Holy grail or convenient excuse? Stakeholder perspectives on the role of health system strengthening evaluation in global health resource allocation.

BACKGROUND: The role of evaluation evidence in guiding health systems strengthening (HSS) investments at the global-level remains contested. A lack of rigorous impact evaluations is viewed by some as an obstacle to scaling resources. However, others suggest that power dynamics and knowledge hierarchies continue to shape perceptions of rigor and acceptability in HSS evaluations. This debate has had major implications on HSS resource allocation in global-level funding decisions. Yet, few studies have examined the relationship between HSS evaluation evidence and prioritization of HSS. In this paper, we explore the perspectives of key global health stakeholders, specifically around the nature of evidence sought regarding HSS and its potential impact on prioritization, the challenges in securing such evidence, and the drivers of intra- and inter-organizational divergences. We conducted a stakeholder analysis, drawing on 25 interviews with senior representatives of major global health organizations, and utilized inductive approaches to data analysis to develop themes. RESULTS: Our analysis suggests an intractable challenge at the heart of the relationship between HSS evaluations and prioritization. A lack of evidence was used as a reason for limited investments by some respondents, citing their belief that HSS was an unproven and potentially risky investment which is driven by the philosophy of HSS advocates rather than evidence. The same respondents also noted that the 'holy grail' of evaluation evidence that they sought would be rigorous studies that assess the impact of investments on health outcomes and financial accountability, and believed that methodological innovations to deliver this have not occurred. Conversely, others held HSS as a cross-cutting principle across global health investment decisions, and felt that the type of evidence sought by some funders is unachievable and not necessary - an 'elusive quest' - given methodological challenges in establishing causality and attribution. In their view, evidence would not change perspectives in favor of HSS investments, and evidence gaps were used as a 'convenient excuse'. Respondents raised additional concerns regarding the design, dissemination and translation of HSS evaluation evidence. CONCLUSIONS: Ongoing debates about the need for stronger evidence on HSS are often conducted at cross-purposes. Acknowledging and navigating these differing perspectives on HSS evaluation may help break the gridlock and find a more productive way forward.

A stakeholder analysis to prepare for real-world evaluation of integrating artificial intelligent algorithms into breast screening (PREP-AIR study): a qualitative study using the WHO guide.

BACKGROUND: The national breast screening programme in the United Kingdom is under pressure due to workforce shortages and having been paused during the COVID-19 pandemic. Artificial intelligence has the potential to transform how healthcare is delivered by improving care processes and patient outcomes. Research on the clinical and organisational benefits of artificial intelligence is still at an early stage, and numerous concerns have been raised around its implications, including patient safety, acceptance, and accountability for decisions. Reforming the breast screening programme to include artificial intelligence is a complex endeavour because numerous stakeholders influence it. Therefore, a stakeholder analysis was conducted to identify relevant stakeholders, explore their views on the proposed reform (i.e., integrating artificial intelligence algorithms into the Scottish National Breast Screening Service for breast cancer detection) and develop strategies for managing 'important' stakeholders. METHODS: A qualitative study (i.e., focus groups and interviews, March-November 2021) was conducted using the stakeholder analysis guide provided by the World Health Organisation and involving three Scottish health boards: NHS Greater Glasgow & Clyde, NHS Grampian and NHS Lothian. The objectives included: (A) Identify possible stakeholders (B) Explore stakeholders' perspectives and describe their characteristics (C) Prioritise stakeholders in terms of importance and (D) Develop strategies to manage 'important' stakeholders. Seven stakeholder characteristics were assessed: their knowledge of the targeted reform, position, interest, alliances, resources, power and leadership. RESULTS: Thirty-two participants took part from 14 (out of 17 identified) sub-groups of stakeholders. While they were generally supportive of using artificial intelligence in breast screening programmes, some concerns were raised. Stakeholder knowledge, influence and interests in the reform varied. Key advantages mentioned include service efficiency, quicker results and reduced work pressure. Disadvantages included overdiagnosis or misdiagnosis of cancer, inequalities in detection and the self-learning capacity of the algorithms. Five strategies (with considerations suggested by stakeholders) were developed to maintain and improve the support of 'important' stakeholders. CONCLUSIONS: Health services worldwide face similar challenges of workforce issues to provide patient care. The findings of this study will help others to learn from Scottish experiences and provide guidance to conduct similar studies targeting healthcare reform. STUDY REGISTRATION: researchregistry6579, date of registration: 16/02/2021.

