Effectiveness of a multi-country implementation-focused network on quality of care: Delivery of interventions and processes for improved maternal, newborn and child health outcomes.

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) aims to work through learning, action, leadership and accountability. We aimed to evaluate the effectiveness of QCN in these four areas at the global level and in four QCN countries: Bangladesh, Ethiopia, Malawi and Uganda. This mixed method evaluation comprised 2-4 iterative rounds of data collection between 2019-2022, involving stakeholder interviews, hospital observations, QCN members survey, and document review. Qualitative data was analysed using a coding framework developed from underlying theories on network effectiveness, behaviour change, and QCN proposed theory of change. Survey data capturing respondents' perception of QCN was analysed with descriptive statistics. The QCN global level, led by the WHO secretariat, was effective in bringing together network countries' governments and global actors via providing online and in-person platforms for communication and learning. In-country, various interventions were delivered in 'learning districts', however often separately by different partners in different locations, and pandemic-disrupted. Governance structures for quality of care were set-up, some preceding QCN, and were found to be stronger and better (though often externally) resourced at national than local levels. Awareness of operational plans and network activities differed between countries, was lower at local than national levels, but increased from 2019 to 2022. Engagement with, and value of, QCN was perceived to be higher in Uganda and Bangladesh than in Malawi or Ethiopia. Capacity building efforts were implemented in all countries-yet often dependent on implementing partners and donors. QCN stakeholders agreed 15 core monitoring indicators though data collection was challenging, especially for indicators requiring new or parallel systems. Accountability initiatives remained nascent in 2022. Global and national leadership elements of QCN have been most effective to date, with action, learning and accountability more challenging, partner or donor dependent, remaining to be scaled-up, and pandemic-disrupted.

The Health Justice Policy Tracker: COVID-19 Policies To Advance Health Justice For Vulnerable Populations.

The rapid spread of COVID-19 throughout the world in early 2020 created unprecedented challenges for national governments. Policies developed during the early months of the pandemic, before the first mRNA vaccines were authorized for emergency use, provide a window into national governments' prioritization of populations that were particularly vulnerable. We developed the COVID-19 Health Justice Policy Tracker to capture and categorize these policies using a health justice lens. In this article we present the results of a preliminary analysis of the tracker data. The tracker focuses on policies for six population groups: children, the elderly, people with disabilities, migrant workers, incarcerated people, and people who were refugees or were seeking political asylum. It includes 610 policies, most targeting children and the elderly and providing financial support. National governments also prioritized measures such as policies to ensure access to mental health care and social services, digital and teleservices, continuity of children's education, and food security. The tracker provides a resource for researchers and policy makers seeking model language and tested policy approaches to advance health justice during future crises.

Influences on policy-formulation, decision-making, organisation and management for maternal, newborn and child health in Bangladesh, Ethiopia, Malawi and Uganda: The roles and legitimacy of a multi-country network.

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) is intended to facilitate learning, action, leadership and accountability for improving quality of care in member countries. This requires legitimacy-a network's right to exert power within national contexts. This is reflected, for example, in a government's buy-in and perceived ownership of the work of the network. During 2019-2022 we conducted iterative rounds of stakeholder interviews, observations of meetings, document review, and hospital observations in Bangladesh, Ethiopia, Malawi, Uganda and at the global level. We developed a framework drawing on three models: Tallberg and Zurn which conceptualizes legitimacy of international organisations dependent on their features, the legitimation process and beliefs of audiences; Nasiritousi and Faber, which looks at legitimacy in terms of problem, purpose, procedure, and performance of institutions; Sanderink and Nasiritousi, to characterize networks in terms of political, normative and cognitive interactions. We used thematic analysis to characterize, compare and contrast institutional interactions in a cross-case synthesis to determine salient features. Political and normative interactions were favourable within and between countries and at global level since collective decisions, collaborative efforts, and commitment to QCN goals were observed at all levels. Sharing resources and common principles were not common between network countries, indicating limits of the network. Cognitive interactions-those related to information sharing and transfer of ideas-were more challenging, with the bi-directional transfer, synthesis and harmonization of concepts and methods, being largely absent among and within countries. These may be required for increasing government ownership of QCN work, the embeddedness of the network, and its legitimacy. While we find evidence supporting the legitimacy of QCN from the perspective of country governments, further work and time are required for governments to own and embed the work of QCN in routine care.

