POLICY AND IMPLEMENTATION GAP : A MULTI - COUNTRY PERSPECTIVE

Background: Widespread evidence on implementation indicates that health policies once adopted are not implemented as envisioned and do not always achieve the intended outcomes. The challenges associated with policy implementation gaps have been widely attributed to several factors, ranging from problematic policies to lack of governance and resources. Yet developing countries continue to experience these problems in their bid to translate policy into outcomes, including reduced health care and health inequity. This study seeks to understand the complexity associated with health policy implementation and why implementation gaps remain a challenge for low-and-middle income countries. Methods: A thematic synthesis of findings from three PhD studies, each focusing on national health policies across three African countries (Malawi, Ghana and Botswana) was undertaken to provide insight into the complex processes and factors influencing implementation outcomes. We developed ?descriptive themes? and ?analytical themes? to elucidate and explain key factors leading to policy implementation gaps guided by theoretical and empirical literature. Through an iterative process of data extraction, core themes from the studies were thematically analysed to highlight the contributing factors leading to implementation gaps. Results and discussion: These three cases provided experience of the system-wide complexity associated with implementing national health policies that seek to promote health care equity. We identified overarching factors contributing towards implementation gaps and policy failures across the three countries which include issues of: collaboration, discretionary powers, resources, governance and socio-cultural appropriateness. These factors are not exclusive but interlinked, illustrating a complex interaction among actors with the processes and context of implementation. The results of our analysis also showed that health policy implementation occurs in a highly dynamic and complex environment that is constantly being shaped and influenced, in unpredictable ways by external and internal factors to the system with people and relationships at the core of these factors. Conclusion: We concluded that implementing health policies is a complex phenomenon that triggers unintended consequences, and that intangible factors are often ignored by policymakers, yet have critical impact on policy processes and outcomes. Therefore, policymakers need to rethink the process of implementing health policies, engaging actors and addressing the multiple factors confronting actors when putting policies into practice.