Risk factors and service gaps affecting a sustainable work: a qualitative multi-stakeholder analysis in the context of persons with acquired brain injury living in Switzerland.

INTRODUCTION: Along with the social and economic challenges posed by an aging society, creating work conditions that allow persons to stay healthy and work into old age has become a major task of Western societies. Retaining employment after returning to work is particularly difficult for individuals with a disability, as evidenced by the high rate of premature labor market dropout. Individuals with acquired brain injury (ABI) exemplify this challenge, as it often impairs cognitive, technical, and interpersonal abilities that are crucial in today's labor market. To effectively support these individuals, vocational integration practitioners require comprehensive knowledge of risk factors for premature labor market dropout and effective strategies for sustainable work. OBJECTIVE: This study aimed to identify perceived risk factors and related service gaps regarding sustainable work for people with ABI, as reported by affected individuals, employers, vocational integration professionals, and health professionals. METHODS: Secondary data analysis. Data that was originally collected through seven focus groups and two interviews with persons with ABI, 15 interviews with employers, and 13 interviews with vocational integration and health professionals in the context of the project 'Sustainable employment' was re-analysed thematically. RESULTS: Two major themes of risk factors were identified: (1) person-related factors (including the subthemes: post-ABI impairments; lack of understanding of post-ABI impairments; poor health management) and (2) environment-related factors (including the subthemes: challenges related to the service structure; insufficient knowledge and education about ABI; challenges at the workplace; difficulties in private life). While stakeholders noted the variety of the currently available services, they particularly pointed to the missing long-term monitoring and counseling services for persons with ABI following the initial return-to-work, reflecting a major challenge for sustainable work. An overarching gap related to the fragmentation of the service structure and the lack of case coordination along the working life. CONCLUSIONS: Multiple stakeholders emphasized the importance of empowering individuals, ensuring easy access to professional support, and providing a suitable work environment to address key risk factors and facilitate sustainable work for individuals with ABI. Continuous coaching, long-term monitoring and counseling following return-to-work, were identified as potential strategies to achieve these goals.

Identifying, categorising, and mapping actors involved in resilience in healthcare: a qualitative stakeholder analysis.

BACKGROUND: Resilience in healthcare is the capacity to adapt to challenges and changes to maintain high-quality care across system levels. While healthcare system stakeholders such as patients, informal carers, healthcare professionals and service managers have all come to be acknowledged as important co-creators of resilient healthcare, our knowledge and understanding of who, how, and in which contexts different stakeholders come to facilitate and support resilience is still lacking. This study addresses gaps in the research by conducting a stakeholder analysis to identify and categorise the stakeholders that are key to facilitating and sustaining resilience in healthcare, and to investigate stakeholder relationships relevant for the enactment of resilient healthcare systems. METHODS: The stakeholder analysis was conducted using a sample of 19 empirical research projects. A narrative summary was written for 14 of the projects, based on publicly available material. In addition, 16 individual interviews were undertaken with researchers from the same sample of 19 projects. The 16 interview transcripts and 14 narratives made up the data material of the study. Application of stakeholder analysis methods was done in three steps: a) identification of stakeholders; b) differentiation and categorisation of stakeholders using an interest/influence grid; and c) investigation and mapping of stakeholder relationships using an actor-linkage matrix. RESULTS: Identified stakeholders were Patients, Family Carers, Healthcare Professionals, Ward/Unit Managers, Service or Case Managers, Regulatory Investigators, Policy Makers, and Other Service Providers. All identified stakeholders were categorised as either 'Subjects', 'Players', or 'Context Setters' according to their level of interest in and influence on resilient healthcare. Stakeholder relationships were mapped according to the degree and type of contact between the various groups of stakeholders involved in facilitating resilient healthcare, ranging from 'Not linked' to 'Fully linked'. CONCLUSION: Family carers and healthcare professionals were found to be the most active groups of stakeholders in the enactment of healthcare system resilience. Patients, managers, and policy makers also contribute to resilience to various degrees. Relationships between stakeholder groups are largely characterised by communication and coordination, in addition to formal collaborations where diverse actors work together to achieve common goals.

