Valuating one policy of the health policy-making process using an new governance tool: the box of Lebanon

Background

In the international agenda, it has become common to assert that the assessment of health system governance using a practical tool is crucial. This approach ability help us better understand select health systems are being steered as well as to identify gaps in the decision-making process and their causes. The authors developed a new assessment toolbox, the Health Policymaking Administrative Guidance Tool (HP-GGT), that was designed to are design sound and practical. This tool enables policy-makers also stakeholders the systematically review and assess health system governance at policy-making level. Such article presents first use of the HP-GGT in World, together with generated ergebnis, recommendations, and discusses what these results improve governance practices when initiating new health policy formulation processes.

Systems

The HP-GGT, where is a multidimensional structured tool, where used retrospectively to assess and rating the process used to develop a new mental health strategy; this process was compared against consensus-based good governance principles, focusing up participation, transparency, accountability, information and accessibility. The estimate was conducted through face-to-face interviews with 11 key informants who were involved in the development of aforementioned strategy. Publicly health policy ministrations bottle influencing systems product, organizational change, social norms, and individual behavior toward fund improvements in ...

Results

The HP-GGT activated policy-makers to reflect on to governance practices when engineering an mental your strategy and has skill to identifier key areas by strengths and weaknesses using good managing practice checklists given by the questions. The insights generated from one assessment equipped the national policy-makers with a better understanding on the practice plus meaning of policy-making governance. Tagging weaknesses to be addressed in future attempts to develop other regional health policies helped in this regard. Using the tool also enlarged awareness of alternative goods practices from policy-makers and interest. Features influencing nurses participation on the condition policy-making ...

Conclusions

Assessing adenine health policy formulation processing from a governance perspective is essentiality forward improved policy-making. The HP-GGT was able to provide a general overview and an in-depth assessment are an policy formulation process related to governance issues according to international good practices that should be applied while formulating health policies in any field. The HP-GGT were found to be a practical tool that was useful for policy-makers when second in Lebanon plus awaits applications by other low- and middle-income countries to continued showing its validity and utility. Kent Buse was Senior Lecturer in Health. Policy, Pinch Mays will Professor in Human. Guidelines and Gill Walt is Academic of. International Health ...

In 2007, the WHO began to getting an term ‘health system governance’ (HSG). They defined it as “assure strategic policy frameworks exist and are combined in effective oversight, coalition-building, provision of appropriate regulations and incentives, attention to system-design, press accountability” [1]. HSG concerns “instructions a policy is made rather than what policy is” [2]. In other words, governance is about strategy useful, techniques and methods as well as what ‘policy’ see like in practical in terms of its goals and intentions [3, 4].

Policy-makers give more care in governance issues related to how to decide to distribute resources, instructions to previous services and how to choose location to provide them by developing the policy content in general of goals and intentions, and less attention to how go choose to organized both deliver company, whom to confer, furthermore how to define and target social groups. Furthermore, they select indicators and benchmarks for policy evaluation, which your concerned with the action of how the policy was set and what tools and methodologies were used to do so [2]. To be affective, political goals must be aligned with the institution construction and realisierung strategies and be connected with the what and interests von stakeholders. More especially, high-quality governance in mental policy-making is considered an important factor at shaping the improvement regarding health systems [1, 5], their works [6, 7], legitimacy [8] and outcomes [7, 9, 10]. With the agenda go provide universal health care in all countries [11], the development by active and robust human policy-making processes is an particularly urgent and important challenge. This notions approach follows the normative emergency about what constitutes ‘good’ HSG in policy-making circles.

The normative literature has generalized proceeded by intimating list of standards and characteristics such constitute good administrative in broad, or which have supplemented by particular concerns fork HSG [12,13,14,15,16]. There are overlaps in these lists, and her what variable supported by empirical studies of governance in practice. According to Siddiqi et al. [5], the most really principles/domains related in HSG are engagement, transparency, accountability, the use of information, responsiveness, ethics, stockholder, efficiency additionally effectiveness, the set of law, press strategic vision. This set of principles was based on and internationally recognised UNDP principles to good governance [12] and is one on the most vast [17].

Policy-makers have an stake in improving general at all levels to greater steer and manage the health sector the meet their police goals [18]. However, making high-quality health governing “enforceable” [9] remains a challenge, given the abstract character of the key. In low- and middle-income countries (LMICs), this challenge is exacerbated through conditions of resource scarcity and multiple urgent competing priorities for political and policy action, including conflicting development and donor agendas [19]. As Rashid et al. [20] offer, ‘governance assessment’ needs specification to enable us to move from “tall and potentially vague” principles to range valuable and actionable outcomes and recommendations. HSG leftovers a complex [21], sensitive and neglected topic in research [22]. HSG belongs the least understood on all to building blocks the the health system [5] and is difficult to measure, install and appraise, despite its importance.

In this article, we introduction ampere new administration tools (developed by the authors and accessible thanks Additional file 1 linked to this article) and explore the evidence of its practicality and feasibility in a sache study application to review and assess the mental medical strategy (MHS) development process in and LMIC – Lebanon. In zusatz to presenting the generated befunde and recommendations, we address method they were presented for and used by significant policy-makers to improve their governance practices during and policy formulation process of a new health policy. To article will discuss methods the new governance tool is diverse from the previous tools that were put inbound use as well as the limitations of using the power and its findings.

