Exploring Politics and Contestation in the Policy Process: The Case of Zambia's Contested Community Health Strategy.

There have been increased calls for low- and middle-income countries to develop community health systems (CHS) policies or strategies. However, emerging global guidance brackets the inherent complexity and contestation of policy development at the country level. This is explored through the case of Zambia's 5-year Community Health Strategy (CH Strategy), formulated in 2017 and then summarily withdrawn and reissued two years later, with largely similar content. This paper examines the events, actors, and contexts behind this abrupt change in the Strategy, through an analysis of documentary sources and interviews with 21 stakeholders involved in the policy process. We describe an environment of contestation, characterised by numerous international partners weighing in on the CH Strategy, interfacing with shifting loci of responsibility for the CHS in the Ministry of Health (MoH). Despite the rhetoric of participation, providers and communities played no part in the policy process. These dynamics created the conditions for the abrupt change in strategy, illustrating the inherently fraught and political nature of policy development on the CHS in many countries. Going forward, we conclude that paying attention to processes of CHS policy development, and in particular the interaction between events, actors, and contexts, is as important as ensuring meaningful policy content.

Community and health provider perspectives on the quality of family planning and contraceptive services in Kabwe District, Zambia.

Quality family planning and contraceptive (FP/C) services result in positive outcomes such as client satisfaction and sustained use of contraceptives. While most assessments of quality in FP/C services are based on measurable reproductive health outcomes, there is limited consideration of the perspectives and experiences of health providers and community members. This study aimed to address this knowledge gap, by exploring health providers' and community perspectives on the elements of quality FP/C services in Kabwe district, Zambia. Fourteen focus group discussions and 10 in-depth interviews were conducted in October-December 2016, involving community members, key community stakeholders such as religious and political leaders, health committee members and frontline and managerial healthcare providers. Data were analysed using a thematic approach. According to study participants, quality FP/C services would include provision by skilled personnel with positive attitudes towards clients, availability of preferred methods and affordable products. Additional factors included appropriate infrastructure, especially counselling services spaces and adequate consultation time. Participants stressed the need for reduced waiting time and opportunity for self-expression. The efficiency and effectiveness of service delivery factors, such as information dissemination and community engagement, were also considered important elements of quality FP/C. This study underscores the value of considering both community and health provider perspectives in efforts to improve the quality of FP/C services, with the overall aim of increasing client satisfaction and sustained utilisation. However, service delivery processes must also be addressed in addition to providing for community participation, if quality is to be achieved in FP/C services.

A critical discourse analysis of adolescent fertility in Zambia: a postcolonial perspective.

BACKGROUND: Despite global and regional policies that promote the reduction of adolescent fertility through ending early marriages and reducing early child-bearing, adolescent fertility remains high in most sub-Saharan countries. This study aimed to explore the competing discourses that shape adolescent fertility control in Zambia. METHODS: A qualitative case study design was adopted, involving 33 individual interviews and 9 focus group discussions with adolescents and other key-informants such as parents, teachers and policymakers. Thematic and critical discourse analysis were used to analyze the data. RESULTS: Adolescents' age significantly reduced their access to Sexual and Reproductive Health, SRH services. Also, adolescent fertility discussions were influenced by marital norms and Christian beliefs, as well as health and rights values. While early marriage or child-bearing was discouraged, married adolescents and adolescents who had given birth before faced fewer challenges when accessing SRH information and services compared to their unmarried or nulliparous counterparts. Besides, the major influencers such as parents, teachers and health workers were also conflicted about how to package SRH information to young people, due to their varying roles in the community. CONCLUSION: The pluralistic view of adolescent fertility is fueled by "multiple consciousnesses". This is evidenced by the divergent discourses that shape adolescent fertility control in Zambia, compounded by the disempowered position of adolescents in their communities. We assert that the competing moral worlds, correct in their own right, viewed within the historical and social context unearth significant barriers to the success of interventions targeted towards adolescents' fertility control in Zambia, thereby propagating the growing problem of high adolescent fertility. This suggests proactive consideration of these discourses when designing and implementing adolescent fertility interventions.

From science to sustainable systems: Evidence based-decision making for adolescent fertility in Zambia.

Adolescent fertility is a global health and sustainable development indicator, and requires robust information systems for priority setting and decision-making to control. Evidence-based decision making for health stresses the use of scientific objective data and methodologies, which typically sieve out the more contextually understood social and economic factors that impact health. Main Text: The rising adolescent fertility rates in Zambia warrant the use of robust information systems for planning and resource allocation. In addition to the shortage of information on adolescent health in general, the existing information systems are limited. Sustainable information systems require an investment in data collection that transcends the existing and heavily relied on quantitative evidence base on adolescent sexual and reproductive health, arguing for the need to include data generated through qualitative and participatory methodologies, generating a more holistic understanding of health phenomena. Conclusion: There is a need to collect data on adolescent fertility using alternative methods to make decisions that work for adolescents.

Facilitating community participation in family planning and contraceptive services provision and uptake: community and health provider perspectives.

BACKGROUND: Although community participation has been identified as being important for improved and sustained health outcomes, designing and successfully implementing it in large scale public health programmes, including family planning and contraceptive (FP/C) service provision, remains challenging. Zambian participants in a multi-country project (the UPTAKE project) took part in the development of an intervention involving community and healthcare provider participation in FP/C services provision and uptake. This study reports key thematic areas identified by the study participants as critical to facilitating community participation in this intervention. METHODS: This was an exploratory qualitative research study, conducted in Kabwe District, Central Province, in 2017. Twelve focus group discussions were conducted with community members (n = 114), two with healthcare providers (n = 19), and ten in-depth interviews with key community and health sector stakeholders. Data were analyzed using a thematic analysis approach. RESULTS: Four thematic categories were identified by the participants as critical to facilitating community participation in FP/C services. Firstly, accountability in the recruitment of community participants and incorporation of community feedback in FP/C. programming. Secondly, engagement of existing community resources and structures in FP/C services provision. Thirdly, building trust in FP/C methods/services through credible community-based distributors and promotion of appropriate FP/C methods/services. Fourthly, promoting strategies that address structural failures, such as the feminisation of FP/C services and the lack FP/C services that are responsive to adolescent needs. CONCLUSIONS: Understanding and considering community members' and healthcare providers' views regarding contextualized and locally relevant participatory approaches, facilitators and challenges to participation, could improve the design, implementation and success of participatory public health programmes, including FP/C.