Thirty-one interviews were conducted with fourteen actors based in Tanzania and seventeen based in different countries. Interviews were analysed using the adapted Shiffman and Smith framework (Table 1) and are presented by category. Interviews with the global health actors were analysed to understand the global policy context and what effect, if any, the global level context had on the policy change in Tanzania.
Policy Community Cohesion
From the interviews it became clear that there was a small group of key actors in child eye health in Tanzania who both knew each other well and were well-connected to policy makers. This is not unexpected from such a highly specialised area of health care. During the interviews it was clear that NGOs and technical experts who were advocates for eye health () had a high degree of cohesion on issues and worked together to advocate for child eye health. As an NGO interviewee stated: “we have been working on this issue for a long time and know we are a small community so it is important for us to support each other”. This cohesion meant that when the opportunity to include eye health in IMNCI arose there was already strong cohesion on other aspects of child eye health, and as one technical expert put it “there is no good reason why this [eye health] should not be included [in IMNCI]”. The IMNCI official from the Ministry of Health (MOH) also noted the “the agreement between the [technical experts] was clear”. Thus, the cohesion was noted from those external to the child eye health community which contributed to the actor’s power to influence the MOH.
There was also community cohesion amongst the global actors regarding the inclusion of eye care in newborn health guidelines, specifically for ROP services. The policy community in newborn health was described by one of the NGO actors as “quite a small group working on newborn [care] and... those relationships... go back at least a decade, I think”. It was, therefore, a close-knit community and many of the issues of newborn health, including eye health, had been discussed over many years in technical sessions and discussions, as explained by this funder: “Those of us in a global public health space were pretty much at the same knowledge level around things like preventing child blindness, ROP, oxygen use........ [I] just learned an extraordinary amount through the various technical sessions and discussions”. Therefore, the issue of including eye health benefitted from having a relatively small and well formed group who had been working together for many years on newborn health. The policy level discussions on ROP at an international level were separate from the policy community in Tanzania and there was no crossover. Therefore, the local policy community in Tanzania remained distinct and separate and was able to lead on its own national priorities.
Leadership
Leadership in this case was provided by an academic collaboration between two universities, one national and one international. The MOH IMNCI official noticed that this collaboration was “clearly ....... capable of leading [the initiative]”. The interviews suggested that these institutions were respected by the other key actors and NGO community and one NGO representative commented “we had worked with them before and it has been a fruitful partnership” as well as noting “it is important to have their technical expertise”. There was also a sense from the NGO interviews that being separate from the NGOs and not part of implementation gave some ‘neutrality’ or independence, thus it was easier for the community to unite, which would, for example, have been more difficult if another NGO was leading. This meant that the leadership was effective in bringing together all the key actors to focus on the issue.
The global child health community, outside Tanzania, also benefitted from leadership, as noted by one NGO representative “So there are some people who are very strong in this community. So, advocates at WHO, UNICEF, also, voices like …. have been incredibly powerful in this community in pushing the agenda forward …and really good at making sure that the things get done and that the pieces of research are out there, etc.” However, this leadership, although important at the global level, did not influence the actors in Tanzania.
Guiding Institutions and Civil Society Mobilisation
There are no specific guiding institutions for child eye health in Tanzania, although there are professional associations for child and eye health separately. Instead, there was a small group of actors who worked collectively with leadership to advocate for change. The global actors had also formed informal networks which guided their work on newborn health, but this did not include eye health or influence the Tanzanian policy. Grassroots organisations and civil societies were not at involved any stage.
‘Ideas’ and influence of global ideas on national context
Internal Frame
The internal frame and the agreement of the policy community on the causes of child eye problems were high and there was an openness to solutions. Many actors referred to the long-standing relationships between the child eye health community in Tanzania, who had a “history of collaboration” on funded projects. An example mentioned by one of the NGOs was a project between the NGO and the two academic institutions (MUHAS and LSHTM) on primary eye care for children, which had taken place five years previously, undertaken by two of the co-authors (MM, CG). This was described by the NGO representative as “very helpful for us to understand this problem in Tanzania” and that it “really spurred so many of us on to take action”. During this project a Theory of Change (TOC) was developed collaboratively which was described as “such an important process” and that “we have used that [theory of change] for many funding applications after”, “it made it easier for us to understand the issues and explain it to others with a local context”. Although the TOC provided a common understanding of the causes of the problem of blinding eye diseases in children, the solutions were less clear. Most actors admitted during interviews that they had not heard of IMNCI before the first stakeholder meeting at the start of the project but found it to be a “common sense” approach and “very practical” saying “we must try every approach and do everything we can that could work”. The key actors, therefore, felt able to support the inclusion of eye care in the IMNCI strategy as a potential solution.