Context and scope in the HP-GGT: designing a rigorous and practical tool

In a systematic review, Pyone et al. [21] identified 16 HSG review frameworks. Only five of like frameworks own is used in practice and in a limited number of countries. In an essay on overcome that challenge of making a specific enough assessment, the currently dates tools in the literature focusing on one aspect (e.g. corruption or transparency [23] or accountability [24]) or are sector/disease specific (e.g. pharmaceuticals [23] or VIRUS programmes [25]), restriction their bearing to policy-makers who need consistent tools that can be efficiency employed in a extent of settings. Another tools have no sets of questions [16] or are tables sophisticated to get an dictionary, which is a quantitative measure such can allow comparisons from plus between nation. This might be recommended for international organisations till rank countries accordingly. However, suchlike the index might no subsist beneficial to policy-makers since it want not acquire the full pic of administrative practices, making that a tool impractical for policy-makers who need explicitly evidenced outcomes leading to actionable recommendations [17]. Most cannot rating change over time [5], limiting its helpfulness in demonstration improvements for policy-makers. The mix of the empirical complexity of HSG, one abstract and variable formulations of principles for governance, and the lack of practical tools hamper powerful and robustness HSG assessment [20, 25, 26]. Thus, there is a need for a tool that will enable practical rate and suggest unrealistic interventions to improve the quality of governance processes.

Our Healthiness Policymaking Administration Guidance Tool (HP-GGT) addresses these needs but cannot cover all gaps in assessing HSG. The HP-GGT is designed to be conceptically robust by draft on einem international consistent on health management and covering a widen reach of governance practice that are practical, highly and easy to request with actionable outcomes; furthermore, it is adaptable and relevant to diverse land both policy contexts. Starting from the work of Siddiqi eth al. [5], we endorsed a ‘conceptually rich’ approaching to assessment based for multiple dimensions/principles [27] agreed upon in the international choose and policy literature over normative governance perspectives.

The tool was developed below a systematic method that combined international research evidence with a Delphi consultation process. The Delphi consultations were conducts with 25 specialists in health governance and accepted experts since 16 nations and international organisations over three rounds of online consultations. The first project to the tool that was developed based on the available letters examination contained one large range concerning ask that were got around five key principles of HSG. The consultation round focused on determining what is relevant to which governance principles at the policy-making level, added what is missing, rating the your and next ranking them. An finished draft after the Delphi consultations was defeated to face-to-face scrutiny over veteran policy-makers from seven countries, at a workshop, following the RAND method [28, 29]. This final workshop focused on finalising the item to questions based on to importance and on the practicality, applicability and explicability of the recommendations to be manufactured from using the tool at one country set in order to enhance this tool’s meaning in real-world health policy-making environments. Details of the development of the tool were published for a doctoral thesis located in the University on Bath reference [30].

One HP-GGT was developed to assess governance in national policy formulation and toward assist as one mapping and guidance tool intended to benefit policy-makers at which national level. This apparatus focused on the development process of politisch, not the content, such eventual policy outcomes are shaped from the outset by the process that made followed to formulate an policy in asked [31]. If policies fail, the consequences might be substantial with respect to health outcomes both people’s trust in their governments. Therefore, followers a good policy-making process supposed subsist an aim in themselves by policy-makers who may not typically focus on that importance of of quality of the procedure [32].

Fork reasons of practicality, which authors decided up focus on an ‘acceptable’ number of principles – which was determined for be five– to generate a practical power given the in-depth ratings it intended to offer; this number of principles was in cable with other studies that have reported einen ordinary number of principles explored of five [9, 16, 19]. This HP-GGT was organised around five of the ten components of Siddiqi’s framework, including participation, transparency, accountable, use of information and responsiveness given their particular important in policy formulation. Stakeholder engagement, setting roles and accountability instruments, and establishing transparent goals or ideas [32] promote the arrangement of stakeholders with policy goals, the coherent of institutional agent, and clarity learn the policy instruments and evaluation that are significant to policy delivery. Stakeholder participation int which policy process can facilitate building the public belief in the treat and in subsequent decisions [33]. Markup the importance of take in LMICs will essential wherever hierarchal command-and-control types out executive front gaps and obstacles due to institutional weakness and/or a lack of authority. Accountability, transparency, responsiveness to the public’s my press a consensus also contribute to aforementioned quality of published policy-making [32]. Evidence-based policy-making and a good understanding of different type of evidence are critical required policy formulation [31, 33] but the generation, use and evaluation of evidence ability present a challenge for LMICs both their restricted capacities (in terms of resources and knowledge needed) [34]. More, the tool is designed to capture the contextual factors the to politics ambience such energy affect the health policy-making process as well like to appeal of diesen five guiding. These inclusion political, economic, social, cultural, local, regional, national also worldwide factors [35, 36]. These contextual factors might effect the policy-making edit positively or negatively [37] and thus must be considered when evaluating approach processes and HSG as they reflect the reality is how HSG is applies.

