Assessing policy dialogues and the role of context: Liberian case study before and during the Ebola outbreak

Understanding and perspectives of stakeholders on the intent of the policy dialogue

In general there were various perceptions and different understanding of the intent
of the dialogues. Some of the respondents perceived the dialogues to be part of a
programme meant to find ways to supplement the shortfalls in funding in the form of
unrestricted funds. Some assumed that the dialogues were the yearly meetings held
by the MoH to review the health systems’ performance. Yet to others the dialogues
were helpful in facilitating the health system to generate new ideas on the structure,
processes, capacity and facilitation of its support systems. It was felt that the
good intentions of the dialogues had been challenged by their limited funding. A number
of respondents felt that the funding was very thin in comparison with the volume of
activities proposed during the dialogues. One respondent noted,

The policy dialogue funding allocation is spread thinly over many activities. And
for some of the activities, in particular the review of the ME policy and plan itself,
I think we had over a 3-year period $10,000 per annum. But the first review spent
in excess of that $10,000 annual allocation. (National level stakeholder)

In addition, the respondents indicated that the disbursement of funds was not carried
out according to the agreed plan.

The respondents’ views on the intent of the dialogues could be grouped under three
main categories: increasing participation during policy-making, harmonising and aligning
partners’ and government goals, and improving implementation of programmes.

Participation in the dialogues and characteristics of the actors

Most of the respondents felt that to generate innovative ideas and best practices,
the policy dialogues had to have good planning, management, participation and governance.
There was general consensus that participation in the dialogues was good, and participation
of different and important actors was highlighted on several occasions as a strong
feature of the dialogues. The inclusion of both national and county level stakeholders
also was lauded.

Some of the respondents felt that participation consistency was affected by other
activities that the stakeholders had to attend and the involvement of top level officials
at both the county and national levels, who often had proxies representing them. The
quotation below demonstrates this,

I think there is good representation of partners and government. Maybe the only issue
is that the level of participation is not consistent sometimes when individuals who
regularly participate and understand the issues send proxies who are not at their
level. (National level stakeholder)

The presence of a range of stakeholders with different capacities, ranging from top-level
and international level experts to sub-national (county) level actors created a sense
of insecurity for the lower level actors. This was exhibited when junior officials
were confronted with questions during their presentations, as one respondent remarked,

Some county health officers will just come and give information and figures and sometimes
if people push them against the wall and ask lots of questions, they are not able
to defend some of these things. (County health representative)

The method employed in group work and discussions also was regarded as ineffective
as it perpetuated the tendency for domination by a few powerful participants. In those
circumstances the influential actors were able to drive their personal agendas, as
a respondent noted,

In group work people come and spend a couple of hours before they have something to
say. I think sometimes it’s driven by just the fact that they need to get per diem.
I agree that some of the stakeholders or participants have genuine interest but not
all of them, so those who were vocal and who want to be heard will dominate the conversation
or group work with their ideas, and those who were kind of shy will never be heard. (National level respondent)

The time allocated for the dialogues was thought to be inadequate from a participation
perspective. Cultural and societal contexts in Liberia commonly allow anyone to voice
his or her opinion regardless of its sense. This was responsible for some prolonged,
meaningless discussions in the dialogues at the expense of quality and relevant input.

There was general consensus that community participation was weak. The respondents
expressed concern over the limited participation of the general community, which was
contrary to the ministry’s declaration of the importance of community engagement.
There was debate also on the definition of community participation, which was deemed
ambiguous. For example, in one of the meetings the participation of superintendents
and their empowerment to make decisions was considered as community participation,
while in other contexts it was the community members, who were beneficiaries of the
health services, who were actively involved in the dialogues.

The participation of the community was critical and genuine during the Ebola outbreak,
as many of the respondents stated. This argument was based on the community members’
involvement in the dialogues during the outbreak. It was stressed that community participation
was key in winning the battle against the Ebola virus disease. Through the dialogues
government officials became aware of the societal constructs and myths surrounding
Ebola and were able to counteract them.

