A qualitative study of governance of evolving response to non-communicable diseases in low-and middle- income countries: current status, risks and options

Abstract

BackgroundSegmented service delivery with consequent inefficiencies in health systems was one of the main concerns raised during scaling up of disease-specific programs in the last two decades. The organized response to NCD is in infancy in most LMICs with little evidence on how the response is evolving in terms of institutional arrangements and policy development processes.MethodsDrawing on qualitative review of policy and program documents from five LMICs and data from global key-informant surveys conducted in 2004 and 2010, we examine current status of governance of response to NCDs at national level along three dimensions— institutional arrangements for stewardship and program management and implementation; policies/plans; and multisectoral coordination and partnerships.ResultsSeveral positive trends were noted in the organization and governance of response to NCDs: shift from specific NCD-based programs to integrated NCD programs, increasing inclusion of NCDs in sector-wide health plans, and establishment of high-level multisectoral coordination mechanisms.Several areas of concern were identified. The evolving NCD-specific institutional structures are being treated as ‘program management and implementation’ entities rather than as lead ‘technical advisory’ bodies, with unclear division of roles and responsibilities between NCD-specific and sector-wide structures. NCD-specific and sector-wide plans are poorly aligned and lack prioritization, costing, and appropriate targets. Finally, the effectiveness of existing multisectoral coordination mechanisms remains questionable.ConclusionsThe ‘technical functions’ and ‘implementation and management functions’ should be clearly separated between NCD-specific units and sector-wide institutional structures to avoid duplicative segmented service delivery systems. Institutional capacity building efforts for NCDs should target both NCD-specific units (for building technical and analytical capacity) and sector-wide organizational units (for building program management and implementation capacity) in MOH.The sector-wide health plans should reflect NCDs in proportion to their public health importance. NCD specific plans should be developed in close consultation with sector-wide health- and non-health stakeholders. These plans should expand on the directions provided by sector-wide health plans specifying strategically prioritized, fully costed activities, and realistic quantifiable targets for NCD control linked with sector-wide expenditure framework. Multisectoral coordination mechanisms need to be strengthened with optimal decision-making powers and resource commitment and monitoring of their outputs.

Health in All Policies Approaches: Pearls from the Western Pacific Region

“…There has been a substantial increase in the number of countries developing NCD‐specific policies since the early 2000s, most likely due to the World Health Assembly (WHA) endorsement of a global strategy on NCDs (Rani et al. ). A similar case can be made for the ‘helmet law’ from Viet Nam.…”

“…In Cambodia and Fiji, the chair of the committee was the Minister of Health, and in Mongolia and Malaysia, the Prime Minister and Deputy Prime Minister, respectively (Rani et al. ).…”

A scoping review of the uses and institutionalisation of knowledge for health policy in low- and middle-income countries

“…Outcomes related to health systems performance were reported for several studies. This included the incorporation of research findings into national-level policy and strategy documents [46], the creation of new state agencies or units [50,51,70,79,80], and agenda-setting for the policy process [40,66]. The utilisation of knowledge to improve financial protection was illustrated in research from Mexico, which resulted in a reduction in out-ofpocket expenditure [44], and research from Colombia that noted a decline in spending for oncological treatment by users [77].…”

“…Additionally, multple articles reflected on the use of research and routine system information to improve access to essential medicines and other pharmaceuticals [50,53,61,68,69,77,82]. Finally, knowledge utilisation was understood to enhance the quality of service delivery in research on integrated community case management in Malawi [64], non-communicable disease service delivery in five Asian countries [80], multiple primary care services in Nigeria [41], and male circumcision for HIV prevention in Uganda [45]. In this way, the review identified numerous studies that could loosely be characterised as corresponding to health system improvements.…”

The role of law and governance reform in the global response to non-communicable diseases

“…This includes governance reforms within the health portfolio, as well as inter-sectoral reforms that take account of the interests of different ministries and create the capacity for a government-wide response [39,40,133]. …”