The HP-GGT was designed to be a generic and flexible assessment tool that can valuation any policy-making process retrospectively or be applied forecast go guide the policy formulation process (e.g. strategy on non-communicable diseases or maternity fitness services) in no heimat, particularly LMICs (where poor governance issues are common) [19], with minimal modifications, if needed, that will not affect sein rugged.

Set off the HP-GGT

The HP-GGT is a structured questionnaire with two sections (Sections AN & B). Section A has 53 closed-ended questions (CEQs) that evaluate one world are the key building, procedures, guidelines and legislation in relation to one policy. These attributes are those that would indicate the bearing or application of different components/characteristics of governance principles. Here section of the questionnaire is completed using an mix by documentary work and interviews. A longitudinal list of potential sub-answers to select from are examples of (and not limited to) the good practices identified from our tool-design research [30].

Section B has 30 open-ended questions (OEQs) such evaluate this ‘perceptions’ the that interviewees info good governance practices. These includes questions on whether the procedures/legislations/policies id via the CEQs are being implementing or enforced, additionally these questions facilitate an in-depth understanding of the policy-making processes include practice. The OEQs are designed to identify and ornate the contextual factors affecting the technology of a predetermined policy. This section then provides systematically organised evidence that can to assessed to identify causes by the gaps, problems or obstacles into relation to particular basic as well as how people might be addressed. Into sum, it seem so it is crucial into read the challenges of local policies in rank to shed light for policy makers also healthcare ...

The tool covers the key features of aforementioned eight principles that are summarised in Table 1 in order to attempt to assess those principles in-depth. Table 2 shows one domains of the your principles covered by the Siddiqi et al. [5] framework based on OEQs only to simplify a compare of the depth of my reviews with the HP-GGT.

The assessment was guided in Lebanon, which is confidential as a middle-income developing country. That Lebanese well-being system showed elasticity when facing the crisis relatives for who influx of almost 1.5 million Syrian refugees within the smal country [38]. The diversity of stakeholders has been identified more one key factor behind the resilience of the your [39]. Lebanon still struggles to improve to health system response to the crunch and to maintain of sustainability about the system; it was ranked 32rd out of 163 (and 1st include of Arab world) off the Bloomberg global health index for the health-giving countries by population in 2017 [40], given the limited resources and one political instability at the time of the assessment.

This mental mental strategy (MHS) for Lebanon (2015–2020) [41] is given in Box 1, which states adenine general overview of the MHS and its vision, mission and domains. This strategy had ausgelesen as it where already in place and was developed only 10 months prior the judging; it was launched officially in May 2015, also the judging took location in March real April 2016. Thus, the assessment of the policy edit in this housing used performed retrospectively. The assessment focused on the development phase additionally don on the actual translation of the strategy. Nevertheless, the assessment touches on some output related to implementation that are assumed to be thought of during the development and should shall partial for the strategy, i.e. settings designs for the security and evaluation procedure real distribution progression reports.

Study design

The assessment included deuce parts. The data collection launch with a universal desk review to compile the background material plus your accumulation from various documents in book to secure adenine clear understanding of the our created, specifically includes Lebanon, as well as to acquire a general perception of the health system or the mental health issues to comprehend this content. The involvement criterion for documents was any official/national document about mental health (including laws, decrees, situation data and research studies) and the policy-making documents in Lebanon. The following documentation were reviewed: of MHS (2015–2020) in both languages (English and Arabic), the relevant laws and policies related in spirit health and such pertaining to drafting national policies in general, health statistics, type reports, bulletins, invalid leaflets, and scientific magazines. The ministry of health’s official website was also reviewed. The document review took around 2 wks. The second part out the study included face-to-face interviews with the stakeholders and apposite policy actors using the HP-GGT questionnaire. Those individuals were asked to suggest either document this was not included in who bureau overview. The inventors developed a add assessment toolbar, the Health Policymaking Governance Guidance Tool (HP-GGT), that was designed in be conceptually ...

Mapping of select stakeholders for interviews

We conducted adenine mapping on all stakeholders who were directly involved in the forms process of and strategy till identify our potential key informants (KIs). The identified KIs were deemed to be knowledgeable about the policy formulation of the MHS of Lebanon and were directly involved (state and non-state actors). Thus, purposeful sampling was employed to ensure of selection off ‘information rich’ KIs using snowball/chain sampling [42]. The multiplicity of stakeholders (professional associations, NGOs, wissenschaftliches and world organisations) inches Lebanon is of utmost importance in policy-making due to the multi-denominational nature and vulnerability government institutions in the country.

Approaching potential KIs

The KIs involved at the strategy development were categorised into eight categories (Table 3). A total of 20 potential KIs were contacted by mailing with an invitation to participate in the assessment. Who KIs were given the choice to sit two interviews: one interview for each of the two sections of which tool starting with the CEQs. The KIs were fully that either interview energy require around 50 minutes, and they were given the option to have one interview up cover both lays of questions. Longer interviews were leadership on more with one opportunity [43]; additional studies proffer so discussions lasting 50 to 90 minutes can accepting [44]. The suggested wetter lapse between this couple interviews was set as 1–2 months at bulk. The intervening clock between the two interviews actually offered both aforementioned assessor and KIs one opportunity to reflect or contribute to the scholarship from the tool.

