Policy Dialogue for the Successful Implementation of System-Strengthening Initiatives in Sub-Saharan Africa: Who Needs to Be Included?

Background: Intentional collaboration and meaningful interaction among stakeholder groups constitute the keystone of using policy dialogue as a tool to ensure the sound design and efficient implementation of system-strengthening initiatives. Yet the literature offers little guidance on how stakeholder-intensive a policy dialogue ought to be. This study sought to determine, from the perspective of health system strengthening (HSS) experts, the optimal level of inclusion required across the phases of a policy dialogue process. Methods: An online survey was administered to 53 HSS experts with extensive experience in Sub-Saharan Africa to gather their insights on (a) which stakeholder groups should be included at each stage of a policy dialogue process, (b) why they should be included, and (c) how their inclusion could be detrimental. The Policy Triangle Framework and SPARC's Health System Change Framework were combined into an actor-centered analytical framework, complemented by established stakeholder-analysis methods, to interpret the findings. Results: The most salient finding is the recognition, across a myriad of stakeholders, that inclusion and collaboration are essential ingredients for a successful HSS process, with each stakeholder group assigned a relatively different level of importance across phases. Communities, or the end-users of the health system, were unanimously identified as one of the most important groups to include, sometimes rated equally or more important than the Ministry of Health; yet in practice, they are rarely engaged in the design and implementation of such systemic interventions. For each phase, definitions of success and candidate indicators to measure it were also elicited. Conclusions: Policy dialogue offers a viable, country-driven alternative to fragmented, donor-led project approaches to HSS. Realizing its potential requires deliberate attention to power asymmetries, competent process facilitation, and the meaningful (rather than tokenistic) inclusion of communities throughout the process.