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Jan 29, 2019

On agenda setting and stakeholder analysis as a prelude to health policy formulation (Post 1 / 2019)

The human mind is unique to humanity. We can think, imagine, create, memorize, communicate, concentrate, contemplate, and all we can think of. Sometimes, this same beautiful mind can be dysfunctional to a limit that it can get vacant or disruptive. In all these, it is a thought process that flowers an idea which can be developed into a beautiful concept and if we focus and persevere with an organized path forward, then we can create, build and construct whatever we possibly can imagine. Such is our power of a beautiful mind. However, to generate excellent ideas and translate them into the tangible outcome, our mind has to be trained, disciplined and framed in such a way that we know our goal and objectives best guided by a uniform vision and mission. 

After decade long political struggle post-1992 popular movement, Nepalese people have suffered immensely such that we have lagged behind by several decades in socioeconomic scale when we compare ourselves in every metric with neighboring countries. All these upheavals brought so much unaccountable and unmeasurable social sufferings we can't measure and sometimes, it seems we fail to contemplate this aspect of our story. Despite all these hardships and sufferings, Nepalese people have compromised with all the changes wanting peace and prosperity so we are able to fulfill our basic necessity. With these aspirations harrassed by repeated political stalemates  - we have been able to proclaim our basic rights for peace, livelihood, dignity, education, health, food and justice through the new constitution of 2072 BC.

These written rights and responsibilities are of galactic (व्रमांड) nature, but I believe, these basic rights are achievable in our lifetime. We need to work hard, not wasting any time on political bickering, if we want to translate all these rights into tangible benefits in our daily lives such that we do not have to die just because hospital is 2 days away or surgeon is in district headquarter 5 days away or some poor should have to suffer humiliation every day just because he is born with certain characteristics and so on the list is endless. No more such sufferings, we have had enough and our children do not have to bear such hardships again.

Now with the federal restructuring of governance in full swing, we are in the best time to translate basic health rights into action and bring well being in people's everyday life. The question is then what can we do? Well, we have so much potential to transform Nepalese way of doing business within current governance structure and functions in evolution. For this, policymakers have to act smart and work in harmony with elected leadership, who bring people's voice and connect with them. We are such a lucky generation that the advent of the 21st century has brought a flood of technological disruption, particularly information technology (IT) that we can accelerate our path to success and catapult ourselves to the wealthy nation-state in the shortest span of time. Again the question comes back before us: how do we do it? Well, we need smartness in how we manage our home affairs, be it administration or politics. We need to bring ourselves out of the traditional mindset of bureaucracy, which we commonly call it a public service administration. It is right time that we change the narrative such that "public service administration is not rocket science." These are all skill set that comprises social, emotional and political skills and in the heart is your educational qualification and experiences. When I say skills, I like to focus here the field of "policy analysis." We have realized lately that policy expertise is one knowledge area all of us need to master and get well acquainted with.  

Our constitution is a master policy of our country. There are directive principles, policies, and obligations of the state. While translating these principles and policies into programs, we need to guide those programs based on specific sectoral policies which are based on evidence. And the process of generating one giant field of pure science as well as social science, which is a mental exercise of deductive nature or synthesis or even experimentation. My point here is that an idea or concept has to go through the rigorous procedure before we utilize that knowledge to guide our policy and strategies, and translating them into public services like health care delivery in our case. So, if we have preventive measures or tools or say even drugs that have evolved through discovery and development phase, then we need to deliver to the people and save their lives or cure them of life-threatening diseases. All these translational phases from discovery to delivery is so complex that sometimes it is political before we can include them in policy within the government system. 


Here come those skills such as agenda setting,  which is "the process (or processes) by which an issue is brought to the attention of policy-makers and it is the first stage of the policy development process." (Manuela et al. 2016) An issue could be anything - preventive a diseases, educating people through a new method and so on.  In order to inject such issues into the radar of policymakers, there are drivers of policy change or introduction or even review - idea, interest, institution and network or coalition (3 I + N). Someone's interest could be guided based on purely academic in nature, while others could be economical or political or purely humanitarian or even social responsibility. (Manuela et al. 2016) There are various theoretical approaches to agenda setting. One of them is Kingston model that imagines 3 streams of problem, policies, and politics, which are at continuous interplay and we as a promoter of any policy agenda look for a convergence whereby there comes a window of opportunity. In this dynamic of the intense interplay between streams, we need "policy entrepreneurs" or we can call "Policy Champion", who can sense and forsee underlying position and power of players with various interests.  In understanding the game of play, we need to be able to figure out the political landscape so we will be able to formulate policy and adopt in the larger framework of the health system. Here, the meaning of power among stakeholders is dictated by their political authority, financial resources, and technical expertise.