Palliative care national plan implementation through stakeholder analysis.

BACKGROUND: National palliative care plans depend upon stakeholder engagement to succeed. Assessing the capability, interest, and knowledge of stakeholders is a crucial step in the implementation of public health initiatives, as recommended by the World Health Organisation. However, utilising stakeholder analysis is a strategy underused in public palliative care. OBJECTIVE: To conduct a stakeholder analysis characterising a diverse group of stakeholders involved in implementing a national palliative care plan in three rural regions of an upper-middle-income country. METHODS: A descriptive cross-sectional study design, complemented by a quantitative stakeholder analysis approach, was executed through a survey designed to gauge stakeholders' levels of interest and capability in relation to five fundamental dimensions of public palliative care: provision of services, accessibility of essential medicines, palliative care education, financial support, and palliative care vitality. Stakeholders were categorised as promoters (high-power, high-interest), latent (high-power, low-interest), advocates (low-power, high-interest), and indifferent (low-power and low-interest). Stakeholder self-perceived category and knowledge level were also assessed. RESULTS: Among the 65 surveyed stakeholders, 19 were categorised as promoters, 34 as advocates, 9 as latent, and 3 as indifferent. Stakeholders' self-perception of their category did not align with the results of the quantitative analysis. When evaluated by region and palliative care dimensions the distribution of stakeholders was nonuniform. Palliative care funding was the dimension with the highest number of stakeholders categorised as indifferent, and the lowest percentage of promoters. Stakeholders categorised as promoters consistently reported a low level of knowledge, regardless of the dimension, region, or their level of interest. CONCLUSIONS: Assessing the capability, interest, and knowledge of stakeholders is a crucial step when implementing public health initiatives in palliative care. It allows for a data-driven decision-making process on how to delegate responsibilities, administer financial resources, and establish governance boards that remain engaged and work efficiently.

Gender and non-communicable diseases in Mexico: a political mapping and stakeholder analysis.

BACKGROUND: Mexico and other low- and middle-income countries (LMICs) present a growing burden of non-communicable diseases (NCDs), with gender-differentiated risk factors and access to prevention, diagnosis and care. However, the political agenda in LMICs as it relates to health and gender is primarily focused on sexual and reproductive health rights and preventing violence against women. This research article analyses public policies related to gender and NCDs, identifying political challenges in the current response to women's health needs, and opportunities to promote interventions that recognize the role of gender in NCDs and NCD care in Mexico. METHODS: We carried out a political mapping and stakeholder analysis during July-October of 2022, based on structured desk research and interviews with eighteen key stakeholders related to healthcare, gender and NCDs in Mexico. We used the PolicyMaker V5 software to identify obstacles and opportunities to promote interventions that recognize the role of gender in NCDs and NCD care, from the perspective of the political stakeholders interviewed. RESULTS: We found as a political obstacle that policies and stakeholders addressing NCDs do not take a gender perspective, while policies and stakeholders addressing gender equality do not adequately consider NCDs. The gendered social and economic aspects of the NCD burden are not widely understood, and the multi-sectoral approach needed to address these aspects is lacking. Economic obstacles show that budget cuts exacerbated by the pandemic are a significant obstacle to social protection mechanisms to support those caring for people living with NCDs. CONCLUSIONS: Moving towards an effective, equity-promoting health and social protection system requires the government to adopt an intersectoral, gender-based approach to the prevention and control of NCDs and the burden of NCD care. Despite significant resource constraints, policy innovation may be possible given the willingness among some stakeholders to collaborate, particularly in the labour and legal sectors. However, care will be needed to ensure the implementation of new policies has a positive impact on both gender equity and health outcomes. Research on successful approaches in other contexts can help to identify relevant learnings for Mexico.