Global priority for the care of orphans and other vulnerable children: transcending problem definition challenges.

BACKGROUND: Tens of millions of children lack adequate care, many having been separated from or lost one or both parents. Despite the problem's severity and its impact on a child's lifelong health and wellbeing, the care of vulnerable children-which includes strengthening the care of children within families, preventing unnecessary family separation, and ensuring quality care alternatives when reunification with the biological parents is not possible or appropriate-is a low global priority. This analysis investigates factors shaping the inadequate global prioritization of the care of vulnerable children. Specifically, the analysis focuses on factors internal to the global policy community addressing children's care, including how they understand, govern, and communicate the problem. METHODS: Drawing on agenda setting scholarship, we triangulated among several sources of data, including 32 interviews with experts, as well as documents including peer-reviewed literature and organizational reports. We undertook a thematic analysis of the data, using these to create a historical narrative on efforts to address children's care, and specifically childcare reform. RESULTS: Divisive disagreements on the definition and legitimacy of deinstitutionalization-a care reform strategy that replaces institution-based care with family-based care-may be hindering priority for children's care. Multiple factors have shaped these disagreements: a contradictory evidence base on the scope of the problem and solutions, divergent experiences between former Soviet bloc and other countries, socio-cultural and legal challenges in introducing formal alternative care arrangements, commercial interests that perpetuate support for residential facilities, as well as the sometimes conflicting views of impacted children, families, and the disability community. These disagreements have led to considerable governance and positioning difficulties, which have complicated efforts to coordinate initiatives, precluded the emergence of leadership that proponents universally trust, hampered the engagement of potential allies, and challenged efforts to secure funding and convince policymakers to act. CONCLUSION: In order to potentially become a more potent force for advancing global priority, children's care proponents within international organizations, donor agencies, and non-governmental agencies working across countries will need to better manage their disagreements around deinstitutionalization as a care reform strategy.

Small vulnerable newborns-big potential for impact.

Despite major achievements in child survival, the burden of neonatal mortality has remained high and even increased in some countries since 1990. Currently, most neonatal deaths are attributable to being born preterm, small for gestational age (SGA), or with low birthweight (LBW). Besides neonatal mortality, these conditions are associated with stillbirth and multiple morbidities, with short-term and long-term adverse consequences for the newborn, their families, and society, resulting in a major loss of human capital. Prevention of preterm birth, SGA, and LBW is thus critical for global child health and broader societal development. Progress has, however, been slow, largely because of the global community's failure to agree on the definition and magnitude of newborn vulnerability and best ways to address it, to frame the problem attractively, and to build a broad coalition of actors and a suitable governance structure to implement a change. We propose a new definition and a conceptual framework, bringing preterm birth, SGA, and LBW together under a broader umbrella term of the small vulnerable newborn (SVN). Adoption of the framework and the unified definition can facilitate improved problem definition and improved programming for SVN prevention. Interventions aiming at SVN prevention would result in a healthier start for live-born infants, while also reducing the number of stillbirths, improving maternal health, and contributing to a positive economic and social development in the society.

Why 'elevating country voice' is not decolonizing global health: A frame analysis of in-depth interviews.

