Abstract
Various global policies have complemented the call from within the NTD community for greater integration by vertical programs. However, a review of the existing literature has shown minimal evidence of the pathways to achieving this policy shift and the implications for health systems and their resilience.In 2016, the NTD Programme in Liberia decided to address the fragmentation and inequity of access to NTD care by developing a novel “Strategic plan for the integrated case management of Neglected Tropical Diseases, 2016 – 2020”. The implementation model outlined in the plan was an integrated health system-based approach that included the mainstreaming of NTDs in multiple health systems elements such as the supply chain, health management information system and disease surveillance.
Multiple chronic stressors and acute shocks have impacted the policy development and implementation to date. At the same time, there is a global impetus behind scaling an integrated model for the case management of NTDs, with close attention to the Liberia model. Through this PhD, I analyse the development and implementation of the integrated NTD Policy in Liberia and its implications for broader health system resilience.
My thesis has four main components. I begin with an analysis of the policy's development and translation process. I explore Liberia's efforts to integrate NTD case management into crucial health system components from the perspectives of multiple stakeholders engaged in the policy process. I employ a qualitative case study design to examine stakeholder experiences and perspectives, utilising multiple analytical frameworks, including the Policy Analysis Triangle, the Power Cube and Network Analysis. Drawing on the literature and my policy analysis, I propose a conceptual framework that identifies key factors in effective health policy development and implementation across five critical domains: people, place, process, politics and power. These five domains are interconnected, dynamic and essential for translating complex health policies into practice. The findings emphasise the need for health policies to embrace the complexities of integrating disease control programmes, calling for a shift from biomedical-focused to multi dimensional and multi-stakeholder approaches and policies. These insights contribute evidence for effective global health policy development, underscoring the importance of contextually relevant and inclusive approaches to address health inequities and strengthen system sustainability.
I, then, interrogate the chronic and acute pressures on integrating NTD services within Liberia's health system and assess the integrated model's contribution to enhancing health system 3 resilience. I frame the integration of NTD services within the broader discourse on health system resilience. I use a single case study design and reflexive thematic analysis, which enables an intensive, in-depth investigation into the experiences and perceptions of those directly involved in the integrated NTD Programme's development, implementation, and resilience. Findings indicate that integration has played a pivotal role in enhancing the everyday resilience of NTD services against ongoing challenges, improving governance and accountability, engaging communities and reorienting the model of care towards a more people-centred approach. The findings also demonstrate that the strategies employed to improve everyday resilience to chronic pressures contribute to broader health system resilience to acute crises.
I propose a framework linking key resilience factors to strategies to increase everyday resilience within health system-based models of NTD care. This framework offers valuable lessons for policymakers and health system stakeholders on adopting integrated and people-centred health services to navigate routine and acute crises effectively.
Thirdly, based on the findings from my thematic framework analysis of the data and the application of elements of power analysis, I examine the opportunities for broader adoption of an integrated health systems-based approach to ending Neglected Tropical Diseases. I explore the transformation needed globally to transition from a siloed approach to NTDs to a model that leverages the benefits of integration and greater collaboration, as outlined in the NTD roadmap 2021 - 2030 (World Health Organization, 2021a). The findings show the multiple impacts of existing structures, systems, norms and practices within the NTD sector on implementing an integrated model of NTDs in eight impact areas (1. Structures, categories and organisation; 2. Policy ecosystem; 3. Measuring Success; 4. Funding structures and agenda setting; 5. Organisational histories, cultures and identities; 6. Power and reflexive praxis; 7. Coordination, clarity and collaboration; and 8. Learning, knowledge exchange and space to complain). The findings also show the critical impact of power and inequity throughout all eight impact areas. My analysis leads me to recommend possible policy options and strategies within each impact area that will mediate and redistribute the multiple manifestations of power and create a significantly more enabling environment for a sustainable national NTD response.
Finally, I have developed a theory of change for the optimal policy development and implementation of equitable and integrated NTD services into resilient health systems. I have identified three key domains of change: 1) policy, 2) practice and 3) context; and five values and principles that are thematic across the domains of change: 1) politics matters in Neglected 4 Tropical Diseases, 2) leadership, ownership, human and political capital, 3) health systems software, 4) trust and time and 5) multisectoral collaboration.
In conclusion, this thesis comprehensively analyses Liberia's integrated NTD policy. The research underscores the critical role of political dynamics and health systems software—values, norms, relationships—in shaping effective policies. These findings provide valuable insights for policymakers advocating multisectoral collaboration and equitable partnerships to advance NTD programs and health system integration in low-resource settings
| Date of Award | 1 Oct 2024 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | Laura Dean (Supervisor), Sally Theobald (Supervisor) & Sassy Molyneux (Supervisor) |