Characteristics and management of the dialogue forums

The organisation of the dialogues in terms of place and participation was considered
commendable by most of the respondents. The dialogue process was principally led by
the MoH’s Planning and Policy Department with technical support from the staff of
the WHO country office in Liberia. The respondents revealed that the dialogue process
involved identification of themes by a small group that included the WHO the MoH’s
Planning and Policy Department focal person. Once the theme was agreed upon a specialist
was invited to make a presentation on it:

For instance, if they want us to focus on maternal health issues, they will have a
specialist on maternal health issues come and do a presentation on best practices
from other countries, then they will have the county health officers make presentations
on issues from their counties to see the level at which each county is… and people
will discuss the way forward and what could be done better. (MoH official)

Once the issues and activities were agreed upon in the general meetings, smaller meetings
were convened between MoH and WHO officials to agree on the practicalities of implementation.
Despite there being a clear process for the dialogues, several shortfalls with the
technicalities of the procedures were highlighted. Primarily it was felt that the
dialogues were not structured well enough to capture and articulate all the key issues.
Most respondents were of the view that the dialogue process did not follow a specified
methodology that included the generation of ideas, building of consensus and agreement
on the way forward based on an informed-decision process. Two of the respondents noted,

The mix of people who participate in dialogue activities is good. But the way of generating
and processing ideas is not very effective. The skills of the facilitators are not
particularly at the right level. (Donor representative)

There are no analytical tools like the strengths, weaknesses, opportunities and threats
(SWOT) framework used to analyse issues to come up with solutions. In my opinion,
there were no critical discussions around issues because there were no defined methodologies
for the deliberations. Further, I am not sure that the proper outcomes were generated. (Donor representative)

The management of presentations was considered to have been improper in terms of how
time was handled and how the main points were generated. The result was superficial
discussion of the issues. The respondents believed that little attention was given
to preparing and distributing background information or documents ahead of time, which
might have contributed to making the discussions more informed. One of the respondents
lamented,

You cannot come to a conference and be expected to read 50 pages given to you a day
before the meeting and give proper input. (NGO national level representative)

Lack of continuity among the meetings was raised as a concern by the respondents.
Despite the time spent in the dialogues, there were instances where some of the suggested
activities were stopped or were not implemented owing to competing priorities. There
were respondents who felt that the dialogues were not different from the regular meetings,
that they were more of a ticking-the-box exercise or another form of process to ensure
that the counties were accountable for implementing their plans, as one of them explained,

It is just another checklist for the counties, because they don’t show that the problems
have been overcome with the resources provided for them. I think one of the issues
the counties recognise from this has been that it is mainly a means of monitoring
them. It’s a good way to show in a transparent way and hold the counties accountable
for what they plan to do. But it’s also a means of shaming the counties. If the counties
make plans but do not achieve them, everyone will know that, but they will not understand
that they couldn’t be achieved without an enabling environment and resources to move
from one point to another. (MoH Sub-national representative)

How the EVD outbreak influenced the policy dialogue

The policy dialogues took a unique shape during the Ebola outbreak. During the early
days of the outbreak, the MoH was rendered powerless, as the leading role in dealing
with the disease was taken over by politicians and donor groups. Some respondents
even attributed the poor response and delay in inhibiting the outbreak to the muddled
leadership. The respondents believed that once the ministry had reassumed its role,
it managed to control the situation:

The Ministry of Health can also take consolation in the fact that the response to
Ebola was taken over by politicians. They even skewed the initial response of the
public. Some accused the ministry of health of raising a false alarm about Ebola in
order to get extra money. (Sub-national NGO representative)

From the study, it was generally felt that the processes of the dialogues were better
organised during the Ebola outbreak. After the initial confusion, the returning of
the coordination role to the MoH made the ministry more authoritative and responsive.
The ministry went the extra mile by assigning responsibilities and coordinating the
partners, as one of the interviewees explained,