Recent calls for global health decolonization suggest that addressing the problems of global health may require more than 'elevating country voice'. We employed a frame analysis of the diagnostic, prognostic, and motivational framings of both discourses and analyzed the implications of convergence or divergence of these frames for global health practice and scholarship. We used two major sources of data-a review of literature and in-depth interviews with actors in global health practice and shapers of discourse around elevating country voice and decolonizing global health. Using NVivo 12, a deductive analysis approach was applied to the literature and interview transcripts using diagnostic, prognostic and motivational framings as themes. We found that calls for elevating country voice consider suppressed low- and middle-income country (LMIC) voice in global health agenda-setting and lack of country ownership of health initiatives as major problems; advancing better LMIC representation in decision making positions, and local ownership of development initiatives as solutions. The rationale for action is greater aid impact. In contrast, calls for decolonizing global health characterize colonialityas the problem. Its prognostic framing, though still in a formative stage, includes greater acceptance of diversity in approaches to knowledge creation and health systems, and a structural transformation of global health governance. Its motivational framing is justice. Conceptually and in terms of possible outcomes, the frames underlying these discourses differ. Actors' origin and nature of involvement with global health work are markers of the frames they align with. In response to calls for country voice elevation, global health institutions working in LMICs may prioritize country representation in rooms near or where power resides, but this falls short of expectations of decolonizing global health advocates. Whether governments, organizations, and communities will sufficiently invest in public health to achieve decolonization remains unknown and will determine the future of the call for decolonization and global health practice at large.

Understanding resilience, self-reliance and increasing country voice: a clash of ideologies in global health.

BACKGROUND: 'Resilience', 'self-reliance' and 'increasing country voice' are widely used terms in global health. However, the terms are understood in diverse ways by various global health actors. We analyse how these terms are understood and why differences in understanding exist. METHODS: Drawing on scholarship concerning ideology, framing and power, we employ a case study of a USAID-sponsored suite of awards called MOMENTUM. Applying a meta-ethnographic approach, we triangulate data from peer-reviewed and grey literature, as well as 27 key informant interviews with actors at the forefront of shaping these discourses and those associated with MOMENTUM, working in development agencies, implementing organisations, low-income and middle-income country governments, and academia. RESULTS: The lack of common understanding of these three terms is in part a result of differences in two perspectives in global health-reformist and transformational-which are animated by fundamentally different ideologies. Reformists, reflecting neoliberal and liberal democratic ideologies, largely take a technocratic approach to understanding health problems and advance incremental solutions, working within existing global and local health systems to effect change. Transformationalists, reflecting threads of neo-Marxist ideology, see the problems as inherently political and seek to overhaul national and global systems and power relations. These ideologies shape differences in how actors define the problem, its solutions and attribute responsibility, resulting in nuanced differences among global health actors in their understanding of resilience, self-reliance and increasing country voice. CONCLUSIONS: Differences in how these terms are employed and framed are not just linguistic; the language that is used is reflective of underlying ideological differences among global health actors, with implications for the way programmes are designed and implemented, the knowledge that is produced and engagement with stakeholders. Laying these distinct ideologies bare may be crucial for managing actor differences and advancing more productive discussions and actions towards achieving global health equity.

Framing and the formation of global health priorities.

Health issues vary in the amount of attention and resources they receive from global health organisations and national governments. How issues are framed could shape differences in levels of priority. We reviewed scholarship on global health policy making to examine the role of framing in shaping global health priorities. The review provides evidence of the influence of three framing processes-securitisation, moralisation, and technification. Securitisation refers to an issue's framing as an existential threat, moralisation as an ethical imperative, and technification as a wise investment that science can solve. These framing processes concern more than how issues are portrayed publicly. They are socio-political processes, characterised by contestation among actors in civil society, government, international organisations, foundations, and research institutions. These actors deploy various forms of power to advance particular frames as a means of securing attention and resources for the issues that concern them. The ascription of an issue as a security concern, an ethical imperative, or a wise investment is historically contingent: it is not inevitable that any given issue will be framed in one or more of these ways. A health issue's inherent characteristics-such as the lethality of a pathogen that causes it-also shape these ascriptions, but do not fully determine them. Although commonly facing resistance, global health elites often determine which frames prevail, raising questions about the legitimacy of priority-setting processes. We draw on the review to offer ideas on how to make these processes fairer than they are at present, including a call for democratic representation even as necessary space is preserved for elite expertise.

The emergence of political priority for addressing child sexual abuse in the United Kingdom.