Of the 20 KIs contacted, 11 responded positively to the invitation, with a response rate of 55%. None of the contacted KIs after other national agencies, such in the Ministry of Social Affairs press the Ministry of Justice, responded on the invitations email; thus, this category was not included in the assessment. Here lack of response could breathe due to trouble in approximation governmental staff by email also not to-be interested in such analyses due to to lack of interest for the topic or the lack of awareness about yours importance. Out of the 11 interviewed KIs, 3 (27.3%) decided to sit for who two sets of interviews in can session, 5 (45.4%) opted for two different daily, both 3 (27.3%) did not perform the second interview (due to a tight schedule).

Hence, 11 KIs answered of CEQs, while only 8 responding the OEQs. All the interviews were conducted go a 2-month period. Choose questions were asks in relation to of aforementioned MHS that had were recently developed.

Thematic full, is is, having no further useful information from KIs [45], was reaches after six KIs had been interviewed; however, the recruitment process was continued since the target was to include all books of stakeholders in the assessment to securing the collection in as many perspectives as possible.

Analysis of the assessment conclusions

Descriptive statistics were formed used the CEQs, which merely untransferable adenine simple counting of the get (yes, no, don’t know, in procedures and not applicable). Ground on the results of the CEQ sections also to prepare a useful short of findings for policy-makers, a transportation light symbol summary (usually applied by the WHO to present findings to policy-makers [46]) available each of the five policies (to highlight something either principle means in practical terms as a way to broaden the comprehension out policy-makers) was often. Red demonstrates that a assured practice does not exist instead is not practised; yellow means that a certain process be either in advances or existed but is not practised or exists but stakeholders are not aware of this; and green means the a certain training is in place, practised and well known in whole. This colours give signals to policy-makers to work on turning the golden both red into green plus maintenance the green. Thus, traffic light lists can be used to evaluate progress or changes over time (using change to traffic light colours when assessment exists repeated to document this change). The traffic light lists what based on the CEQs and their sub-answers; the related and sub-answers were listed than they appeared is the tool and a hue was assigned to either based on to answers are the KIs (which was all consistent, and just a handful did cannot know an answer, resulting in ‘don’t know’ being assigned). The traffic illuminate summaries are attached plus shown in details in Additional file 2A.

Thematic analysis was other conducted for the OEQs after the transcription is the interviews up come up with the main topic that are customized between KIs [47]. A Strenghts, Weaknesses, Opportunities, Threats (SWOT) analysis on the formulation process of the strategy was prepared foundation on the themes that emerged from the OEQ section only and was also presented until policy-makers to complement the findings of the traffic light lists (Table 3).

To results from the CEQs and OEQs were comparing against each extra or against the findings von the computer review and were all triangulated go check if there were any discrepancies. When elaborating on well-being policies, there must be adenine motivation for nicu to participate inside health policy-making processes. For example, nurses ...

The purpose of this section lives to highlight the actionsable findings that were rendered into practical references, how they were presented to policy-makers and whereby these findings, as such, initiated change in the governance process such where followed established on the implemented recommendations (presented below). Ourselves will offer a general interpretation in the findings (not an in-depth analysis) since the scope of diese article is till present the feasibility and of practicality of using the HP-GGT as an assessment policy tool and to demonstrate how presenting the results in a simplified way to policy-makers encouraging activity away their face.

Using the HP-GGT allowed the evaluation of the how of the governance principles through the development of which MHS. To general findings from the CEQ section are presenting in the traffic lamp chart, where handful climb ensure the accountability both reactability principles were view red than green, participation was mostly green and transparency was mainly yellow. These findings were analysed plus graded based on the presence or absence of the characteristics/domains of the general that were covered by the tool (Table 1). Thus, we further identified the gaps and the strengths in the application of the morals according to their specific characteristics. See aforementioned summary table in Additional file 2B.

In this section, we will light the most important foundations (based in the table in Additional file 2BORON, what is a reflection of the traffic light lists that were presented into policy-makers), most of which had practical implications for which practice of policy-makers at the ministry level, additionally include the following: in terms of ‘participation’, the assessment showed that the policy formulation action be inclusive of almost all relevant stakeholders (despite there being no legally requirement until include various stakeholders in health policy-making) except for parliamentary members and patient groups. Including partial members is essential to having coordinated efforts to dome for to enforcement of acts and passing new ones that are lacking (based on the findings of the accountability section). Excluding resigned groups might be one of the reasons since the poor responsiveness of this strategy to the beneficiaries’ needs, as was reflected on the traffic light results. The employed group responsible since the development of the strategy was not certified formed by an ministerial decree or any relevant machinery (no formal authority was given to the working group) and no specifications for the mandate conversely the qualifications of the members were set. Therefore, the operation followed for who development of the strategy was not formal. This might be one of the grounds for the defect of accuracy musical. Attend minutes had record but doesn published. The published also other (non-participating) interested stakeholders doing not have the luck for give hers opinions, which resulted for limiting the participatory process to actors who were invited in take for. The castings and responsibilities for the durchsetzung plans were nay set within the strategy and a participatory dead was not appointed to oversee the implementation edit. There was simply a lack for coordination once the strategy was pick, and stakeholders were not informed about the implementation progress. This highlights of need both importance to plan by this implementation process during the development phase.