In the effort for policy formulation and its process, we need never forget the importance of stakeholder analysis (SA), which is as an objective assessment tool has commonly been used in business, change management and development. (Makan et al., 2015) SA can be defined as "as a systemic technique for gathering insights relating to a proposed action or reform" by "identifying, categorizing and analyzing individuals or groups that are likely to have a "stake" in a proposed action, and explore opportunities for increased stakeholder engagement." (Makan et al., 2015) This can be conducted by gathering data through document review, media analysis and in-depth interview or by brainstorming with knowledgable participants. (Gilson et al.) Qualitative content analysis, an extension of stakeholder analysis, is also a useful means for summarizing stakeholder interest, power and positions and possible future impact regarding the scale-up of a proposed action and also demonstrated its relevance as a tool to prioritize engagement activities among already mobilized stakeholders.  (Makan et al., 2015) While the force field analysis is helpful in summarising multiple stakeholder analysis (e.g, cross-country stakeholder analysis) done in multiple locations and provide a comprehensive picture of the balance of support and power around a "political management strategy" (Gilson et al.)  SA is also useful in an illuminating host of opportunities available to narrow the gap between research, and its translation into knowledge, including policy and practice. Notably improve the translation of evidence-based research into policy and practice (Makan et al., 2015) and generate better outcomes out of the implemented programs/projects for the improvement of the health system. In this effort, we need to understand the theory of change (ToC), which is "essentially a comprehensive description and illustration of how and why the desired change is expected to happen in a particular context." This can be defined as "a specific type of methodology for planningparticipation, and evaluation that is used in the philanthropynot-for-profit and government sectors to promote social change and defines long-term goals and then maps backward to identify necessary preconditions". In addition, we also need to be able to develop research uptake and communication strategy, which is a good way to prioritize stakeholders for the purposes of strategic research uptake management (Makan et al., 2015) The research uptake is defined by Development Research Uptake in Sub-Saharan Africa ( DRUSSA) as a management process "working with scientific research that has both a traditional focus on building and disseminating the bodies of knowledge created in the academic domains, and a newer and wider focus on maximising the conditions for the application of these bodies of knowledge to achieve outcomes that have a developmental impact." 

On the final note, once we are done with evidence generation, its synthesis, securing funding and champions to always speak for and defend the idea/method, agenda setting and stakeholder analysis part and parcel of policy analysis along with political analysis, the policy is formulated and finally adopted into the health system. In order for the policy to translate into programmatic implementation, the middle of the process of policy formulation and its adoption has to go through at least 7 layered steps as below: (Manuela et al. 2016) 
  1. General policy alternatives
  2. Deliberation and/or consultation
  3. Advocacy for specific alternative
  4. Lobbying for specific alternative
  5. Negotiation on a policy alternative
  6. Drafting or enactment of policy
  7. Guidance/influence on its implementation

  • Manuela et al. . 2016 May; 31(4): 493–503
  • Makan et al. Int J Ment Health Syst (2015) 9:27
  • Gilson et al. Health Policy and Planning 2012;27:i64–i76 doi:10.1093/heapol/czs007 

Jan 28, 2019

Role of Heath Informatics for Universal Health Coverage (Post 24/24)

It is common these days that all of us (policy makers, planners, managers, and even politicians) are advocating for evidence-based management, data-based decision (3D) making, or evidence-based medicine and so on. In all of these disciplines, “evidence base” is the heart of the matter and without which it is hard to push forward an agenda in a world where rationality, accountability, and fairness exist. We can also state here that our statement or any thought processes based on solid evidence is a practice that has been handed over to us since ancient years. In a way, it is a practice of seeking truth or near the truth. And truly, we have arrived at such a juncture of history that we are witnessing a rapid boom in Information technology (IT) that we are now entering into an era of Artificial Intelligence (AI). We hear of automation (autonomous car/rocket/ 3D printing), big data, drones, Internet of Things (IoT), open data, Mars travel, human colonization of exoplanets or more recently of plasma-based engines, space-faring civilizations, ultimate traveling to planets around Alpha Centauri, our nearest star. Why I am bringing these technology-based revolutions that are happening and disrupting the way we do science, simply because we need to catch up and explore in that direction of utilizing these available ideas and tools for our day to day work and activities. For our case in strengthening our health care delivery system from the health information system to hospital management to logistic supply and its delivery to remote parts of our country and improving the lives of our citizens.