BACKGROUND: Child sexual abuse (CSA) is widespread. Few countries, however, prioritize the issue. The United Kingdom is an exception, ranked first in its response to the issue in a 2019 country comparison. In 2015, Prime Minister David Cameron designated the issue one of three national threats. Funding commitments and policies to address CSA followed. OBJECTIVE: To investigate how CSA emerged as a national political priority in the United Kingdom, and to identify insights for proponents seeking to advance priority for addressing the issue. PARTICIPANTS AND SETTING: Documents were analyzed and semi-structured interviews conducted with actors in the United Kingdom central to CSA advocacy, research, and/or programming, as well as with policymakers. METHODS: Drawing on the multiple streams public policy model, a thematic analysis was conducted on collected documents (n = 160) and 21 interview transcripts. RESULTS: Our analysis delineates three critical developments that led to national prioritization for addressing CSA. First, high-profile scandals and the re-framing of CSA survivors as deserving of support raised public awareness of the problem. Second, champions concerned with CSA developed evidence-based and politically-feasible solutions. Third, the Prime Minister's concern and other political developments opened a policy window. CONCLUSIONS: The case provides insights for proponents on generating political priority for addressing CSA. Proponents need to (1) ensure survivors are not seen as culpable but rather as deserving of support, (2) be ready with solutions and (3) cultivate high-level political support, so that when policy windows open they can jump to push the issue onto the national agenda.

Understanding factors impacting global priority of emergency care: a qualitative policy analysis.

INTRODUCTION: The high burden of emergency medical conditions has not been met with adequate financial and political prioritisation especially in low and middle-income countries. We examined the factors that have shaped the priority of global emergency care and highlight potential responses by emergency care advocates. METHODS: We conducted semistructured interviews with key experts in global emergency care practice, public health, health policy and advocacy. We then applied a policy framework based on political ethnography and content analysis to code for underlying themes. RESULTS: We identified problem definition, coalition building, paucity of data and positioning, as the main challenges faced by emergency care advocates. Problem definition remains the key issue, with divergent ideas on what emergency care is, should be and what solutions are to be prioritised. Proponents have struggled to portray the urgency of the issue in a way that commands action from decision-makers. The lack of data further limits their effectiveness. However, there is much reason for optimism given the network's commitment to the issue, the emerging leadership and the existence of policy windows. CONCLUSION: To improve global priority for emergency care, proponents should take advantage of the emerging governance structure and build consensus on definitions, generate data-driven solutions, find strategic framings and engage with non-traditional allies.

Regulatory Resistance? Narratives and Uses of Evidence around "Black Market" Provision of Gambling during the British Gambling Act Review.

Commercial gambling is increasingly viewed as being part of the unhealthy commodities industries, in which products contribute to preventable ill-health globally. Britain has one of the world's most liberal gambling markets, meaning that the regulatory changes there have implications for developments elsewhere. A review of the British Gambling Act 2005 is underway. This has generated a range of actions by the industry, including mobilising arguments around the threat of the "black market". We critically explore industry's framing of these issues as part of their strategy to resist regulatory change during the Gambling Act review. We used a predefined review protocol to explore industry narratives about the "black market" in media reports published between 8 December 2020 and 26 May 2021. Fifty-five articles were identified and reviewed, and themes were narratively synthesised to examine industry framing of the "black market". The black market was framed in terms of economic threat and loss, and a direct connection was made between its growth and increased regulation. The articles mainly presented gambling industry perspectives uncritically, citing industry-generated evidence (n = 40). Industry narratives around the "black market" speak to economically and emotionally salient concerns: fear, safety, consumer freedom and economic growth. This dominant framing in political, mainstream and industry media may influence political and public opinion to support the current status quo: "protecting" the existing regulated market rather than "protecting" people. Debates should be reframed to consider all policy options, especially those designed to protect public health.

A global priority: addressing violence against children.

