title: Power and pro-poor policies: the case of iCCM in Niger.
abstract: Analyses of health policy in low- and middle-income countries frequently mention but rarely adequately explore power dynamics, whether or not the policy in question targets the poor. We present a case study in Niger of integrated community case management (iCCM), a policy to provide basic care for poor rural children sick with malaria, diarrhoea and pneumonia, which has contributed to measurable reductions in child mortality. We focus on the three dimensions of power in policymaking: political authority, financial resources and technical expertise. Data collection took place March to August 2012 and included semi-structured interviews with policy actors (N = 32), a document review (N = 103) and contextual analysis. Preliminary data analysis relied on process tracing methodology to examine why iCCM was prioritized and identify dimensions of power most relevant to the Nigerien case; we then applied theoretical categories deductively to our data. We find that political authorities, namely President Mamadou Tandja, created the underlying health infrastructure for the policy ('health huts') as a way to distribute rents from development aid through client networks while claiming the mantle of political legitimacy. Conditional influxes of financial resources created an incentive to declare fee exemptions for children below 5 years, a key condition for the policy's success. Technical expertise was concentrated among international actors from multi-lateral and bilateral agencies who packaged and delivered scientific arguments in support of iCCM to Nigerien policymakers, whose input was limited mainly to operational decisions. The Nigerien case sheds light on the dimensions of power in health policymaking, particularly in neo-patrimonial African regimes, and provides insights on how external actors can work within these contexts to promote pro-poor policies.
authors.affiliation: Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health Baltimore, MD 21205, USA, sdalgli1@jhu.edu.
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Dalglish
authors.affiliation: Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health Baltimore, MD 21205, USA.
authors.forename: Pamela J
authors.initials: PJ
authors.lastname: Surkan
authors.affiliation: Laboratoire d'Etudes et de recherche sur les Dynamiques sociales et le développement local, Niamey, Niger and.
authors.forename: Aïssa
authors.initials: A
authors.lastname: Diarra
authors.affiliation: Laboratoire d'Etudes et de recherche sur les Dynamiques sociales et le développement local, Niamey, Niger and.
authors.forename: Abdoutan
authors.initials: A
authors.lastname: Harouna
authors.affiliation: Department of International Health, Health Systems Program, Johns Hopkins Bloomberg School of Public Health Baltimore, MD 21205, USA.
authors.forename: Sara
authors.initials: S
authors.lastname: Bennett
mesh_terms: D019090:Case Management; D000067576:Child Health; D002662:Child Health Services; D046688:Child Mortality; D002675:Child, Preschool; D003150:Community Health Workers; D006291:Health Policy; D006801:Humans; D007407:Interviews as Topic; D009548:Niger / Q000453:epidemiology; D011050:Policy Making; D011203:Poverty / Q000331:legislation & jurisprudence*; D036301:Qualitative Research; D012423:Rural Health
keywords: Africa; child mortality; health policy; power; rural health