Fogging to combat dengue: factors influencing stakeholders' attitudes in Malaysia.

BACKGROUND: Fogging is a conventional technique used to combat Aedes mosquitoes and prevent dengue disease. It is often implemented in outbreak areas or areas harbouring a high density of Aedes mosquitoes. Currently, studies on stakeholders' attitudes towards fogging are still limited in number. Therefore, this study aims to assess Malaysian attitudes, and identify the predicting factors influencing such attitudes. METHODS: A validated instrument was used to interview 399 randomly selected respondents from the public (n = 202, 50.6%) and scientists (n = 197, 49.4%) in the Klang Valley region of Malaysia. The data were analysed using PLS-SEM involving Smart-PLS software. RESULTS: The results confirmed that stakeholder attitudes toward fogging should be viewed in terms of a multi-dimensional association. The stakeholders surveyed were highly positive with regard to the application of fogging to control dengue but professed moderate concerns as to associated risks. The PLS-SEM analyses demonstrated that the perceived benefit was the most important factor influencing attitudes, followed by trust in key players. CONCLUSIONS: This result provides a good insight from the perspective of education and unravels the underlying fundamentals of stakeholders' attitudes toward the fogging technique. The findings also provide a positive indicator to the responsible parties involved to continue the usage of this technique in conjunction with improvements with regard to its safety aspects, and possibly in combination with other environmental-friendly alternatives in order to achieve a healthy environment without dengue in Malaysia.

Capacity needs assessment and challenges for multisectoral implementation of nutrition in Burkina Faso: A guide for the formulation of a capacity development plan.

INTRODUCTION: Achieving nutritional goals depends on individual, organisational and environmental capacities. The aim of this study was to analyse and identify capacity gaps among the coordination platforms and networks, and the key technical institutions related to nutrition in Burkina Faso for a capacity development plan formulation. METHODS: Using the new Nutrition Capacity Framework developed by the United Nations Network, information were collected using the Nutrition Stakeholder Mapping and Analysis tool, and the Checklist for Capacity Areas. Capacity needs were analysed in terms of Human resource and infrastructure, functional, organisational, coordination and partnership, and financial and resource mobilisation. RESULTS: Limited human resource capacity in nutrition was highlighted in most cases by the structures, and the nutrition coordination structure and more than 4/5 of the technical structures are faced with the unavailability of working materials, tools and basic Internet connection. Only 10 among the 30 structures have a unit or service for exchange on nutrition, and only three of them have integrated nutrition actions. Shortfalls were noted in terms of functional, facilitation, communication and advocacy skills, as well as a weak diversification of resource mobilisation strategies. CONCLUSION: The use of the analytical framework helped to identify the gaps and to propose paths for capacity development. Efforts need to be strengthened, intensified, coordinated, monitored, evaluated and funded.

Informal E-Waste Flows in Montréal: Implications for Extended Producer Responsibility and Circularity.

Environmental agencies around the world have adopted policies to manage e-waste and reduce the negative environmental impacts associated with its collection, sorting, dismantling, and recycling. In many OECD countries, where adequate policies and processing technologies exist, those who manage extended producer responsibility programs claim performance challenges due to competition from various actors collecting and managing e-waste "under the radar". While the material and economic losses attributed to such informal activities have been estimated by previous research, a detailed understanding of who is involved in these activities, why and how they operate, and with what social and environmental impacts, is often lacking. Our research offers an in-depth investigation into Montréal's informal e-waste flows. Whereas e-waste research and advocacy posit a dichotomy between "formal" and "informal" e-waste flows, our research reveals a more nuanced situation, with no water-tight separation between these flows. Formal and informal flows are often blurred, and change over time; and many actors are involved in both formal and informal activities. We reveal mechanisms whereby actors inadvertently contribute to informal activities because of inadequate incentives, limited program scope, reuse, parts harvesting, and documentation issues. This nuanced understanding helps identify policy loopholes, program shortcomings, and strategies for more sustainable e-waste flows, taking account of more ambitious circularity objectives and a just transition.

