The Institute for Global Health and Development
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Item Navigating power in policy adoption: the political economy of noncommunicable diseases in Sierra Leone(Elsevier, 2025-10-06) Loffreda, Giulia; Senesi, Reynold; Diaconu, Karin; Idriss, Ayesha; Witter, SophieNon-communicable diseases (NCDs) represent a rising health burden globally, yet low- and middle-income countries (LMICs), particularly fragile states, face persistent barriers to NCD prevention and control policy adoption and implementation. This qualitative case study examines the factors influencing NCD policy adoption in Sierra Leone, a country that, in recent years, has focused on tackling these conditions. Drawing on 20 key informant interviews and 39 policy documents and media analysis, the study highlights the interplay of global health norms, commercial determinants, and local capacities. Findings reveal how international frameworks like WHO’s ‘best buys’ provide essential guidance but often fail to accommodate local socio-political realities. The analysis underscores how multisectoral coalitions, power dynamics, and commercial interests shape outcomes of policy adoption, while chronic underfunding and donor-driven priorities further complicate governance. Recommendations emphasize the importance of context-sensitive strategies that integrate local knowledge systems, strengthen leadership, and embed implementation research. Ultimately, fostering adaptive, accountable, and well-resourced health systems, supported by global solidarity and coordinated governance reforms, is essential to achieving sustainable NCD responses, particularly in an era marked by fractured multilateralism and weakened collective action, where strengthening local capacities and political commitment becomes even more critical.Item Understanding and addressing mental health needs and non-communicable disease in situations of fragility: RUHF research programme synopsis(NIHR, 2025) Ager, Alastair; Witter, Sophie; Diaconu, Karin; Wurie, Haja; Samai, Mohamed; Saleh, ShadiBackground: Fragile settings – marked by conflict and political, environmental, social, or economic crisis – present severe challenges to population health and the delivery of services. This is particularly the case for health conditions that require continuity of care such as non-communicable disease and mental ill-health. Objectives: To understand existing patterns of health seeking in relation to noncommunicable disease and mental health and the barriers to equitable access to quality provision. To then evaluate the feasibility, effectiveness and quality of interventions designed to address these conditions in contexts of fragility. Design and methods: Building on a foundation of focused scoping reviews, we used participatory methods – including group model building – to map pathways of access to community and health system resources in relation to non-communicable diseases and mental health. We then used a range of surveys and key informant interviews to evaluate implemented interventions. In addition, we undertook a series of global reviews of relevant topics, such as conceptualisation of fragility, the role of trust in health-seeking for noncommunicable disease care in fragile settings, analysis of policy and funding priorities of global actors regarding non-communicable diseases in low- and middle-income countries, and the political economy of NCD policy adoption and implementation at national level. Setting and participants: Field studies were focused at the district or governorate level in a range of fragile settings, including Lebanon, Sierra Leone, El Salvador and, latterly, Nigeria and Gaza. Participants included service users, (formal and informal) health providers and policy makers. Interventions: Interventions addressing NCDs included treatment protocols for hypertension and diabetes (with report cards and desk guides supporting primary care-based disease management) and a local co-created salt reduction programme (featuring community drama, school outreach and radio messaging). Mental health needs were primarily addressed in relation to the provision of community-based psychosocial support either through specific interventions (including a lay-woman-led problem solving intervention for perinatal women) or the development of assessment tools (such as a Participatory Assessment Tool for Mapping Social Connections) and contextually valid screening measures (including the Sierra Leone Psychological Distress Scale and the Sierra Leone Perinatal Psychological Distress Scale) to inform interventions. The programme also developed relevant training interventions. Main outcome measures: Measures focused on access to, and utilisation and quality of, services, including user perceptions of provision. Results: We identified a range of barriers to effective health provision in fragile settings. These reflected the cultural, political, social, economic particularities of the setting and its health system. However, trust (in specific health providers, within social and community networks, and in government) was consistently found to be a key factor in securing targeted outcomes. The skills, methods and confidence of providers was also found to be an important influence on such outcomes. Providing contextually relevant training, mentorship and tools equipped health providers in primary care settings to maintain effective, evidencebased management of diabetes and hypertension despite the ongoing challenges of their fragile context. Mobilisation of community-level resources to address non-communicable disease and