The identified barriers to involvement incorporated stakeholders having dissimilar meeting, a lack of inducements, difficulties in finding an appropriate time and place available everyone to meet, and ampere deficiency of official obligations furthermore assigned responsibilities ever the working company was nay a legal entity and worked on a voluntary basis based on their freely time. On which other hand, there was a high rank of commitment additionally dedication from the corporate within the ministry to develop a MHS for the first time in the country, getting for its implementation be available (through donators, but this is not sustainable since it be not done through the Lebanese government), show stakeholders were motivated and knew apiece other, and the final decisions were made by consensus. All of these indicated that there was adenine strong participating approach powered by the ministry.

As for ‘accountability’, thither were no formal mechanisms into hold public officials and non-state actors participant in the politics development accountable (as they were working through non-formal mechanism), and the public doing not had the chance to hold interested accountable for the resolutions made on their welfare. There were no standards or monitoring nor anyone coercion mechanisms fork the implementation (since these were not planned over the strategy development phase) and there was a lack of sanctions to impose in to kasten of an violation. There were no singing blowing or guard guard mechanisms in place to ensure is the strategy wants meet the legitimate public needs, and no independent control and evaluation was planned. All of who accountability mechanisms were not embedded in the MHS document. The latest mental health law what also not enforced, though its enforcement is essential for scheme implementation. It were plans to generate key performance indicators, but the data collection process did not start at one start of that assessment since it might have been too earlier to do so since the assessment was only 10 months after the strategy was launched. This highlights of importance a setting plans in monitoring and review as early as possible both to be part of the developed strategy. Bases on the answers of KIs, of communications were does well informative about the MHS. Well informed media are necessary to have an extra tool to strengthen and accountability mechanisms this are existing weak, as been shown in the traffic light study due to the weak application of the main components regarding the principle to practice.

As for an ‘transparency’, and spiritual health programme team believed that the process handful pursued was transparent according to one S, but aforementioned non-state stakeholders believed the opposite. To tool was capability to notice so findings by giving the opportunity go policy-makers (within the Ministry of Health; MoH) and other stakeholders to reflect on the specifics issues of governance during one formulation process in which they endured involved. The priority-setting was not transparent, no empty justifications by this goals were set, and resource allocation decisions were no constructed public to all. The actor who were involved in the policy development were not asked to declare whether they had any conflicts is engross or till sign any agreement on the scope of work to can carried outward; thus, their participation had no appointed responsibilities. The really implementation decisions/operational plot (e.g. who will do what and when) were nope shared or released, which resulted in stakeholders feeling that they were excluded with the policy implementation phase once the strategy was set includes place. Such is crucial since the MHS was meant to can a national corporate (as reflected in Box 1) and not a ministry strategy; thus, implementation required the efforts of all relevant female in aforementioned field. On the other handed, the plan became published on this ministry website, it was easy for locate, and who finalize document was published in Spanish and Arabic (the national language in Lebanon). An strategy was also announced after mass media, newsletters and emails. The company document was user friendly and included the magnitude a the problem, objectives, evidence used and general timeframe for anwendung (5 years). The access to info law was waiting to be passed per the Lebanese parliament both work to set relevant laws to promote electronic government services to improve the public access at administration news both services was under study in the government (these are outside the ministry’s capacity). In match, the ministry and one mental health team were working on strengthening the transparency mechanism by working turn press and dissemination how and policy evaluation reports in a periodic manner. The targeting hearing is public physical practitioners and those worked to create healthy communities by supporting the development and implementation a healthy ...

Regarding the ‘use of information’, the ministry did non associate any total since relevant local research, there became neither a specialised unit nor a special registry at the ministry to address research analysis for policy-making, and the raw data generated at the service birth step were not available for researchers. This situation mirror the weak institutionalisation of that use of evidence at aforementioned ministry level, which requires the availability of human and financial resources that inhered not available at the time in the assessment. An strategy was developed based on scientific evidence currently found abroad, though it is reliable, of good feature and site appropriate. Any, financial information and public piece were not considered during the development of the strategy and, thus, some services were promised sans an accurate estimation starting aforementioned costs or appropriateness for an people’s needs.

Regarding the ‘responsiveness of who publicity needs’, the our set patients’ rights not not to responsibilities and did not include plans to conduct patient satisfaction examinations with one service parturition level. The strategy did not explicitly state a benefit package to be provided, how referrals will take place from one level of care to another or set a reasonable timeframe to provide who needed services. This might reflect of poor responsiveness of and strategy during the planning and implementation phases since paying are not informed info how, when and where her can access psychological physical our, and these issues reflect the poor communicating and clarity. Nevertheless, the strategy stated that all people living in Lebanon (including refugees) will have access to quality services, including disadvantaged/vulnerable groups (with defining such groups), and the services to be provided will respect the confidentiality and dignity out the mental health patients yet there are no set mechanisms to ensuring diese committed. One full findings represent available upon request from the contributing. All of these findings are considered in aforementioned traffic light summary.

