Country-level policymaking, informed by WHO guidance, has been a vigorous topic on HIFA for several years, with thanks to support from the Special Programme for Research and Training in Tropical Diseases (TDR) (2016-18).
Here is a new paper on this topic. Citation, abstract and a comment from me below.
CITATION: Adoption of evidence-based global policies at the national level: intermittent preventive treatment for malaria in pregnancy and first trimester treatment in Kenya, Malawi, Mali and The Gambia
Jayne Webster, Jenna Hoyt, Samba Diarra, Lucinda Manda-Taylor, George Okoth, Jane Achan, Ludovica Ghilardi, Umberto D’Alessandro, Mwayi Madanista, Simon Kariuki et al.
Health Policy and Planning, https://doi.org/10.1093/heapol/czaa132
Published: 12 November 2020
In 2012, the World Health Organization (WHO) updated its policy on intermittent preventive treatment in pregnancy with sulphadoxine–pyrimethamine (IPTp-SP). A global recommendation to revise the WHO policy on the treatment of malaria in the first trimester is under review. We conducted a retrospective study of the national policy adoption process for revised IPTp-SP dosing in four sub-Saharan African countries. Alongside this retrospective study, we conducted a prospective policy adoption study of treatment of first trimester malaria with artemisinin combination therapies (ACTs). A document review informed development and interpretation of stakeholder interviews. An analytical framework was used to analyse data exploring stakeholder perceptions of the policies from 47 in-depth interviews with a purposively selected range of national level stakeholders. National policy adoption processes were categorized into four stages: (1) identify policy need; (2) review the evidence; (3) consult stakeholders and (4) endorse and draft policy. Actors at each stage were identified with the roles of evidence generation; technical advice; consultative and statutory endorsement. Adoption of the revised IPTp-SP policy was perceived to be based on strong evidence, support from WHO, consensus from stakeholders; and followed these stages. Poor tolerability of quinine was highlighted as a strong reason for a potential change in treatment policy. However, the evidence on safety of ACTs in the first trimester was considered weak. For some, trust in WHO was such that the anticipated announcement on the change in policy would allay these fears. For others, local evidence would first need to be generated to support a change in treatment policy. A national policy change from quinine to ACTs for the treatment of first trimester malaria will be less straightforward than experienced with increasing the IPTp dosing regimen despite following the same policy processes. Strong leadership will be needed for consultation and consensus building at national level.
- National policy decision-makers are responsible for the translation of global policies to national policies and their implementation. There is a lack of understanding of the variability in policy processes and factors influencing this.
- Our retrospective study of a prevention policy and prospective analysis of a treatment policy, found that the main drivers of policy adoption were: the methodological quality of the research, the relevance of the data to the local context and its prospects for effective implementation. Trust in WHO policy processes could override these factors.
- These findings contribute to gaps in understanding the translation of global to national policies.
Comment (NPW): I have not had a chance to read the full text in detail, but reported comments from policymakers suggest a misunderstanding of the role of WHO guidance:
'Respondent: "WHO is the truth. So WHO says it has to happen, it has to happen" (Kenya_UN/bilateral).
Respondent: "If WHO already approves it is no longer worth doing operational studies" (Mali_UN/bilateral).'
WHO guidance is not there to dictate, but to help inform country-level policymaking.
Best wishes, Neil
Coordinator, HIFA Project on Evidence-Informed Policy and Practice
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