Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa

Abstract

BackgroundLack of political will is frequently invoked as a rhetorical tool to explain the gap between commitment and action for health reforms in sub-Saharan Africa (SSA). However, the concept remains vague, ill defined and risks being used as a scapegoat to actually examine what shapes reforms in a given context, and what to do about it. This study sought to go beyond the rhetoric of political will to gain a deeper understanding of what drives health reforms in SSA.MethodsWe conducted a scoping review using Arksey and O’Malley (2005) to understand the drivers of health reforms in SSA.ResultsWe reviewed 84 published papers that focused on the politics of health reforms in SSA covering the period 2002–2022. Out of these, more than half of the papers covered aspects related to health financing, HIV/AIDS and maternal health with a dominant focus on policy agenda setting and formulation. We found that health reforms in SSA are influenced by six; often interconnected drivers namely (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) policy diffusion.ConclusionPolitical will is relevant but insufficient to drive health reform in SSA. A framework of differential reform politics that considers how the power and beliefs of policy elites is likely to shape policies within a given context can be useful in guiding future policy analysis.

Understanding the factors affecting global political priority for controlling sexually transmitted infections: a qualitative policy analysis

“…The role of advocacy coalitions in global health is well described, particularly in the case of HIV and access to antiretroviral treatments. These coalitions derive power from their ability to bring together diverse stakeholders, leverage shared resources and create unified messages that resonate with policy-makers 58. The field of STI control currently, however, appears to lack such cohesive and coordinated efforts beyond congenital syphilis and HPV vaccines.…”

“…These coalitions derive power from their ability to bring together diverse stakeholders, leverage shared resources and create unified messages that resonate with policy-makers. 58 The field of STI control currently, however, appears to lack such cohesive and coordinated efforts beyond congenital syphilis and HPV vaccines. Initiatives to identify and engage with a range of stakeholders across civil society, reproductive health advocates, adolescent health champions, etc, are needed to foster a strong and successful advocacy movement for STI control.…”

Policy action points and approaches to promote fertility care in The Gambia: Findings from a mixed-methods study

“…However, a strong political commitment toward a specific health matter is not always the sole driver favoring prioritization and policy creation and/or reform. Other factors exist that can have equal or even stronger influence forming political commitment, including social and religious values, activism, and the desire of politicians to stay in power [ 26 ]. Those drivers may work with or against political will and can influence policymaking and policy reform.…”

Barriers and Opportunities for WHO "Best Buys" Non-communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review

“…Furthermore, it underscores the importance of learning from multiple unhealthy industries, considering their unique characteristics. 12 A deeper exploration of the drivers that influence political decisions, beyond the oversimplification of “political will,” such as neoliberalism’s impact on political decisions, 47 or the desire to win or stay in government, 48 is also recommended. Future research should explore the advancement of complexity methods to support NCDs policy processes and explicitly unravel power dynamics, especially concerning the CDoH.…”