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Table 5 Determinants of implementation from a policy perspective and the factors that characterize the determinants

From: Understanding the implementation of evidence-informed policies and practices from a policy perspective: a critical interpretive synthesis

Determinant Description Factors that characterize determinant
I. Characteristics of the EIPP 1. Not possible to predict the success or failure of a particular policy package based on its intrinsic characteristics alone [56]
2. Need to examine questions such as whether the policy selected:
(a) Is an appropriate fit with the problem [78, 91]
(b) Aligned with existing context [12, 88]
1. Relative advantage [26, 37]
2. Compatibility [26, 37]
3. Complexity of goals and ease of implementation [26, 37, 67]
4. Obligations [26, 37]
5. Resources [26, 37]
6. Existing relationship with state and provider [103]
7. Level of ambiguity of the EIPP [64]
8. Level of conflict among stakeholders [64]
9. Interaction of policy characteristics with other determinants [56]
II. Policy formulation process 1. Shape given to a policy by the initial formation processes has an impact on its implementation [56]
2. Depending on the implementation approach, the government may distribute responsibility for some or almost all of the policy formulation process to other stakeholders [12]
3. Level of involvement of service organizations, street-level bureaucrats and recipients may influence the confidence in, and support of, the policy decision and improve the chances for successful implementation [97]
1. Government actors responsible for formulating policy [56]
2. Perceived legitimacy of government actors [56]
3. Extent to which there is opportunity to provide feedback [56]
4. Responsiveness of policymakers to feedback [56]
5. Level of involvement of non-governmental actors [12, 78, 97]
6. Adequacy of planning for implementation (consideration of resources for implementation) [97]
7. Constraints experienced during formulation [12, 26]
III. Vertical public administration and thickness of hierarchy 1. Vertical Public Administration
(a) Term used to identify the layers in the policy transfer process
(b) Refers to separate governments exercising their authority with relative autonomy [56]
(c) Policies generated outside of a socio-political level may be more or less acceptable to that level
2. Thickness of Hierarchy
(a) Number and complexity of institutions, departments, or agencies at a particular socio-political level
(b) The thicker the hierarchy, the more managerial competence, professionalism, and governance skills are required by public servants in order to support effective implementation [59]
1. Number of socio-political levels [56]
2. Acceptability of policy generated outside of a particular socio-political level [114]
3. Appropriateness of socio-political level [86]
4. Thickness of each socio-political level (number and complexity of institutions, departments, or agencies and their coordination and interdependence) [55]
IV. Networks/inter-organizational relationships 1. Reflects the existence and nature of the relationships between parallel organizations who must collaborative in order to achieve effective implementation and who do not have a hierarchical relationship [56]
2. Better connections among stakeholders also increases the opportunity for rapid diffusion and informal spread of innovation, facilitating implementation
1. Degree of coordination among:
(a) Systems [80]
(b) Organizations [86]
(c) Donors /other funders [84]
(d) Leaders [12]
2. Formality (formal or informal) [72]
3. Network type (e.g., policy or inter-organizational) [53]
4. Coherence and strength of connections [112]
V. Implementing agency responses 1. Factors affecting the responses of implementing agencies can be divided into:
(a) Issues related to the overall characteristics of the agencies
(b) Behavior of front-line or street-level staff [56]
2. Overall “health” of organizations and how front-line/street-level bureaucrats use their discretion and power impact implementation success
1. Overall characteristics of the agencies:
(a) Level of organizational control [56, 76]
(b) Rate of staff turnover [88]
(c) Organizational decision-making processes [88]
(d) Extent of policy and behavior-related change required [14, 67]
(e) Attitudes of the agencies [14, 47]
(f) Resources of the agencies (e.g., minimum “investment threshold” in implementation infrastructure [97] or cost-absorptive capacity of agency to absorb additional costs associated with implementation [12] or certainty of funding [49])
(g) Impetus for chang e[77] (e.g., external mandates may increase an agency’s predisposition (i.e. motivation), but not its capacity to adopt an innovation; mandates may divert activity away from other innovations or locally generated priorities [26])
(h) Perception of implementation approach (e.g. if approach is punitive, mandatory, or “top down”) [82]
2. Behavior of front-line or street-level staff
(a) Level of discretion and level of relative autonomy from organizational authority affect the amount of interpretation of EIPP [13, 76]
(b) Competing accountabilities (e.g., state, market, professional, societal) [76]
(c) Power distribution between actors at the front-line, agency, and political levels [30]
(d) Personal characteristics including their knowledge, skills, and perceived support from colleagues [88]
VI. Attributes and responses from those affected by EIPP 1. The characteristics of the people affected by the EIPP, their response to it, and the impact of the responses
2. Most evident when those affected are powerful, such as in regulatory policy when those regulated are large organizations [56]
1. Diversity of target group behavior [14]
2. Target group as percentage of the population [14]
3. Impacts on stability of the workforce and responses to instability [12]
VII. Timing/sequencing 1. Implementation processes at scale require adequate time, which does not always align with the cycles they are subject to and some authors have identified the lack of time or short-term opportunism as barriers to effective implementation [e53, 54]
2. The sequencing of activities and alignment of implementation with other cycles is also important
1. Balance of predictability and adaptiveness to changing circumstances [68, 93]
2. The simultaneous address of system levers (including policy changes, measurement systems, and regulatory mechanisms) [97]
3. Timing and pace of cycles, such as political, policy, and funding cycles [104]
4. Specific aspects of time that impact implementation:
(a) The phased structure of the implementation process [104]
(b) When and how the implementation efforts are initiated [104]
(c) Timeframes for funding and leadership support [104]
(d) The need to demonstrate the impacts early
(e) Return on investment of time and money [104]
VIII. External environment or policy context 1. Factors outside of the policy area of focus may influence implementation
2. Can be referred to generally as the “political and social climate”, as unmodifiable or macro “context” or as “socio-economic conditions” [9, 14, 38, 40, 52, 70, 75, 80]
3. While most included articles did not address these determinants in depth, an overall examination of extracted data suggested two theoretical frameworks would be useful for classifying and understanding these determinants:
(a) 3I+E framework that identifies the institutions, interests, ideas, and external events that help explain what influences policy choices [113]
(b) Taxonomy of health and social system arrangements classified according to the governance, financial, and delivery arrangements [114]
4. These broader context and system arrangements may be critically important in explaining implementation outcomes and these frameworks provide some logic and organization to potential variables
1. 3I+E framework
(a) Ideas (e.g., the interplay between beliefs and values of policymakers and research evidence in a general way [38])
(b) Interests (e.g., the political culture and the depth of social cleavages [58])
(c) Institutions (e.g., relevant policies from other areas that “may represent potentially powerful contextual effects” [74, 78])
(d) External factors (e.g., technology and technological changes [14, 40]) economic forces operating in the overall society [60], and environmental (in)stability [53, 67]
2. Taxonomy of health and social system arrangements [114].
(a) Governance arrangements that are not specific to the EIPP being implemented but are still relevant to understanding implementation outcomes (e.g., centralization and power distribution of government [30, 72] or the form of governance structures (omnibus/discrete) [72])
(b) Financial arrangements (e.g., private/public contractual relations, reimbursement rates and mechanisms [72], and existing resource distribution [30])
(c) Delivery arrangements—referred to more generally in the health-focused articles as “health(care) system and services context” [38, 75] or “medical delivery system” [40]