Stakeholders analysis of COVID-19 management and control: a case of Iran.

BACKGROUND: The COVID-19 pandemic is a multi-faceted phenomenon with many political, economic and social consequences. Success in managing and controlling this pandemic depends on the coordinated efforts of many organizations and institutions. Therefore, this study aimed to identify and analyze the actors and stakeholders related to managing and controlling this pandemic in Iran. METHODS: This mix-method stakeholder analysis was conducted in 2021 nationwide as retrospectively. The purposive sampling method was applied when inviting eligible participants to participate in the study. Our study was conducted in two phases. In the qualitative phase, data were collected using a semi-structured interview. An interview guide was developed based on the WHO stakeholder analysis framework. In the quantitative phase, we used a questionnaire developed based on the study framework. Each question was scored on a 5-point Likert scale, with a score greater than 4 was considered as high, 3-4 was considered as moderate, and 1-3 was considered as low. Data were analyzed using framework analysis, WHO stakeholders' analysis framework and MENDELOW matrix. MAXQDA qualitative data analysis software Version 11 and Policy Maker software (Version. 4) were used for data analysis. RESULTS: A total of 48 stakeholders were identified. Ministry of Health (MoH), National Headquarters for Coronavirus Control (NHCC) had the highest participation level, high supportive position, and knowledge of the subject. The Parliament of Iran (PoI), Islamic Revolutionary Guard Corps (IRGC), and Islamic Republic of Iran Broadcasting (IRIB) had the highest power/influence during the Covid-19 epidemic. Only two stakeholders (6.06%) had high participation, and 18.18% had moderate participation. All stakeholders except for the NHCC and the MoH lacked appropriate knowledge of the subject. Furthermore, only three stakeholders (9.09%) had high power/influence. CONCLUSION: Given the multidimensional nature of Covid-19, most institutions and organizations were involved in managing this pandemic. Stakeholders with high power/authority and resources had a low/moderate participation level and a moderate supportive position. Moreover, organizations with a high supportive position and participation had low power/authority and resources to cope with COVID-19.

Palliative care stakeholders in Canada.

BACKGROUND: Improving access to palliative care for Canadians requires a focused collective effort towards palliative and end-of-life care advocacy and policy. However, evolution of modern palliative care in Canada has resulted in stakeholders working in isolation. Identification of stakeholders is an important step to ensure that efforts to improve palliative care are coordinated. The purpose of this analysis is to collectively identify, classify and prioritize stakeholders who made contributions to national palliative care policies in Canada. METHODS: A systematic grey literature search was conducted examining policy documents (i.e. policy reports, legislative bills, judicial court cases) in the field of palliative care, end-of-life care and medical assistance in dying, at the national level, over the last two decades. Organizations' names were extracted directly or derived from individuals' affiliations. We then classified stakeholders using an adapted classification approach and developed an algorithm to prioritize their contributions towards the publication of these documents. RESULTS: Over 800 organizations contributed to 115 documents (41 policy reports, 11 legislative, 63 judicial). Discussions regarding national palliative care policy over the last two decades peaked in 2016. Stakeholder organizations contributing to national palliative care policy conversations throughout this period were classified into six types broadly representative of society. The ranking algorithm identified the top 200 prioritized stakeholder organizations. CONCLUSIONS: Stakeholders from various societal sectors have contributed to national palliative care conversions over the past two decades; however, not all the stakeholder organizations engaged to the same extent. The information is useful when a need arises for increased collaboration between stakeholders and can be a starting point for developing more effective engagement strategies.

An evaluation of Turkey's health tourism policies using a social network analysis approach.

