The politics of health systems policies during COVID-19: reflections on experiences from Latin America and the Caribbean.

Politics as the exercise of power always influence public policies-which reflects the multifaceted nature of decision-making-but "using politics" as a motivation for self-serving interests of government leaders and their allies poses problems. This article reviews the impacts of COVID-19 on health systems of the Latin American and Caribbean region from a political lens. We highlight the overriding influence of politics in health policies, weak governance structures that became compromised, exacerbation of corruption, and breakdowns in the communication and trust between governments and their citizens.

HIV programme sustainability in Southern and Eastern Africa and the changing role of external assistance for health.

High human immunodeficiency virus (HIV)-prevalence countries in Southern and Eastern Africa continue to receive substantial external assistance (EA) for HIV programming, yet countries are at risk of transitioning out of HIV aid without achieving epidemic control. We sought to address two questions: (1) to what extent has HIV EA in the region been programmed and delivered in a way that supports long-term sustainability and (2) how should development agencies change operational approaches to support long-term, sustainable HIV control? We conducted 20 semi-structured key informant interviews with global and country-level respondents coupled with an analysis of Global Fund budget data for Malawi, Uganda, and Zambia (from 2017 until the present). We assessed EA practice along six dimensions of sustainability, namely financial, epidemiological, programmatic, rights-based, structural and political sustainability.

Geographic prioritisation in Kenya and Uganda: a power analysis of donor transition.

Donor transition for HIV/AIDS programmes remains sensitive, marking a significant shift away from the traditional investment model of large-scale, vertical investments to control the epidemic and achieve rapid scaling-up of services. In late 2015, the United States President's Emergency Plan for AIDS Relief (PEPFAR) headquarters instructed their country missions to implement 'geographic prioritisation' (GP), whereby PEPFAR investments would target geographic areas with high HIV burden and reduce or cease support in areas with low burden. Using Gaventa's power cube framework, we compare how power is distributed and manifested using qualitative data collected in an evaluation of the GP's impact in Kenya and Uganda.

Political economy analysis of subnational health management in Kenya, Malawi and Uganda.

The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate.

From External to Local: Opportunities and Lessons Learned from Transitioning COMSA-Mozambique.

Donor transitions, where externally funded programs transfer to country ownership and management, are increasingly common. The Countrywide Mortality Surveillance for Action - Mozambique (COMSA) project established a nationwide surveillance system capturing vital events at the community level with funding from the Bill and Melinda Gates Foundation. COMSA was implemented in partnership between Johns Hopkins University (a U.

Political economy analysis of sub-national health sector planning and budgeting: A case study of three counties in Kenya.

Devolution represented a concerted attempt to bring decision making closer to service delivery in Kenya, including within the health sector. This transformation created county governments with independent executive (responsible for implementing) and legislative (responsible for agenda-setting) arms. These new arrangements have undergone several growing pains that complicate management practices, such as planning and budgeting.

Understanding reasons for and strategic responses to administrative health data misreporting in an Indian state.

The misreporting of administrative health data creates an inequitable distribution of scarce health resources and weakens transparency and accountability within health systems. In the mid-2010s, an Indian state introduced a district ranking system to monitor the monthly performance of health programmes alongside a set of data quality initiatives. However, questions remain about the role of data manipulation in compromising the accuracy of data available for decision-making.

Evidence attack in public health: Diverse actors' experiences with translating controversial or misrepresented evidence in health policy and systems research.

Bringing evidence into policy and practice discussions is political; more so when evidence from health studies or programme data are deemed controversial or unexpected, or when results are manipulated and misrepresented. Furthermore, opinion and misinformation in recent years has challenged our notions about how to achieve evidence-informed decision-making (EIDM). Health policy and systems (HPS) researchers and practitioners are battling misrepresentation that only serves to detract from important health issues or, worse, benefit powerful interests.

Examining policy intentions and actual implementation practices: How organizational factors influence health management information systems in Uttar Pradesh, India.

This study investigates the implementation of a recent health management information systems (HMIS) policy reform in Uttar Pradesh, India, which aims to improve the quality and use of HMIS data in decision-making. Through in-depth interviews, meeting observations and a policy document review, this study sought to capture the experiences of district-level staff (street-level bureaucrats) who were responsible for HMIS policy implementation. Findings revealed that issues of weak HMIS implementation were partly due to human resources shortages both in number and technical skill.

Experiential Learning and Mentorship in Global Health Leadership Programs: Capturing Lessons from Across the Globe.

Objectives: The changing global landscape of disease and public health crises, such as the current COVID-19 pandemic, call for a new generation of global health leaders. As global health leadership programs evolve, many have incorporated experiential learning and mentoring (ELM) components into their structure. However, there has been incomplete consideration on how ELM activities are deployed, what challenges they face and how programs adapt to meet those challenges.

Exploring perceived effects from loss of PEPFAR support for outreach in Kenya and Uganda.

Introduction: In 2015, the President's Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda.

Methods: Qualitative data collection was conducted as a part of a broader mixed-methods evaluation.

Effects of transition on HIV and non-HIV services and health systems in Kenya: a mixed methods evaluation of donor transition.

Background: In 2015 the US President's Emergency Plan for AIDS Relief (PEPFAR) initiated its Geographic Prioritization (GP) process whereby it prioritized high burden areas within countries, with the goal of more rapidly achieving the UNAIDS 90-90-90 targets. In Kenya, PEPFAR designated over 400 health facilities in Northeastern Kenya to be transitioned to government support (known as central support (CS)).

Methods: We conducted a mixed methods evaluation exploring the effect of GP on health systems, and HIV and non-HIV service delivery in CS facilities.

