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Background: There is a growing interest in implementing intersectoral approaches to address social determinants especially within the Sustainable Development Goals (SDGs) era. However, there is limited research that uses policy analysis approaches to understand the barriers to adoption and implementation of intersectoral approaches. In this paper we apply a policy analysis lens in examining implementation of the first thousand days (FTD) of childhood initiative in the Western Cape province of South Africa. This initiative aims to improve child outcomes through a holistic intersectoral approach, referred to as nurturing care. Methods: The case of the FTD initiative was constructed through a triangulated analysis of document reviews (34), in depth interviews (22) and observations. The analysis drew on Hall’s ‘ideas, interests and institutions’ framework to understand the shift from political agendas to the implementation of the FTD. Results: In the Western Cape province, the FTD agenda setting process was catalysed by the increasing global evidence on the life-long impacts of brain development during the early childhood years. This created a window of opportunity for active lobbying by policy entrepreneurs and a favourable provincial context for a holistic focus on children. However, during implementation, the intersectoral goal of the FTD got lost, with limited bureaucratic support from service-delivery actors and minimal cross-sector involvement. Challenges facing the health sector, such as overburdened facilities, competing policies and the limited consideration of implementation realities (such as health providers’ capacity), were perceived by implementing actors as the key constraints to intersectoral action. As a result, FTD actors, whose decision-making power largely resided in health services, reformulated FTD as a traditional maternal-child health mandate. Ambiguity and contestation between key actors regarding FTD interventions contributed to this narrowing of focus. Conclusion: This study highlights conditions that should be considered for the effective implementation of intersectoral action – including engaging cross-sector players in agenda setting processes and creating spaces that allow the consideration of actors’ interests especially those at service-delivery level. Networks that prioritise relationship building and trust can be valuable in allowing the emergence of common goals that further embrace collective interests.
The study adopted a qualitative research methodology and a case study approach 39,40 to analyse the adoption and implementation processes of the FTD initiative in the Western Cape province. Data were collected between May 2018 and August 2019 through document reviews, in-depth interviews and observations. Table 1 provides an overview of the data collection activities and of the study participants. Abbreviations: FTD, first thousand days; PICH, Parent, Infant and Child Health; NGOs, non-governmental organisations; CBS, community-based services; ECD, early childhood development. Observation methods are an established qualitative method of inquiry rooted in ethnographic research that help the researcher understand actor behaviour and processes occurring in context. 39 Direct observations of relevant meetings were conducted to learn which stakeholders were involved, their levels of engagement and influence and how interventions were prioritised. The researcher attended and observed meetings of two working groups (the Parent, Infant and Child Health [PICH] working group and the community-based services group) and three FTD-related workshops (Table 1). Although observations were useful to establish familiarity with key informants and to access key documents, we acknowledge the limitations of this method in studying processes of policy-making, especially as the emergence of decisions can be hard to identify within widespread networks of actors. 41 Observational data is also subject to researcher bias which we accounted for by triangulating field notes with interviews and documentary evidence. Documents reviewedincluded minutes of the meetings and workshops, official policy documents from the provincial website, research newsletters covering the FTD and annual reports from all relevant departments. National level policies that focused on the FTD, including maternal and child health policies and relevant scientific literature, were also included. Additional literature was sourced through hand searches of references in these documents. A total of 34 documents were analysed and data extracted provided information on administrative procedures, proposed interventions, actor involvement and collaborative engagements. We aimed to interview key informants that were involved in the adoption and early implementation processes of the FTD. An initial list of key informants was provided by one of the members of the Community-Based Services (CBS) working group while other informants were identified through snowballing. Interviews continued until saturation was reached resulting in a total of 22 participants. During the recruitment process, it became apparent that other key government Departments (Education and Community and Safety) had limited involvement in the formulation processes, and so respondents from these Departments were not pursued for interviews. This presented a limitation to the study as respondents were largely drawn from the health sector. Follow up interviews were also conducted with two of the key informants from the FTD executive committee a year after initial interviews, to explore if any changes had occurred. Interviews were undertaken by the first author, guided by a semi-structured interview guide. Respondents were asked about the FTD agenda setting processes, the goals and interventions of the FTD, actor roles and relationships, collaborative processes and contextual factors influencing policy processes. Nineteen face to face and three skype interviews were conducted with informed consent provided by all participants prior to their interviews. Interviews were recorded and transcribed verbatim and lasted between 30 minutes and one hour. Interview transcripts, outputs of document reviews and field notes from observations were imported into Atlas.ti software. This initial step of data analysis involved generating a timeline mapping the key events associated with the FTD between 2015 and 2019. Further analysis organised data into codes through abduction. 42 After initial coding a, further interpretation sought to elicit themes through a thematic approach 39 that explained how key events of the FTD unfolded and why. Our analytical strategy was therefore both inductive based on what emerged from the data and deductive influenced by the Ideas, Interests, Institutions (3Is) framework 43 to understand the adoption and early implementation experiences of the FTD. The 3Is framework, draws from a range of theoretical perspectives and identifies the interaction of ideas, interests and institutions as crucial in shaping policy experiences. 43-45 Ideas refer to how policy problems and solutions are framed and the ability of actors to identify with common goals. 43,45 Interests encompass the motivations of various actors and the relative sources of power they draw on to influence outcomes. 45 The concept of institutions has been defined and used in a number of ways. 44,46,47 Here we draw on the definition of institutions applied to the governance of multisector action. 45 We refer to institutions as formal laws and the bureaucratic arrangements that govern relationships between different sectoral entities and consider how they, as well as organisational capacity, can affect intersectoral action. 45 This framework was selected for this study as the three variables assisted in revealing the influence of these critical factors in the FTD experience, especially during adoption and implementation.
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