The ministry came up with the issues and presented them to the donors, saying, “partners,
this is what is required, and what can you offer?” They even went further to streamline
activities among the different donors/partners. For example they would say, “This
organisation is taking the lead in safe and dignified burial during the Ebola crisis,
so you can tackle another area.” (NGO national representative)

In relation to the dialogues both before and during the Ebola outbreak, it was perceived
that some of the dialogue documents had been produced in a hasty manner, which potentially
affected the quality and inclusiveness of the dialogues, as one of the respondents
stated,

I think there is tension that exists between the external demands to produce a product
by a certain deadline…which might affect the content and quality. (Sub-national level representative)

From a procedural perspective, the process of developing the investment plan was cited
in many instances as having been carried out in a rush with inadequate consultation
of Liberians. This is what two respondents said about it,

Very recently, with a number of technical experts from outside, we tried to develop
the investment plan for Liberia to restore itself after the Ebola crisis. My impression
of it was that it went so fast that a lot of people did not sort of know what was
going on. This was by necessity not because the intention was to be non-transparent,
but it just had to go quickly because there were funding deadlines that had international
implications and could not be shifted. My impression was that there was a plan that
was produced, but largely, except for the people who were deeply involved in it, people
weren’t really appropriately familiarised with the plan afterwards. (National level representative)

… it’s great to have this health investment plan and it’s proved to be a wonderful fund-raising
tool for the country, for the president, for the minister, but it’s certainly, I think,
something that people are still sort of, like, “What’s actually in there?” “Who put
that in there?” “Why is that in there?” To me, I just see that as sort of like a victory
in one … But it doesn’t seem to be owned by even the middle management and other ministry
stakeholders. (National level NGO representative)

Priority issues and supportive evidence discussed during the dialogues

There was general consensus among the respondents that the dialogues were addressing
pertinent issues of the Liberian health system. The priority issues included the health
system’s performance, health financing, human resources for health, and emergent health
situations such as the Ebola outbreak (see Table 3).

Table 3. Issues featured in policy dialogue meetings in Liberia

Opinions about the process for generating and selecting priority issues for the dialogues
were extremely divergent among the respondents. A number of them were not aware of
how the themes were generated or decided upon. A few others who were knowledgeable
of that process described it as having evolved from several proposals at the MoH from
which at least three priorities were selected and circulated to the main stakeholders
such as the United Nations Population Fund, WHO, the United Nations Children’s Fund
and the United States Agency for International Development, and all the other health
partners for the final decision. The respondents felt that only a few of the health
partners had an important role in the decision on the priorities.

Sometimes the issues for discussion were generated from various departments within
the MoH, such as in instances where an issue could not be resolved in the department.
For example, the decisions to generate evidence or collect data on user fees and to
conduct perception studies on the health systems were all justified by departmental
needs.

Some respondents felt that the planning systems had been structured in a way that
allowed the policy issues discussed in the dialogues to be determined by external
forces such as the global health initiatives, international donors, and partners,
often biased by their interests. As a result most of the policy issues given priority
were predetermined and some evolving issues in the health sector were not accorded
prominence. The respondents also perceived certain issues to have been driven by the
funders of the dialogues, such as those cited in these examples,

Our biggest challenge is the fact that people want to have certain things done, for
example issues related to national health accounts. How many people know what a national
health account is or what it means? People don’t understand but the ministry included
it, as it was influenced by donors. (National level representative)

… with respect to how we build consensus on this policy dialogue thematic areas, that
discussion has largely been between the Ministry of Health and our technical colleagues
at WHO. (MoH coordinator, ME)

The validity of the data used in the dialogues was a concern cited by a number of
respondents, such as the one who made this comment,

For example, somebody comes and presents wrong data about Sinoe and I know the situation,
and I wonder where they got that data. (Sub-region NGO representative)

Time was cited as a major stumbling block, as there were usually too many issues to
be discussed within the allocated time for the dialogue. This led to superficial discussion
of issues with the proposed solutions and interventions being suboptimal.