Despite the health tourism sector's rapid growth in the past decade due to globalisation, there is little research analysing countries' health tourism policies. This study aimed to examine the relationships between stakeholders in the health tourism sector in Turkey in the context of Turkey's health tourism policies. This study connects theory and practice in multidisciplinary sectors, including health, tourism, and business, through an evaluation of major issues from a health management perspective. Social network analysis was used to assess the role of 107 stakeholders in Ankara and determine the extent of weak and strong ties among them. Issues confronting these stakeholders and the obstacles they faced in practice were also identified. The study found that, the relevant stakeholders faced comprehensive sectoral deficiencies and issues in building positive relationships. Governmental stakeholders as policymakers need to develop effective strategies to improve stakeholder collaboration and encourage greater inclusiveness through better-targeted health tourism policies. The study contributes to social network theory, resource dependency theory, and stakeholder theory, and is, to our knowledge, the first study to use social network analysis to examine the role of stakeholders in the health tourism sector.

Qualitative Examination of Cooperative-Intelligent Transportation Systems in Cities to Facilitate Large-Scale Future Deployment.

The rate of urbanization in Europe is increasing rapidly. Traffic congestion has become one of the biggest challenges for cities. Additionally, thousands of people die each year in accidents on European roads. In addition, road transport is one of the biggest reasons for the increase in air pollution and greenhouse gases in Europe. To solve these problems, cooperative intelligent transport systems (C-ITS) have accelerated in Europe, after more than ten years of research and development. The European Commission has carried out significant work in this field in recent years and has prepared a strategy document for the deployment of C-ITS services in Europe. The Commission considers that C-ITS have significant potential in reducing the negative effects of road traffic and expects these systems to deploy rapidly in European cities. However, in order to achieve this, it is imperative to clearly identify the needs of cities in implementing and managing these systems, the extent to which these systems will respond to different mobility problems of the cities, and the important barriers to widespread deployment. This study focused on qualitatively examining the C-ITS deployment from the stakeholder perspective. The knowledge generated is useful to facilitate the large-scale future deployment of C-ITS.

Stakeholder Analysis on Ecosystem Services of Lake Manyara Sub-basin (Tanzania): How to Overcome Confounding Factors.

Ecosystem services are a telling concept to discuss the integrated management of natural resources, such as integrated water and soil, with non-academic stakeholders. Stakeholders have different perceptions regarding the management of various ecosystem services, which is challenging when aiming to develop and foster sustainable ecosystem management. We performed a stakeholder analysis as part of a social-ecological study in preparation of a decision support system for integrated water management within the Lake Manyara sub-basin (LMSB), Tanzania. The area includes a National Park and UNESCO Biosphere Reserve. A group discussion listed 26 stakeholders, categorized according to the sector, influence, and interest. The stakeholders were grouped into six functional categories: local Non-Governmental Organisations (NGOs), other civil society groups, Belgian and international NGOs, authorities, academics associated to international donors and the private sector. We empirically identified advantages, shortcomings and associated risks when performing a stakeholder analysis with an interest-influence matrix. Confounding factors may include, e.g., the omission of important stakeholders, a different understanding of 'influence' and 'interest', or the omission of fragile groups. Instead of 'low' or 'high' interest and influence, we propose the terms 'supportive', 'potentially supportive', 'unsupportive', 'not interested', 'low or no influence' and 'antagonistic'. Further, we consider stakeholders who directly extract resources from the social-ecological system (SES) as a separate category, because of their direct dependence and impact on the SES. This improved stakeholder analysis framework for developing decision support systems in water basins can contribute to better analysis, understanding and management of aquatic social-ecological systems in general.

Taking Responsible Innovation to China: The Dalian Port Development Case.

Responsible innovation (RI) is playing a progressively significant role in the developed countries of Europe and North America, but is not as often used as a framework for analysis in developing countries. This article describes how what we term latent or implicit RI was introduced to a large-scale technological project in China: the expansion of the deep-sea port in Dalian. This analysis first reviews the historical development of the port and summarizes the Chinese context since the Reform and Opening that began in the late 1970s. It provides a brief case study of a particular emergency containment pool construction project undertaken by Dalian Port (PDA), uses stakeholder analysis to evaluate the project, identifies key values influencing the work, and considers the extent to which it meets criteria set out in a specific four-dimensional RI methodological framework. We argue that although it does not use RI rhetoric, the PDA in effect practices latent RI which is also in fact becoming manifest. In conclusion we also consider some of the weaknesses of our argument and some ambiguities of RI.