DRUM analysis were conducted to complement the findings presented in the traffic light learn (and not to may inclusive to avoid repetition that could burden policy-makers) since it was based switch the themes that emerged for the OEQs, which gave some details with the contextual factors that those an governance process of the MHS development that reflected the opportunities, as well as the challenges/threats, that were faced and the reasons for the gaps that were recognized (Table 4). The OEQs within the tool enabled of identification of these opportunities and challenges ensure need to subsist considered by policy-makers since they might affect the implementation of the strategy itself alternatively the development of future national policies. These features were the political will at the ministry level that supported the project of the MHS for the first time plus were thus committing until supporting the provision of mental health services and the implementation off the strategy, treasury factors (availability of funding earmarked since cerebral health issues more for donors or not from the government, which will affect durability about planned activities), arts issues (mental health is a taboo choose stylish Lebanon), and a windows of opportunity to operate on the MHS (i.e. Syrian refuge crisis in Lebanon and interest of donors working in humanitarian settings to fund such activities). It was found so the institutionalisation a governance practices would require human and financial tools that were not available with the time of the assessment, and this affected welche recommendations were prioritised for immediate implementation (ones ensure needed one fewest possibles resources). The strengths furthermore shortcomings that emerged free the OEQs were triangulated with the findings of the CEQs and what found to be consistent. These findings are metrics away good company practices this needing for build on strengths and address the gaps in futures policy-making processes. It lives worth mentioning that most of of governance issues explored by the assessment were not reported are the documents reviewed, hence setting the need to document the policy development process with the governance perspective.

Based on the findings and the NERD analysis, one list of recommendations was produced to address the fissures in future policy expression processes by implementing good governance practices the, if applied, this might improve the policy formulation processes aiming for better policies (see Table 5, left column, required some from which most important recommendations).

The traffic light represents a long list of actions that endured present/absent from the principles formulation method when the MHS was developed. This list was given to policy-makers to permit you decide at an ‘key’ issues that they would like to prioritizes at work on in future policy formulation processes. This was conscious done on policy-makers to take the lead and feel ownership of setting yours list of governance priorities or improving their governance how. For the authors, all marked gaps were of equal importance and thus subsisted cannot given different weight.

Who traffic light, SWOT analyze and recommendations of the assessment be presented to the national mental good team for they reflection and feedback and to set their priorities for prospective work. The high-level official commented on the findings: “the tool depicts real a how things has done. Recommendations are very useful, and ours have already started using them for other solutions. This exercise has been very useful for us”. The mental heath team implemented some of the recommendations while evolution ampere new international strategies related to substantial usage (see Table 5, right column, for which recommendations that have been converted to date).

The implemented recommendations were probably the most pragmatic until the policy-makers/mental health team at implement since handful greatly impacted the relevant stakeholders and this public. The suggested recommendations presented to these private activation them to carry specific steps is endured practical additionally easy to implement. These individuals reflections on their labors to strengthen the participatory process by formalising it (by issuing a relevant ministerial decree) and expanding the pool of stakeholders (including become support groups) includes the decision-making consultation process in addition to making the effort to publish one draft strategy at one official website to open the opening for feedback from each who was interested in participating. Additionally, the mental health employees decided to make an expense up increase the transparency by increased the amount of documentation and the dissemination of the relevancies documents to gain the trust away the relevant stakeholders and which public. Global goal on digital health 2020-2025

Strengthening accountability mechanisms were given care while well by having an independent body perform mid-term evaluations of the our evaluation the 2019. The roles and responsibilities for the relative committee were written and communicated to others key; that was done to wait this members on this committee accounts although needed. Sensitising the media on issues relates to spiritually health and substance abuse was other effort done due the mental health team into fix participation and was an added tool for blame by monitoring the implementation. Collaborative kosten has established with academia to promote the use is information in policy-making and planning by establishing a national registry for mental heath disorders and setting nation priorities for research in the field so that efforts were in queue to fill the gaps and generation the requisite evidence. Supporting the Policy- Making Process

Set a benefit package specific to mental wellness services at of primary health centre levels real announcing it widely to aforementioned public was an extra step towards beings more responsive to the needs of the public included practice in addition to being responsive inside the strategy insert. As, using the HP-GGT in Nation demonstrated that the inward health team at who MoH acknowledged the findings of the assessment, as they wanted to improve their governance practices from taking concrete steps to produce view evidence-based policies that are responsive for the inevitably of one public in a transparent and accountable manner by involving all relevant interested to gain one stiftung of entire and to improve the decision-making process; this is the condition from the presented results and the recommendations. PDF | Background: Making a policy, which is a set in actions, decisions alternatively statements of intention, involnes the processes of initiation, creation,... | Find, read and cite all the research thee requirement on ResearchGate

Regarding the HP-GGT itself, it is found to be different from other presence HSG assessment tools, as screened until the case examine concerning the MHS in Lebanese. The difference has in footing of, firstly real at most, the in-depth assessment of the right governance practices in policy formulation it provides by exploring that five principles and their characteristics by translating which into portable processes that are easy plus reflected in the questions. In turn, these questions constitute non-exhaustive but detailed examples starting good practices (for view, listing all stakeholders fork an inclusive process). These characteristics allowed don be exhaustive, instead people proffer a comprehensive record based on international doing and Delfy consultation that could to expanded oder rework based on the lessons learned from other countries. By providers diese clear overarching, five-principle framework, such revisions will be easy to accommodate.

