Once agreement on the need for policy change has been reached, maximize momentum so that evidence is converted into action

The political environment can shift rapidly. It is helpful to be aware of broader political, economic, or sectoral changes and trends and reflect on how these may affect the content and timing of a proposed policy and/or its implementation. When appropriate, it can be useful to seek support from multiple political parties or contingencies. There may be finite windows of opportunity for introducing a policy, and if additional time passes, momentum may be lost. As national priorities or political and fiscal climates shift, one can consider either making adjustments to the proposed policy intervention or taking a phased approach. When strategies are particularly innovative or comprehensive, they may be viewed as too expensive, introducing too great a change, and/or requiring action by too broad a range of implementers. In these cases, stakeholders may end up implementing the policy in a piecemeal or stepwise manner rather than as a complete package. It is not always possible to achieve a collective vision for full implementation of a policy. Major, comprehensive reform does not happen often or without considerable investments of time and advocacy. In addition, in some instances, decentralization may limit the ability of central authorities to impose policies on districts, particularly where local management committees oversee health facility administration. Thus, if HRH policies are to be implemented at the district level, it is recommended that there be district-level involvement in policy development, particularly in the evidence review and decision-making processes.


Where there are windows of opportunity, such as budget development, policy revision, or strategic planning cycles, it is useful to take advantage of those periods to push for action. It may take a few cycles to see a result. In Uganda, the initial impetus for a retention strategy—the health worker motivation study—took place in 2008. The discrete choice experiment was conducted and costed two years later, and the results of the exercise were shared with the HRH TWG, including a presentation of costed incentive packages for doctors, nurses, pharmacists, and laboratory technicians (Rockers et al. 2011). It was not until the end of 2012—four years after the motivation study—that the consistent advocacy efforts resulted in the government’s substantial wage bill increase and the corresponding massive recruitment of health workers mentioned above. While the proposed retention strategy was not adapted in its entirety, decision-makers must weigh not only the technical aspects of a strategy but also its political, economic, and social implications. Further, it is important to note that personnel functions within the MOH, such as human resources recruitment and management, are decentralized to District Service Commissions (Ssengooba et al. 2007). Thus, components of the discrete choice experiment-elicited health worker job packages and other aspects of the overall retention strategy may have fallen outside the realm of the central MOH.

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