OBJECTIVE: To determine the reasons for the lack of priority given to addressing violence against children, and to identify the challenges that proponents must address to improve prioritization of this issue. METHODS: We reviewed relevant literature to identify experts to interview. We carried out a thematic analysis of the literature and interview transcripts. We iteratively developed data coding on the many characteristics of violence against children, on the framing of the issue by proponents, and on the problem of governance - that is, how proponents organize themselves for collective action. FINDINGS: The analysis of our data sources reveals many obstacles for global prioritization of addressing violence against children, including the forms of violence considered, inadequate data to describe prevalence and a lack of evidence of the effectiveness of proposed solutions. There exists fundamental disagreement among proponents on the recently introduced frame of violence against children, including differences in the types of violence that should be prioritized and in the proposed solutions (e.g. prevention or remediation). On governance, competition between networks focused on specific forms of violence is hampering efforts to create strong governing institutions. CONCLUSION: Despite the complex challenges identified, proponents have made some progress in global prioritization of addressing violence against children. To improve this prioritization further, proponents must resolve framing tensions and strengthen governance mechanisms to promote shared goals, while ensuring that networks focused on particular forms of violence are able to maintain their distinct identities.

The rise and fall of global health issues: an arenas model applied to the COVID-19 pandemic shock.

BACKGROUND: The global health agenda is ill-defined as an analytical construct, complicating attempts by scholars and proponents to make claims about the agenda status of issues. We draw on Kingdon's definition of the agenda and Hilgartner and Bosk's public arenas model to conceptualize the global health agenda as those subjects or problems to which collectivities of actors operating nationally and globally are paying serious attention at any given time. We propose an arenas model for global health agenda setting and illustrate its potential utility by assessing priority indicators in five arenas, including international aid, pharmaceutical industry, scientific research, news media and civil society. We then apply the model to illustrate how the status of established (HIV/AIDS), emergent (diabetes) and rising (Alzheimer's disease) issues might be measured, compared and change in light of a pandemic shock (COVID-19). RESULTS: Coronavirus priority indicators rose precipitously in all five arenas in 2020, reflecting the kind of punctuation often caused by focusing events. The magnitude of change varied somewhat by arena, with the most pronounced shift in the global news media arena. Priority indicators for the other issues showed decreases of up to 21% and increases of up to 41% between 2019 and 2020, with increases suggesting that the agenda for global health issues expanded in some arenas in 2020- COVID-19 did not consistently displace priority for HIV/AIDS, diabetes or Alzheimer's disease, though it might have for other issues. CONCLUSIONS: We advance an arenas model as a novel means of addressing conceptual and measurement challenges that often undermine the validity of claims concerning the global health agenda status of problems and contributing causal factors. Our presentation of the model and illustrative analysis lays the groundwork for more systematic investigation of trends in global health agenda setting. Further specification of the model is needed to ensure accurate representation of vital national and transnational arenas and their interactions, applicability to a range of disease-specific, health systems, governance and policy issues, and sensitivity to subtler influences on global health agenda setting than pandemic shocks.

Challenges to Establish Effective Public-Private Partnerships to Address Malnutrition in All Its Forms.

BACKGROUND: Every country is affected by some form of malnutrition. Some governments and nutrition experts look to public-private partnerships (PPPs) to address the burden of malnutrition. However, nutrition-related PPPs face opposition, are difficult to form, and there is limited evidence of their effectiveness. METHODS: We conducted a literature review and 30 semi-structured interviews with individuals involved in or researching nutrition-related PPPs to identify the factors that shape their creation and effectiveness in food systems. RESULTS: Several factors make it difficult to establish nutrition-related PPPs in food systems: a lack of understanding of the causal pathways behind many nutrition problems; a weak architecture for the global governance of nutrition; power imbalances between public and private sector nutrition actors; and disagreements in the nutrition community on the advisability of engaging the private sector. These complexities in turn make it difficult for PPPs to be effective once established due to goal ambiguity and misalignment, resource imbalances, and weak accountability. CONCLUSION: If effective nutrition-related PPPs are to be established, private sector conflicts of interest must be addressed, trust deficits between private and public sector actors must be surmounted, and evidence must be assessed as to whether PPPs can achieve more for public health nutrition than private and public sector actors working separately.