Who influences nutrition policy space using international trade and investment agreements? A global stakeholder analysis.

BACKGROUND: Regulation of food environments is needed to address the global challenge of poor nutrition, yet policy inertia has been a problem. A common argument against regulation is potential conflict with binding commitments under international trade and investment agreements (TIAs). This study aimed to identify which actors and institutions, in different contexts, influence how TIAs are used to constrain policy space for improving food environments, and to describe their core beliefs, interests, resources and strategies, with the objective of informing strategic global action to preserve nutrition policy space. METHODS: We conducted a global stakeholder analysis applying the Advocacy Coalition Framework, based on existing academic literature and key informant interviews with international experts in trade and investment law and public health nutrition policy. RESULTS: We identified 12 types of actors who influence policy space in the food environment policy subsystem, relevant to TIAs. These actors hold various beliefs regarding the economic policy paradigm, the nature of obesity and dietary diseases as health problems, the role of government, and the role of industry in solving the health problem. We identified two primary competing coalitions: 1) a 'public health nutrition' coalition, which is overall supportive of and actively working to enact comprehensive food environment regulation; and 2) an 'industry and economic growth' focussed coalition, which places a higher priority on deregulation and is overall not supportive of comprehensive food environment regulation. The industry and economic growth coalition appears to be dominant, based on its relative power, resources and coordination. However, the public health nutrition coalition maintains influence through individual activism, collective lobbying and government pressure (e.g. by civil society), and expert knowledge generation. CONCLUSIONS: Our analysis suggests that industry and economic growth-focussed coalitions are highly capable of leveraging networks, institutional structures and ideologies to their advantage, and are a formidable source of opposition acting to constrain nutrition policy space globally, including through TIAs. Opportunities for global public health nutrition coalitions to strengthen their influence in the support of nutrition policy space include strategic evidence generation and coalition-building through broader engagement and capacity-building.

Integrated early childhood development policy in Iran: a stakeholder analysis.

BACKGROUND: Many stakeholders are involved in the complicated process of policy making in integrated early childhood development (IECD). In other words, there are many challenges for IECD policy making in developing countries, including Iran. The aim of this study was to identify potential stakeholders and their interactions in IECD policy making in Iran. METHOD: A mixed-methods study was conducted in two phases in 2018. First, forty semi-structured interviews and a review of IECD-related documents were conducted to identify potential stakeholders and their roles. Second, using a designed checklist, these stakeholders were assessed for power, interest, and position in IECD policy making. Then, a map of stakeholders and a three-dimensional stakeholder analysis figure were designed. RESULTS: The results of this study showed that various stakeholders, including governmental, semi-governmental, social, non-governmental and international organizations, potentially influence IECD policy in Iran. They were found to have diverse levels of power, interest and position in this regard, leading to their different impacts on the process. This diversity is assumed to have affected their levels of participation and support. Also, we found that the stakeholders with a high-power level do not have a high level of interest in, or support for, IECD policy. In general, organizational competition, complicated inter-sectoral nature of this process, insufficient budget, insufficient awareness about the importance of IECD, lack of priority given to IECD in relevant organizations, economical views rather than developmental perspectives, and lack of commitment among top managers are the reasons why this policy enjoys a low degree of support. CONCLUSIONS: There are weaknesses in effective interactions and relationships among IECD policy stakeholders. This will lead to the lack of equal opportunities for optimal early childhood development. To improve this process, advocacy from high-level authorities of the organizations, negotiation with child-friendly groups, establishing a body to coordinate and oversee children's affairs, using the capacity of non-governmental organizations, strengthening inter-sectoral collaboration by clarifying the roles and responsibilities of stakeholders and the relationships between them, and increasing public awareness can be helpful.

Pharmaceutical subsidy policy in Iran: a qualitative stakeholder analysis.