The effects of polio eradication efforts on health systems: a cross-country analysis using the Develop-Distort Dilemma.

Vertical disease control programmes have enormous potential to benefit or weaken health systems, and it is critical to understand how programmes' design and implementation impact the health systems and communities in which they operate. We use the Develop-Distort Dilemma (DDD) framework to understand how the Global Polio Eradication Initiative (GPEI) distorted or developed local health systems. We include document review and 176 interviews with respondents at the global level and across seven focus countries (Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Indonesia and Nigeria).

Barriers and facilitators to knowledge translation activities within academic institutions in low- and middle-income countries.

The barriers and facilitators of conducting knowledge translation (KT) activities are well-established but less is known about the institutional forces that drive these barriers, particularly in low resource settings. Understanding organizational readiness has been used to assess and address such barriers but the employment of readiness assessments has largely been done in high-income countries. We conducted a qualitative study to describe the institutional needs and barriers in KT specific to academic institutions in low- and middle-income countries.

How donors support civil society as government accountability advocates: a review of strategies and implications for transition of donor funding in global health.

Background: Global health donors are increasingly transitioning funding responsibility to host governments as aid budgets plateau or decline and countries meet development and disease burden goals. Civil society organizations (CSOs) can play a critical role as accountability mechanisms over their governments, but transitions raise questions about how donor-supported CSOs will fare following transition, especially in environments of limited political commitment. Decreases in funding may force CSOs to scale back activities, seek other funding, or rely on their governments for funding.

Applying the Theoretical Domains Framework to understand knowledge broker decisions in selecting evidence for knowledge translation in low- and middle-income countries.

Background: Health-related organisations disseminate an abundance of clinical and implementation evidence that has potential to improve health outcomes in low- and middle-income countries (LMICs), but little is known about what influences a user decision to select particular evidence for action. Knowledge brokers (KBs) play a part as intermediaries supporting evidence-informed health policy and practice by selecting and synthesising evidence for research users, and therefore understanding the basis for KB decisions, can help inform knowledge translation strategies. The Theoretical Domains Framework (TDF), a synthesis of psychological theories, was selected as a promising analysis approach because of its widespread use in identifying influences on decisions to act on evidence-based healthcare guidelines.

Implementing health system strengthening projects at USAID: Findings from five cases using an integrated framework.

Evidence on the implementation of health systems strengthening (HSS) interventions is scarce. Donors need this information to prioritise investments and lobby for continued financial support. To develop a deeper understanding of the implementation dynamics of robust HSS interventions, we retrospectively compared five USAID-supported projects in the Dominican Republic, Ethiopia, Kazakhstan, Rwanda, and Zambia.

How is implementation research applied to advance health in low-income and middle-income countries?

This paper examines the characteristics of implementation research (IR) efforts in low-income and middle-income countries (LMICs) by describing how key IR principles and concepts have been used in published health research in LMICs between 1998 and 2016, with focus on how to better apply these principles and concepts to support large-scale impact of health interventions in LMICs. There is a stark discrepancy between principles of IR and what has been published. Most IR studies have been conducted under conditions where the researchers have considerable influence over implementation and with extra resources, rather than in 'real world' conditions.

Understanding political priority development for public health issues in Turkey: lessons from tobacco control and road safety.

Background: Tobacco use and road traffic injuries are major public health problems in Turkey. During the last decade, the former issue received political priority in the country, while the latter did not despite the immense health and economic burden that road traffic injuries pose on the Turkish population. Political priority can facilitate the attainment of public health goals.

What Does It Take to Be an Effective National Steward of Digital Health Integration for Health Systems Strengthening in Low- and Middle-Income Countries?

Background: Digital innovations have evolved over the last 15 years to support health activities, and their introduction in low- and middle-income countries has shown the potential to catalyze gains in health systems and service delivery. Despite widespread efforts to roll out these technologies, standardized approaches for formalizing national stewardship responsibilities and ensuring that digital health is a routine, mature, sustainable, and country-owned component of the health system are lacking. In this paper, we define digital health stewardship, with a focus on the ministry of health's role; describe practices undertaken to date; and identify gaps where increased attention could improve sustainability, impact, and local ownership.

A framework for medical power in two case studies of health policymaking in India and Niger.

Medical professionals influence health policymaking but the power they exercise is not well understood in low- and middle-income countries. We explore medical power in national health policymaking for child survival in Niger (late 1990s-2012) and emergency medicine specialisation in India (early 1990s-2015). Both case studies used document review, in-depth interviews and non-participant observation; combined analysis traced policy processes and established theoretical categories around power to build a conceptual framework of medical power in health policymaking.

Assessing the capacity of ministries of health to use research in decision-making: conceptual framework and tool.

Background: The capacity to demand and use research is critical for governments if they are to develop policies that are informed by evidence. Existing tools designed to assess how government officials use evidence in decision-making have significant limitations for low- and middle-income countries (LMICs); they are rarely tested in LMICs and focus only on individual capacity. This paper introduces an instrument that was developed to assess Ministry of Health (MoH) capacity to demand and use research evidence for decision-making, which was tested for reliability and validity in eight LMICs (Bangladesh, Fiji, India, Lebanon, Moldova, Pakistan, South Africa, Zambia).

Political commitment for vulnerable populations during donor transition.

The responsibilities for the programmatic, technical and financial support of health programmes are increasingly being passed from external donors to governments. Programmes for family planning, human immunodeficiency virus, immunization, malaria and tuberculosis have already faced such donor transition, which is a difficult and often political process. Wherever programmes and services aimed at vulnerable populations are primarily supported by donors, the post-transition future is uncertain.