Dalglish Sarah L, Surkan Pamela J, Diarra Aïssa, Harouna Abdoutan, Bennett Sara
Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health Baltimore, MD 21205, USA,
Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health Baltimore, MD 21205, USA.
Health Policy Plan. 2015 Dec;30 Suppl 2:ii84-ii94. doi: 10.1093/heapol/czv064.
Analyses of health policy in low- and middle-income countries frequently mention but rarely adequately explore power dynamics, whether or not the policy in question targets the poor. We present a case study in Niger of integrated community case management (iCCM), a policy to provide basic care for poor rural children sick with malaria, diarrhoea and pneumonia, which has contributed to measurable reductions in child mortality. We focus on the three dimensions of power in policymaking: political authority, financial resources and technical expertise. Data collection took place March to August 2012 and included semi-structured interviews with policy actors (N = 32), a document review (N = 103) and contextual analysis. Preliminary data analysis relied on process tracing methodology to examine why iCCM was prioritized and identify dimensions of power most relevant to the Nigerien case; we then applied theoretical categories deductively to our data. We find that political authorities, namely President Mamadou Tandja, created the underlying health infrastructure for the policy ('health huts') as a way to distribute rents from development aid through client networks while claiming the mantle of political legitimacy. Conditional influxes of financial resources created an incentive to declare fee exemptions for children below 5 years, a key condition for the policy's success. Technical expertise was concentrated among international actors from multi-lateral and bilateral agencies who packaged and delivered scientific arguments in support of iCCM to Nigerien policymakers, whose input was limited mainly to operational decisions. The Nigerien case sheds light on the dimensions of power in health policymaking, particularly in neo-patrimonial African regimes, and provides insights on how external actors can work within these contexts to promote pro-poor policies.
对低收入和中等收入国家卫生政策的分析经常提及权力动态，但很少进行充分探讨，无论所讨论的政策是否以贫困人口为目标。我们介绍了尼日尔综合社区病例管理（iCCM）的案例研究，这是一项为患有疟疾、腹泻和肺炎的农村贫困儿童提供基本护理的政策，该政策已使儿童死亡率显著降低。我们关注政策制定中权力的三个维度：政治权威、财政资源和技术专长。数据收集于2012年3月至8月进行，包括对政策行为者的半结构化访谈（N = 32）、文件审查（N = 103）和背景分析。初步数据分析依靠过程追踪方法来研究为何iCCM被列为优先事项，并确定与尼日尔案例最相关的权力维度；然后我们将理论类别演绎应用于我们的数据。我们发现，政治权威，即总统马马杜·坦贾，为该政策创建了基础卫生基础设施（“卫生小屋”），以此通过客户网络分配发展援助的租金，同时宣称拥有政治合法性。有条件的资金流入促使宣布对5岁以下儿童免除费用，这是该政策成功的关键条件。技术专长集中在多边和双边机构的国际行为者手中，他们整理并向尼日尔政策制定者提供支持iCCM的科学论据，而尼日尔政策制定者的投入主要限于运营决策。尼日尔案例揭示了卫生政策制定中权力的维度，特别是在新家长制的非洲政权中，并提供了关于外部行为者如何在这些背景下促进扶贫政策的见解。