The global actors focussed specifically on ROP within newborn health and considered it a quality of care issue, as noted by one academic: “[ROP is a] quality improvement issue ... it’s like a ‘signal issue’ .... if they can’t manage that [ROP] well, then they probably can’t manage all the other critical care issues that will arise”. Awareness of the impact of poor-quality neonatal care on the eye was a very powerful internal frame used by global actors. However, this did not affect the frame in Tanzania which focused on primary level care.
External Frame
The external frame focussed on eye health being ‘missing’ from IMNCI. When the solution of including eye care in IMNCI was advocated to the MOH they were also able to see “all the experts and organisations - local and international - seem to be in agreement” which “made us feel we will be able to make this [the eye IMNCI strategy] work well”.
One powerful strength noted in the interviews from this external frame was that including child eye health became an issue for the policy makers (in this case the MOH) as well as for the policy community. This was reflected in interviews with MOH representatives with their repeated use of the word “we” when discussing the eye IMNCI strategy: “We could see that this idea [including eye health in IMNCI] was something that made sense for all of us, why would we not do it?”. This sense of ownership by the MOH became apparent after the first stakeholder meeting of the research project, as the MOH led the development of the eye module. The MOH used their own team and processes and took responsibility for the production of the module, stating: “We felt we could manage this well within our department and it was our responsibility for our people to make sure it was done in the proper manner”. The eye module was initially developed in Swahili (the national language of Tanzania) with technical assistance from the academic collaboration, and was then translated into English. The MOH used their own team and processes and took responsibility for the production of the module which was critical in their ownership of the programme and influential for the policy change.
‘Political contexts’ global and national
Policy Windows
Policy windows are “a favourable confluence of events providing an opportunity for advocates to press political leaders”.16 Unknown to the child eye health advocates in Tanzania, an IMNCI strategy review by the MOH and key stake holders, including WHO AFRO, was planned for May 2019. The meeting took place shortly after the eye health module had been pilot tested. This meant that the inclusion of eye health in the IMNCI strategy could be ratified and included in national policy very quickly. The MOH interviewee said “the timing [of the IMNCI pilot study] was perfect”. The WHO representative also said “the timing could not have been better [for the development of the eye module]” as they described the timing of the development of the eye module and the internal review at WHO’s national and regional offices. The WHO AFRO interviewee described the regional and global shift in WHO strategic thinking on how IMNCI could move beyond child survival to support the child “thrive” agenda.
The global policy window was occasioned by the shift of the global child health agenda from ‘survive’ to ‘thrive’, which provided an opportunity to advocate for the importance of including eye health. There was also a general move towards more comprehensive care for the newborn, as noted by one global level NGO interviewee as: “Making sure that it’s comprehensive care, that you’re not just trying to focus on one thing. So that might be why [eye health is gaining prominence]; it might just part of the overall trend.”
Global Governance Structure and Historical Experience
No global governance structure influenced the inclusion of eye health in the IMNCI strategy, and it was not on the global agenda.
There was also no historical experience of including eye health in general child health polices nor the IMNCI strategy. The eye NGO representatives in their interviews noted that IMNCI was not a strategy they knew much about, and explained that their child eye health programmes had been vertical and limited to specific geographical areas. However, the strength of historical experience among the eye health community in working in child eye health set the environment where the idea was well received, as noted by one NGO “We did not know about IMNCI but the idea made common sense”.
Political Feasibility, Culture and Recent shifts and changes
The MOH in Tanzania has an assigned specific person to lead the IMNCI strategy which indicates that it is given some political priority. One of the characteristics of the IMNCI strategy is that although it is globally led, there is scope for national adaptation, and new modules can be introduced without affecting the rest of the strategy. The MOH interviewees explained that there was a precedent to adapt the strategy nationally: “we added ‘well child’ and ‘severe bacterial infections’ at the last [IMNCI] review”. Although these modules had been guided by global leverage, the experience meant the policy makers were open to adaptation at a national level.