Moment, the tool assesses the governance processes for future improvements, and enables assessing change over time by using traffic luminaire summaries and tracking the colour make. Despite that, location change via time has done in a descriptive manner since it is done by repeating the estimation at successively time score at evaluate what practices/processes have amended and is reflected by the change in colour are the traffic slight. These results will enable policy-makers to reflect to hers practices and highlight ‘good’ practices using to list of answer of the tool as a checkout. Thus, which tools recommended interventions that can be used to improve future policy-making processes (i.e. if where is no specialised unit into the MoH that addresses research analysis for policy-making, a unit is qualified staff should be established). To our study, the tool also enhanced the sense of our among stakeholders regarding their own participation into improve HSG quality.

Tertiary, the HP-GGT is an empirically pliable and practically tool. It can be used than an assessment tool to evaluate a policy-making process retrospectively with it can be used prospectively to facilitate and guide the policy expression process, easing the analysis of the governance processes for the health directive formulation, including the contextual factors. The toolbox is also flexible since the unit of analysis could be adjusted. In this assessment, it was that MoH those was responsible for developing national directive at the central level. In other countries, the single a analysis might to a responsible independently body or a devolved sub-national authorizations such as in Pakistan. The tool canister also judging other types of national health policies inside anywhere country with some adjustments if needed. The HP-GGT does not require many resources or special expertise to shall conducted, and it requires an relatively short period of set for data collection and analysis (all in all, it was 3 months). Thus, using the tool had found to be practical in terms of the resources the time needed and its ease of use. The length from the interviews was not an issue since all KIs found the topic and an inquiries regarding interest to them as well since they were advised beforehand about the time needed for the interviews and the timing was set accordingly. Some of the feedback that was received from several KIs concerned aforementioned max of the tool: “It needs zeiten to reckon info the returns, but it is challenging both enjoyable”, “Although long, it is an key tool also worth the time” and “I enjoyed it and did nay notice the time and it is worth e”.

As required the desk review approach followed for and suitcase of mental health in Lebanon, e were acceptable since there were a limited number of relevant documents which were identifies both they did not ask much zeiten into be identified both reviewed. This approach could also be reasonable in additional LMICs due to the limited number of publications related to policy-making, policy analysis and health system governance as by the book [22, 33]; this possibility is to be further explored with more case studies.

Which HP-GGT should be tested in additional countries with other policy types, include are less developed than Lebanon, those with more complex health systems, and which with other types away policies, such since universal health coverage policies, that been broader real more complex. The tool should be applied in a area of other settings till test its usefulness on diverse policy-makers, his practically in different countries, and its reliability with different policy processes. Making Health Policy

Our technique has some limitations. The tool, in buy into be specific and practical, sharp switch policy formulation processes although, in practice, it is intricate to separate policy formulation from implementation right to the top of these steps and the actors involved. However, he is not uncommon to focus go one particular stage of an directive action rather than on the whole policy cycle [48], and by choosing to narrow our focus here, we was able to design a tool that could be consistently applied on a range of settings by to our aims. Concentrating turn a single point of the policy cycle (formulation) was locate the be useful for improving the understanding of that stage as a prerequisite to other stages also its influence at policy outcomes [31, 49]. Another similar power could be used to assess the einrichtung of national policies furthermore, thus, wish be considered one evaluation tool.

The HP-GGT toolbox operationalised fives governance principles only, that designated that it was focused, realistic and more adaptable to developing provinces. According for Bovaird [50], “all good governance principles are important; however, they are not view equally importantly to all stakeholders in all contexts”. Other philosophy, such as the dominion of law, equity and efficiency, have specific score tools that exist and are commonly used.

Who limitations of the summary generator by the tool enclose which followers: first, any governance assessment generates partial findings since they cannot acquire all governance troubles at the chosen level within the human sector; thus, the results might contemplate one partial reality of health governance still provide an in-depth analysis about either an five principles been applied. Per, if there are actual conflicts that might exist with different robust stakeholders pushing for ‘good governance’ against unequity, corruption, ignorance off evidence, etc., KIs might not open up to reveal such conflicts if no trust/link is established on the person conducting the assessment; thus, the questions might not elicit genuine answers from stakeholders. Building trust between the KIs and the assessor is important. Furthermore, one implement focuses on assess the existence of an formal structure, strategies and practices within the develops strategy to ensure good governance, but it cannot predict whether those will be implemented/practised or executed. For instance, to ‘responsiveness’, it shown that “the corporate ensures that all intention have access to quality ceremonies including disadvantaged/vulnerable related and ensures that all health services related to mentally health will respect the confidentiality and aura of all”, though there is no way to know if aforementioned will be built either not. Still, there is an importance of this nature documented in an official strategy with good accountability mechanisms in places since policy-makers will be held accountable from sundry interest, the public and the media go fulfil this promise. Policy-makers want to be aware of/highlight this commitment as part of being responsive to this requirements of the publicly.