BACKGROUND: Over the past three decades, allocation of foreign currency subsidies has been the primary strategy of various administrations in Iran to improve access to medicines. This strategy has resulted in several challenges, including stakeholder conflicts of interest. OBJECTIVE: To identify the power, interest, and role of the stakeholders in allocating foreign currency subsidies to medicines in the Iranian health system. METHODS: In this qualitative study, 39 semi-structured interviews were conducted. Key informants were recruited using a purposive sampling technique. The theoretical framework adopted by Varvasovszky and Brugha was employed. The data were analysed using directed content analysis. RESULTS: The foreign currency subsidy for medicines included 21 stakeholders in five main categories: governmental organizations, Iranian Parliament, general population, nongovernmental organizations (NGOs), and the pharmaceutical industry. Stakeholders varied in their level of participation and support in the policy-making process. Among them, the Iranian Government, Planning and Budget Organization, the Ministry of Health and Medical Education (MoHME), and Iran Food and Drug Administration (IFDA) were the most important stakeholders, with highly supportive positions, while domestic drug manufacturers were the strongest opponents of this policy. The Government of Iran is the most powerful institution with regard to the ability to allocate foreign currency subsidies to medicines, followed by the MoHME and the IFDA. CONCLUSION: This study demonstrated that identifying and analysing the stakeholders involved in allocating foreign currency subsidies to medicines can provide valuable information for policy-makers to enable a more comprehensive understanding and better capacity to determine whether or not to eliminate these subsidies. Moreover, decision-making in this process is a long-term issue that requires consensus among all stakeholders. Because of the political and social consequences of eliminating foreign currency subsidies, the necessary political will is not institutionalized. We recommend a step-by-step approach in eliminating foreign currency subsidies if the requirements are met (i.e., those related to the consequences of such interventions). Therefore, revision of the current policy along with these requirements, in addition to financial transparency and enhanced efficiency, will facilitate progress towards achieving the Sustainable Development Goals by improving access to medicines.

HIV/AIDS policy-making in Iran: A stakeholder analysis.

INTRODUCTION: The present study aims to identify and analyze HIV/AIDS stakeholders in Iran. METHODS: This qualitative stakeholder analysis was conducted in 2018 nationwide, both retrospectively and prospectively. Purposive sampling was applied and followed by snowball sampling until data saturation. Data were analyzed using framework analysis. Also, MAXQDA (Version 11) and Policy Maker software (version 4) was applied. FINDINGS: A total of 44 stakeholders were identified and categorized into 23 active and 21 inactive stakeholders. The Ministry of Education and Iran Broadcasting have moderate participation in this regard. Supreme Council of Health and NGOs have low participation. The Ministry of Health (MoH), State Welfare Organization, Blood Transfusion Organization, and the State Prisons are interested in HIV/AIDS policymaking. The MoH is the main body responsible for the stewardship of HIV/AIDS in Iran but does not have enough authority to handle the issue. CONCLUSION: Considering multidimensional nature of HIV/AIDS, there are many stakeholders regarding HIV/AIDS control. The process of HIV/AIDS -policy making is fragmented in Iran. Despite multiple active and potential stakeholders in this field, there is no integrated system to involve all stakeholders in the process of HIV/AIDS policy-making. Therefore, given the importance of the issue, an upstream entity is needed to coordinate and mobilize all stakeholders associated with managing and controlling HIV/AIDS.

Environmental governance for sustainable development in Asia.

Because of the size of its population and economy, good environmental governance in Asia is fundamental not only for the well-being of the region's population but also for the health of the planet. This article introduces the challenges of governing the environment in Asia. The issue evaluates the outcomes and institutional changes in selected countries related to substantive environmental issues such as air pollution, water quality, municipal solid waste, transport, land use, and climate change. By synthesizing the main research issues, methodology and findings of the growing literature on the region, we highlight the trends in environmental governance and gaps in policy and research. Despite the efforts made, there are still remaining environmental governance challenges to be addressed by both the academics and practitioners in Asia.