the adoption of the HiAP approach can leverage on SDGs implementation in Kenya | Mixed method/Kenya | Strong political commitment Draw on existing structures Funding strategy was not captured the framework | Health in all Policies |  | Multisectoral approach is a prerequisite for a successful comprehensive policy. Fragmentation of the various sectors will be a disadvantage to policy development and implementation |
(Modisenyane et al., 2017) | Understand how South Africa integrates domestic health policy into its foreign policy | Qualitative/South Africa | Social, political, economic and institutional factors influence the integration process The integration process was driven by national and external developments, stakeholder interests and advocacy and collaborative efforts from civil society as well as global advocacy movement | Antiretroviral Policy | Global pressures to make access to antiretroviral treatment a fundamental human right compelled the local health system to prioritize the ARV policy | Global and transnational systems can influence local policy focus by changing policy priorities |
(Mukuru et al., 2021) | Examine the roles of policy elites and how their interests drove maternal health policies | Qualitative/Uganda | The policies were driven by senior MoH officials, cabinet members, health development partners | Maternal Health Policies | The policies were skewed towards elite personal political and economic interests rather than reducing maternal mortality | The policies on maternal health in Uganda were informed by the personal interest of elites and not by the aim of reducing maternal mortality |
(Murray & Rutland, 2022) | Tests hypotheses from public health policy-making literature concerning the influence of medical, political, social, economic and external factors on African countries’ issuance of Stay-at-Home Orders (SAHOs) in response to the early COVID-19 pandemic | Quantitative/54 African countries | The analysis indicates that medical factors and external influences significantly shaped decisions, whereas political factors had minimal impact. Social and economic factors did not appear to play a significant role | Stay-at-Home Orders (SAHOs) in response to the COVID-19 pandemic | While effective in curbing disease transmission, these measures have considerably disrupted social and economic structures | African leaders balanced competing factors during the initial phases of a public health crisis |
(Mwisongo et al., 2016) | Understand the how power influences policy processes | Qualitative/Cabo Verde, Chad, Guinea, Liberia and Togo | Different types of power were used Positive or negative power, transitive, disproportional and structural power | National policies | When negatively applied, can influence and slow down the entire process as well as change its focus | Power could positively or negatively influence the policy process, at various stages of the process |
(Novignon et al., 2021) | Document the political path to the establishment of the Ghana National Health Insurance Scheme (NHIS) | Qualitative/Ghana | Drivers: an open policy window Government’s political will (manifesto promise) Strong collaboration between the actors on financing the policy Massive interest and support from development partners Politics cut across the entire policy process External actor politics, beneficiary politics, interest groups, leadership politics, budget politics, bureaucratic politics | NHIS | The strong politic interest of the sitting government and the opposition facilitated the development of the policy without unnecessary delays | Ghana’s NHIS policy development and implementation benefited from a good political atmosphere and leadership drive to achieve a manifesto promise. In addition, the engagement and collaboration between the internal and external actors was crucial to its success. Finally, the willingness of stakeholders to manage fragmentations to arrive at compromises easily facilitated the process |
(Okedo-Alex et al., 2021) | Assessment of the status of domestic funding and advocacy Strategies for improving funding of Health Policy and Systems Research (HPSR) | Qualitative/Nigeria | Barriers of domestic funding of HPSR are political and policy transition, corruption and bureaucratic bottlenecks | Health policies | Lack of domestic funding of HPSR is affecting the generation of strong evidence base data to inform and guide policy | Improved private sector involvement, continuous advocacy, multi-stakeholder coalitions for advocacy and researcher skill building on advocacy were suggested as the way forwards |
(Oraro et al., 2020) | Examined actor values and interest that influence agenda setting in health financing | Qualitative/Kenya | Lack of strategic leadership Fragmentation of stakeholders Understanding and interpretation of context by stakeholders | Universal Healthcare Policy | Conflicts in priorities of key actors threatens smooth progress towards the expansion of healthcare coverage as well us financing it | Properly contextualizing the competing health needs and prioritizing them in the policy arena is a more practical way of achieving results |
(Parkhurst et al., 2021) | Explore the impact of national and global network and related politics on malaria control in sub-Saharan Africa | Qualitative/sub-Saharan Africa | Balancing global goals with local realities Managing expectations and coordination of non-state stakeholders Peculiar NMCP institutionalized systems, structures and processes capable of influencing local capacity building |  |  | Although NMCPs are very well structured and adequately resourced by global partners and Ministries of Health, the programme can not be isolated from the local contexual realities |