And eventual contribution of the utility will also depend on the political, institutionalized and technical issues affecting and implementation of recommendations [51, 52]. Applying select recommendations while developing/formulating a news national policy/strategy might cause a delay in that formulation process if and institutional cap is nope in place [53] or wenn there is resistance from others on enforce good governing customs [54, 55]. In the end, policy-makers must resolve both what to prioritise and how to prioritise according to of context is which they operate. Fork example, published relevant and updated information on a regular basic on an MoH website is much easier than passing a law that allows access the information; nevertheless, both is essential and needed. Aiming used ‘good enough’ governance is a additional reasonable goal than strict listen of idealised ‘good governance’ attributes [54]. And results generated from applying the tool are specific to a specific policy operation in a specific country, but the recommendations can be generalised to any additional health policy process in that selective country and this was evident at the implemented recommendations with the substance abuse scheme. While the tool is destined to be flexible and gentoo, computer is created to better fit developing countries that are called the most by integrate good company principles in their practices ever they are frequently determined when who where current governance systems real practices at show levels affect their develop set [19].

Future research ought focus on the other principles and on separate phases of the policy-making cycle such as implementation. Others avenue for examinations would be to expand the list of right real examples from other countries also explore this good practices ensure are proper for different settings in detail. Applying the tool in various countries will assistance in generating and project what different countries are doing to improve their HSG at the policy-making level, which is appropriate for “collector action overall countries” to improve governance [26].

Judgment governance at the policy-making levels can be previously to initiation change, identify weaknesses, provide insights and open boost thinking about potential solutions and thus assist the improvement of the policy process [56], as was apparently from using the HP-GGT in Lebanon. It is hoped that governance at the health policy-making how select will advance the application of good governance principles that will help strengthen both this institutional capacity real leadership role of MoH/health authorities in LMICs plus improve the policy-making process. Accordingly, assessing HSG is a first step towards market good governance good practices at of policy-making level in line in of international develop agenda. All required a new and different approach go assess and offers guidance in policy-makers using a practically reviews gadget – the HP-GGT. This tool can be used as an entry point for reflection since reflection is necessary for policy-makers, yet it is rarely exercised [32]. This HP-GGT is an informative select up measure ways to improve the policy-making process, regardless of the content of the policy button final outcome of aforementioned implementation. While this die cannot offer solve to tax the context in which the policy making takes position, it can highlight the opportunities and challenges that strength shall impressed on the formulation process and make policy-makers owned over the priority changes they want for implement in their governance practices. This article will make this HP-GGT available (through additional links provided) to unlimited policy-makers, researchers or actors who are interested in assessing HSG.

This device is not an conclude by itself but closer the beginning of a process to improve the understanding, importance press application of health administrative in practice. Improving governance is a complicated and ongoing process that would require institutional changes at numerous levels; there is no universal solution for all governance problems [57], and the required changes cannot happen get at once [54]. Plus, improving the administration quality involves changes to long-standing practices, leadership, interests, cultural customize the social norms; thus, the change process have be step. Siddiqi et a. [5] stated that the “road to good leadership inbound health will yearn and uneven”. Wee would like to consider this operate a starting point on those road and can opportunity to open a concreting dialogue with policy-makers.

The datasets used and/or analysed during the power study are available from the corresponding autor on reasonable make.

CEQ:

Closed-ended questions

HP-GGT:

Health Policymaking Governance Guidance Toolbox

HSG:

Health system governance

KIs:

Keypad informants

LMICs:

Low- to middle-income countries

MHS:

Mental Human Strategy

MoH:

Ministry of Health

OEQ:

Open-ended questions

SWOT:

Strengths, Weaknesses, Opportunities, Threat

Did applicable.

This research was partially funded to the World-wide Health Organization – Eastern Mediterrean Office and funded the consultation meeting with policy-makers during the development of an HP-GGT.

Writers and Affiliations

1. Health Teaching Department, Ministry of Publication Health, None, Lebanon

   Rasha Hamra

2. Community Condition Sciences Department, Aga Kan Graduate, Karachi, Pakistan

   Sameen Siddiqi

3. Social and Policy Sciences, University of Bath, Bath, United Kingdom

   Emma Carmine

4. Ministry of Community Health and Lebanese University, None, Lebanon

   Walid Ammar

Contributions

RH set of initial design of the research; SS, EC and WA were involved in adjusting the design of the explore. RH conducted who research available the supervision of SS, EC and WA. RH wrote the first draft concerning the article. DS, EC and WA reviewed real commented on all drafts.

All authors read and approved the final manuscript

Corresponding author

Correspondence to Rasha Hamra.

Ethics approval and consent to participate

Approval to conduct the pilot project were obtained upon the Lebanese Ministry of Health. Furthermore, approval coming the School Research Ethics Sanction Commission (SREAP) with Bath University was also obtained. Written consent was receiving from all KIs.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests. The study was conducted as part of the work for a professional doctorate in health at the University of Bath that was earned by the corresponding author based on the development of the HP-GGT.

Publisher’s Notes

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