We can safely say that IT and health sectors are two fields that have proportionately grown at a fast pace compared to other fields. Just recently (2017), Nepal Telecommunication (NTC) launched 4G/LTE service. Now, we can communicate in video mode and google any information from any towns all of the countries, be it in Simikot or Mugu. Such a fast pace we are moving ahead in this field. Also, we have to stress here that public health services are one of the most widely distributed public services that reach each and every corner of our country. There are numerous challenges that have been discussed for such a long time that we need to fix the ailing health care delivery platform if we are to provide quality health care. It is said that poor quality health care kills more people than communicable or non-communicable diseases. It is very clear in front of us, we can solve many such governances, management, logistics as well as a hospital as well as public health issues utilizing IT as well as informatics integrated into the health system. For this matter, we are so lucky that Health Informatics is a term describing “the acquiring, storing, retrieving and using of healthcare information to foster better collaboration among a patient’s various healthcare providers. Health Informatics plays “a critical role in the push toward healthcare reform.” This field is  “an evolving specialization that links information technology, communications, and healthcare to improve the quality and safety of patient care.

It is timely to remind us here  and that the Nepal Constitution 2072 in its Clause 51 (Policies of the State) and that relates to Sub-clause “(b) Policies relating to political and governance system of State” also says that:

While Sub clause “Policies relating to development” also reiterate:

Whatever we proclaim as fundamental rights in our constitution, we will not be able to achieve such goals if we are not efficient in measuring the inputs, processes, outcome, and impact of any budget and program allocated and implemented through public services. Therefore, it is exactly true when we say, “ if we do not measure then we do not know where we are going”. Compare this scenario to an aeroplane taking off, in flight and during landing, if the pilots are equipped without all those radars and other metrics that measure altitude, speed, direction, fuel gauge, temperature, pressure, wind speed and so on, then we can’t imagine from traveling from A to B in an airplane. So is the similar scenario of health - care delivery.

As we enter the 21st century, the world population is approaching 8 billion and most of this humanity reside in Asia, particularly India and China. In between these two giants  - Nepal is situated with a population approaching 30 million for this small country. We are sustaining to our habits and habitat till now. However, time ahead does not look that easy with increasing population density, climate changes, alarming deforestation, rising poverty, and unemployment rate and brewing conflict with political instability despite a decade long wasted years of people’s war. Despite all these challenges in the vicinity, people have expectation from elected government and our new constitution 2072 have loudly stated that fundamental rights related to health and welfare, education, food security, clean air and water, transportation and so many aspirations are written in letters. In this respect, our government of Nepal (GoN) recently passed public health and safer motherhood acts in order to ensure basic health rights that include emergency care wherever and whenever. Above all, GoN is also a signatory to global health as well as developmental commitments such as Universal Health Coverage (UHC) and Sustainable Development Goals (SDG). The key principle that underlies all these noble endeavors is that “no one should die or fall ill not because one is poor such that no one is left behind”. Therefore, it is the responsibility of the government to provide financial protection from illness or diseases such that nobody has to get trapped in poverty.

For this, the best approach would be the comprehensive approach that SDG has espoused to fight poverty, inequality, pollution, illiteracy. So to be a part of this noble cause of global as well nation’s commitment, we need to implement the key strategies that are e-governance policy of Nepal. For this to be successful, we need to establish a dedicated Health Informatics division within MoHP such as "Health Informatics and Analytic"  as a division to be lead by 11 level or alternatively, we can accommodate this "Health Informatics & Analytic" component into the current Population Management Division to be lead by 11 level health professional or population scientist. For this, we can follow the model of measure evaluation. We need to establish a framework for strong coordination and collaboration specifically to align Policy, Planning, Monitoring, Regulation, Quality of Care, Health Economics and Research wings and carry out following key activities:
  • Strengthen data-based decision making, which will feed Evidence-Based Policy and Planning within MoHP
  • Provide technical leadership through collaboration at local (provincial governments), national (Other governmental sectors, NHRC/CBC/VBDRTC/Universities/Research Organizations / non - gov organizations etc), and global levels (UN organizations/foundations/universities/research organizations etc) to advance the field of global health monitoring and evaluation.
  • Build the sustainable capacity in evidence-informed decision making, which will vitalize evidence-based Policy and Planning within MoHP
  • Create, implement, and facilitate state-of-the-art methods for and approaches to improving monitoring and evaluation, health information systems, and data use.
  • Establish data derived decision (3D) making framework, which is vital for aligning policy, planning, monitoring and evaluation, quality of care, health economics and Implementation research activities within the broad framework of UHC as well as PHC revitalization.
  • Establish a health economy unit (Attention: we should not minimize the importance of the health economy as a discipline)


Anuj in Himalayas

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