(Ridde & Faye, 2022) | Understand how the COVID-19 response policy was formulated in Senegal | Qualitative/Senegal | Leadership and coordination conflicts Inadequate community participation and engagement with scientific community Power dominance by international donor | COVID-19 policy | The highly centralized and biomedical processes employed in the development of this policy, with very little intersectoral involvement and contribution from the scientific community, resulted in challenges with implementation | Policy-making should be guided by evidence and context, not only politics |
(Ruhara et al., 2021) | Described the policy landscape, identify and analyse the facilitators of and barriers to strengthening taxation on sugar-sweetened beverages | Qualitative/Rwanda | Government commitment to boosting sugar production Failure of existing policy to identify sugar as a risk factor for noncommunicable diseases | Tax to reduce the consumption of sugary beverages |  | The setting for sugar-sweetened beverage tax strengthening is a very complex There are several impediments as well as facilitators in the policy environment to strengthen the existing tax |
(Sambala & Manderson, 2017) | Examine the public health policy perspectives on vaccination to prevent the spread of infection under post-pandemic conditions | Qualitative/Ghana and Malawi | The programme was motivated by policy-makers own financial incentives as well as government and foreign policy conditionalities | Policy on influenza virus vaccination | Confusion about the targets and the coverage among the policy actors. For some policy-makers the process was successful, but others think otherwise | The vaccination intervention was problematic, its implementation was too late |
(Omar et al., 2010) | This paper delves into the formulation of suitable mental health policies and their successful execution | Qualitative/ Ghana, South Africa, Uganda and Zambia | Mental health policy processes in all four countries were inadequate, leading to either weak or non-existent policies, with an impact on mental health services | Mental health policy | Health policy processes frequently lack strength and adequate resources, especially in the realm of mental health. This deficiency often leads to bureaucratic delays and under-utilization of available evidence | More work is needed to improve mental health policy processes in African countries. Involving a wider range of stakeholders is crucial due to the diverse nature of mental health issues |
(Seddoh & Akor, 2012) | Conceptualize the various levers of policy formulation | Qualitative/Ghana | Various stakeholders, that is technical expects, civil society, academicians and politicians, had their various interests | NHIS | Â | During the policy process, it is important that the actors consider the content as well as the context to appreciate the viewpoints of others |
(Shiroya et al., 2019) | Presents Kenya’s experience of translating the UN declaration to national policies for diabetes prevention and control | Qualitative/Kenya | Open policy windows, political drive triggered by diabetes community, Scant local evidence | Policy for noncommunicable diseases | Suboptimal gains due to poor engagement with and participation of non-healthy sector players, fragmented health governance and week monitoring systems | Contrary to global recommendations, the policy process was largely driven by the health sector without the involvement of other sectors. Efforts to achieve population-wide impart will be enhanced when other sector players are brought on board |
(Simen-Kapeu et al., 2021) | Examined the process of developing community health policies to extract insights from Liberia’s efforts to strengthen its health system after the Ebola Virus Disease (EVD) crisis | Mixed method/Liberia | Establishing a coordination mechanism and harnessing partnership support, adopting a systemic approach to better guide policy changes, enhancing community involvement and conducting planning based on evidence to advise policy-makers | Community health policy | The policy was completed and at implementation stage | To enhance resilience against future shocks and bolster primary healthcare (PHC), community-based systems should assume a more significant role. This necessitates viewing communities not merely as recipients of health services but as |
(Thow et al., 2021) | Examine how historical economic policy agendas and paradigms have influenced current food and nutrition policy and politics in Ghana | Qualitative/Ghana | Poor integration of nutrition into existing food policies Existing food policies overly focused on food production, creating employment and economic returns at the expense of nutrition sensitive food supply | Food and nutrition policy |  |  |
(Wanjohi et al., 2021) | Assess the policy and stakeholder landscape relevant to nutrition related noncommunicable diseases and sugar-sweetened beverage taxation | Qualitative/Kenya | The role of nutrition in noncommunicable disease prevention is not a priority for policy-makers Government has competing roles such as growing the sugar and feed processing industries The dangers of sugar-sweetened beverages have not gained national consensus | Sugar-sweetened beverages tax policy | Taxation of sugar-sweetened beverages is not a policy priority | There is the need for local advocacy in favour of sugary beverage taxation Public and policy-maker education to understand the dangers of sugary beverages and refined foods |
(Zulu et al., 2022) | Examined the events, actors, and contexts behind the withdrawal of Zambia’s Community Health Strategy | Qualitative/Zambia | Divided perspectives of actors Numerous international partners with various interests Shifted locus of the strategy at the MoH No service provider and community participation in the policy process | Community Health Strategy | The policy development process was highly political and characterized by fraught external This led to its abrupt termination | Interaction between events, actors and context in policy development cannot be overlooked. The success of these interactions in the driving force behind any successful policy |