mental health needs was demonstrated as relevant, feasible and potentially effective in all settings. Limitations: There was great diversity across the particular settings studied, as well as ongoing gaps in knowledge in relation to these conditions in particular. Caution should be shown in generalisation of specific findings to other situations that may not share important features. The COVID 19 pandemic disrupted data collection in both Sierra Leone and Lebanon, although the targeted power of studies was generally secured. More generally, the pandemic significantly impacted health systems operations in all settings studied, an influence that is discussed in all relevant papers. Conclusions: The research programme contributed to addressing gaps in the literature regarding effective tools and strategies to strengthen provision regarding mental health and non-communicable disease in fragile settings. Assessment of needs and barriers to accessing services is an important foundation for effective working in such contexts. This is achievable with research methods (such as group model building and remote data capture) that can accommodate the diverse challenges and uncertainty associated with these settings. Incorporating such information in service design – at the level of the community, health facility or policymaker – can secure improvement in access to, and quality of, important services. Donors and policy makers need to attend not just to the drivers of fragility but also to coherent investment in public health systems and in processes of community engagement if health needs are to be meaningfully addressed. Future work: The conceptualisation of fragility (and resilience) developed through this programme is informing the design of community, health system and wider cross-sectoral interventions in fragile contexts through the ReBuild for Resilience programme in settings including Sierra Leone, Lebanon, Myanmar and Nepal. Further work across diverse contexts of fragility is required to both identify common features and principles required for health response in these settings and refine strategies and tools that can readily be adapted to the unique characteristics of any particular context.Item Barriers and Opportunities for WHO ‘Best Buys’ Non-Communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review(Maad Rayan Publishing Company, 2023-12-31) Loffreda, Giulia; Arakelyan, Stella; Bou-Orm, Ibrahim; Holmer, Hampus; Allen, Luke N.; Witter, Sophie; Ager, Alastair; Diaconu, KarinBackground: Improving the adoption and implementation of policies to curb noncommunicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policymakers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation. Methods: We conducted a complex systematic review of articles discussing the adoption and implementation of WHO's ‘best buys' NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria. Results: Our CLD highlights a central feedback loop encompassing three vital variables: 1) the ability to define, (re)shape and pass appropriate policy into law; 2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); 3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies. Conclusion: To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions.Item A theory-based evaluation of the Leadership for Universal Health Coverage Programme: insights for multisectoral leadership development in global health.(2022-09-29) Witter, Sophie; Brikci, Nouria; Scherer, DavidLeadership to manage the complex political and technical challenges of moving towards universal health coverage (UHC) is widely recognized as critical, but there are few studies which evaluate how to expand capacities in this area. This article aims to fill some of this gap by presenting the methods and findings of an evaluation of the Leadership for UHC (L4UHC) programme in 2019-2020. Given the complexity of the intervention and environment, we adopted a theory-driven evaluation approach that allowed us to understand the role of the programme, amongst other factors. Data from a range of sources and tools were compared with a programme theory of change, with analysis structured using an evaluation matrix organized according to the Organisation for Economic Co-operation and Development-Development Assistance Committee (OECD-DAC) criteria. Data sources included key informant (KI) interviews (89 in total); surveys of the 80 workshop participants; a range of secondary data sources; case studies in two countries; and observation of activities and modules by the evaluator. Participants and KIs at the global and country levels reported high relevance of the programme and a lack of alternatives aiming at similar goals. In relation to effectiveness, at the individual level, there was an increase in some competencies, particularly for those with less experience at the baseline. Less change was observed in commitment to UHC as that started at a relatively high level. Understanding of UHC complexity grew, particularly for those coming from a non-health background. Connections across institutional divides for team members in-country increased, although variably across the countries, but the programme has not as yet had a major impact on national coalitions for UHC. Impacts on health policy and practice outcomes were evident in two out of seven countries. We examined factors favouring success and explanatory factors. We identified positive but no negative unintended effects. While noting methodological constraints, the theory-based evaluation approach is found suitable for assessing and learning lessons from complex global programmes. We conclude that