MOH interviewees also explained that in-service training of the primary health care workers in IMNCI had changed from an eleven day face-to-face training programme to distance learning with three face-to-face training days over a three-month period. The MOH representative indicated that this had practical and economic implications: “it was not possible before to add more as the training was already too long and expensive…. But now this training is very flexible”. The change to distance learning drastically reduced costs (by 70%), reducing the burden on health facilities as staff were not required to be absent for 11 days, and allowed the MOH greater flexibility to make changes to the training programme.
At the global level there is a move in the childhood agenda to focus on more than ‘survival’ issues, meaning that child development and reducing morbidity and disability also require consideration. A global level academic reflected on this, saying: “So not just the survive but the thrive - and as soon as you move into the thrive you have to be much more intentional on every aspect of the baby, not just their eyes alone but eyes and brain, and growth, and bonding, and support, and support to families and so on;”. Another global level NGO actor corroborated this: “so we needed to go beyond survival and think about ... how can the babies thrive?” and “Eye health, just ... part of helping a child to thrive".
‘Issue characteristics’ at a national level
Credible indicators, Severity and Effective interventions
From a public health perspective, the eye health of children has several challenges compared with other child health issues. Firstly, the outcome of most interventions, visual acuity, is not measurable in infants and is difficult to measure in pre-school age children. In addition, due to visual development and neuro-plasticity the final acuity outcome needs to be measured at the age of five years or above. Secondly, visually impairing conditions are not as common as other childhood conditions and there is a paucity of prevalence and incidence data which hinders advocacy efforts.7 Thirdly, while there are effective methods for child eye screening, they are not as easy to administer as screening methods for other childhood conditions and are often viewed as “too specialised” for routine child healthcare workers.9
One advantage in the Tanzania setting was the presence of local evidence of the burden of child eye problems and potential solutions from recent published and unpublished studies.8 25 26 Studies had also shown that training primary health workers in child eye health was effective at detecting eye conditions at the primary care level.10 11 The MOH representative explained that this local evidence was vital for their decision to include the eye health module: “the evidence was clear that this was an issue we had to address for the children in Tanzania, and that we could” and “we have local evidence of what is the problem and what can be the solutions in Tanzania”. The IMNCI representative said, “we thought it may be difficult to include eye health but after seeing it has been implemented in parts of the country, we thought we can do this everywhere”.
Another important factor highlighted was the availability of a simple, low-cost ophthalmoscope, called the ‘Arclight’, which can be used by primary healthcare workers to examine children’s eyes. This technology has been tested and validated in Tanzania and other low resource settings, providing evidence that it can be effective.10 11 Testing children’s eyes with the Arclight was included in the eye health module and its importance was noted by the MOH: “this Arclight is really useful as we can give one to every primary healthcare worker” and also by the WHO Tanzania representative: “now we have something [the Arclight] that they [primary health workers] can use which makes [eye examination]possible”.
Table 2
Summary of key determinants in policy change in Tanzania
Element | Factors shaping political priority | KeY DETERMINANTS IN TANZANIA |
Actor power within eye and child health community at national and global level | • Policy community cohesion local and global • Leadership • Guiding institutions • Civil society mobilisation | • Strong community cohesion with history of collaboration on eye health, even though not on specific issue of including eye health in IMNCI, benefitted the issue of integration • Joint leadership through national and international academics widely respected • No guiding institutions • No civil society mobilisation |
Ideas and influence of global ideas on national context | • Internal frame • External frame | • Consensus on problem and solutions on eye health in general with agreed Theory of Change allowed for idea of inclusion of eye health in IMNCI, as fitted within an already agreed framework • Global influence of presentation of eye health being part of child development, quality of care and comprehensive care was important external frame which leveraged the shift in global policies around child health • Presentation of eye health as ‘missing’ from IMNCI and a gap of child health resonated strongly as external frame |
Political contexts global and national (adapted from Gill and Walt)21 | • Policy windows • Global governance structure • Historical experience • Political feasibility • Culture • Recent shifts and changes | • IMNCI national review timing (unknown to policy community) allowed for ratification of inclusion of eye health within national policy • Benefits from global shift in child health agenda from ‘survival’ to ‘thrive’ and supporting early childhood development • No global governance on issue or historical experience of including eye health in child health policies • Politically feasible due to how IMNCI managed with flexibility at national level • Recent changes in structure of strategy allowing greater flexibility and feasibility to include eye health |
Issue characteristics national context | • Credible indicators • Severity • Effective interventions | • Paucity of data in low resource settings but local evidence of burden and solutions which was used effectively • New low-cost technologies available were important turning point |