L4UHC is an important addition to the global and national health ecosystem, addressing a relevant need with some strong results, and also highlight challenges which can inform other programmes with similar objectives. [Abstract copyright: © 2022. The Author(s).]Item How do participatory methods shape policy? Applying a realist approach to the formulation of a new tuberculosis policy in Georgia(2021-06-29) Marchal, Bruno; Abejirinde, Ibukun-Oluwa Omolade; Sulaberidze, Lela; Chikovani, Ivdity; Uchaneishvili, Maia; Shengelia, Natia; Diaconu, Karin; Vassall, Anna; Zoidze, Akaki; Giralt, Ariadna Nebot; Witter, SophieThis paper presents the iterative process of participatory multistakeholder engagement that informed the development of a new national tuberculosis (TB) policy in Georgia, and the lessons learnt. Guided by realist evaluation methods, a multistakeholder dialogue was organised to elicit stakeholders' assumptions on challenges and possible solutions for better TB control. Two participatory workshops were conducted with key actors, interspersed by reflection meetings within the research team and discussions with policymakers. Using concept mapping and causal mapping techniques, and drawing causal loop diagrams, we visualised how actors understood TB service provision challenges and the potential means by which a results-based financing (RBF) policy could address these. The study was conducted in Tbilisi, Georgia. A total of 64 key actors from the Ministry of Labour, Health and Social Affairs, staff of the Global Fund to Fight AIDS, TB and Malaria Georgia Project, the National Centre for Disease Control and Public Health, the National TB programme, TB service providers and members of the research team were involved in the workshops. Findings showed that beyond provider incentives, additional policy components were necessary. These included broadening the incentive package to include institutional and organisational incentives, retraining service providers, clear redistribution of roles to support an integrated care model, and refinement of monitoring tools. Health system elements, such as effective referral systems and health information systems were highlighted as necessary for service improvement. Developing policies that address complex issues requires methods that facilitate linkages between multiple stakeholders and between theory and practice. Such participatory approaches can be informed by realist evaluation principles and visually facilitated by causal loop diagrams. This approach allowed us leverage stakeholders' knowledge and expertise on TB service delivery and RBF to codesign a new policy. [Abstract copyright: © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.]Item Understanding the resilience of health systems(Springer, 2020-02-26) Blanchet, Karl; Diaconu, Karin; Witter, Sophie; Bozorgmehr, Kayvan; Roberts, Bayard; Razum, Oliver; Biddle, LouiseGlobally, displacement is now at the highest level ever recorded with 68.5 million people being forcibly displaced due to violence, political instability or poor economic conditions. Migration towards neighbouring countries or more distant high-income settings in Europe is creating new challenges for national health systems. This chapter explores health systems resilience, i.e. the capacity of health systems to adapt and transform themselves in response to challenges. We offer reflections and a new conceptual framework on resilience based on systems thinking and complexity theories. The chapter also offers examples of migration-related challenges and resilience responses in health systems and policies in order to illustrate the utility and relevance of the developed conceptual framework for European and neighbouring health systems faced by population flows and conflict. Finally, we make recommendations for a new research agenda.Item "Three Nooses on Our Head": The influence of district health reforms on maternal health service delivery in Vietnam(Kerman University of Medical Sciences, 2017-11-22) Nguyen, Thi Hoai Thu; McDonald, Fiona; Witter, Sophie; Wilson, AndrewBackground: The impact of reorganisation on health services delivery is a recurring issue in every healthcare system. In 2005 Vietnam reorganised the delivery of health services at the district level by splitting preventive, curative, and administrative roles. This qualitative study explored how these reforms impacted on the organisation of maternal health service delivery at district and commune levels. Methods: Forty-three semi-structured interviews were conducted with health staff and managers involved in the provision of maternal health services from the commune to the central level within five districts of two Northern provinces in Vietnam. The data were analysed thematically. Results: The results showed that 10 years after the reforms created three district-level entities, participants reported difficulties in management of health services at the district and commune levels in Vietnam. The reforms were largely perceived to negatively affect the efficient and effective use of clinical and other resources. At the commune level, the reforms are said to have affected the quality of supervision of the communes and their staff and increased the workload in community health centres. Conclusion: The findings from this study suggest that the current organisation of district health services in Vietnam may have had unintended negative consequences. It also indicates that countries which decide to reform their systems in a manner similar to Vietnam need to pay attention to coordination between a multiplicity of agencies at the district level.