ChangeLab Solutions

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomesMethods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries.Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation.Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

The objective of health in all policies (HiAP) is straightforward: integrating health and equity considerations into policies across all sectors of government will transform systems and environments in ways that support healthier, more equitable outcomes. However, pursuing that objective is complex and achieving those outcomes takes time. This article examines three communities (Minneapolis, MN, Seattle, WA, and Richmond, CA) which have been pursuing HiAP long enough to achieve meaningful policy, systems, and environmental change. We identify when and how each community employed five key strategies for effectively adopting and implementing HiAP. And we present policies each community has adopted with examples of outcomes these initiatives have achieved. The purpose of this assessment is to set realistic expectations for how long it may take to achieve HiAP and to identify themes that could help other communities realize this level of progress more quickly and efficiently. Based on our assessment of these communities, we conclude that it is not uncommon for it to take ten years or more to integrate health and equity into a substantial and coordinated set of policies across government agencies and departments. However, we also see that each step taken toward HiAP makes subsequent steps easier. And as more policies include health and equity concerns, the entire system does become more effective at improving health and equity outcomes. Finally, we show that that integrating health and equity across a range of plans and policies does shape decisions, lead to actual community transformation, and improve community health outcomes.

Municipal and state governments are surging ahead in obesity prevention, providing a testing ground for innovative policies and shifting social norms in the process. Though high-profile measures such as New York City's soda portion rule attract significant media attention, we catalog the broader array of initiatives in less-known localities. Local innovation advances prevention policy, but faces legal and political constraints-constitutional challenges, preemption, charges of paternalism, lack of evidence, and widening health inequalities. These arguments can be met with astute framing, empirical evidence, and policy design, enabling local governments to remain at the forefront in transforming obesogenic environments.

Competitive foods remain prevalent in schools even though the majority of states' laws have addressed this for several years. Whereas updated federal standards take effect during school year 2014-2015, aspects of competitive food regulation will remain relegated to the states and districts and concerns exist about compliance with the federal standards. This study examined compliance provisions codified into state law that focused on incentives, monetary penalties, or contracts which could provide examples for other jurisdictions. Codified statutory and administrative laws effective as of January 2013 for all 50 states and the District of Columbia were compiled using Boolean searches in Lexis-Nexis and Westlaw. All laws were analyzed by 2 study authors to determine the presence and components of relevant provisions. Eighteen states' laws contained compliance mechanisms including financial and/or programmatic incentives (5 states), contract provisions (11 states), and monetary penalties for noncompliance (7 states). Five states' laws contained a combination of approaches. Compliance measures help to strengthen competitive food laws by providing state agencies with an enforcement mechanism. Enforcing such provisions will help to create healthier school environments. This study will provide useful insight for governments at all levels as they implement competitive food laws.

An emerging body of research examines the health and economic impacts of healthy corner store interventions, although implementing valid mechanisms to capture changes in diet remains a challenge. Healthy corner store interventions employ strategies to help corner stores procure, maintain and market healthier foods such as fruits and vegetables, whole grains and low-fat dairy items like skim milk. A recent national convening of partners yielded a series of research and evaluation questions that need answers in order for the field to progress. Participants in the Healthy Corner Stores Symposium identified several challenges to developing a sustainable business model for small-scale healthy food retail. This group of practitioners, funders, lenders, academics, and other leaders ranked what they saw as the most promising opportunities for maximizing the positive impact these businesses have on the community. Unique to this forum, the agenda was born from a program-operation perspective and not from the more common approach where an independent researcher evaluates the efficacy of a program or intervention. As efforts to improve food systems emerge, such an approach to research is critical. The central challenges and a prioritized list of research questions are discussed.

Urban agriculture (UA) is cropping up in backyards, vacant lots, rooftops, and city parks across North America. Despite popular interest, zoning often serves as an obstacle to UA's expansion. In this reflective case study, we document the efforts of the Oakland Food Policy Council (OFPC) to develop recommendations for urban agriculture zoning in Oakland, California, as a means of fostering UA's expansion. First, we focus on the role of zoning in urban agriculture planning, draw¬ing on best practices from around the country. Then we provide an overview of Oakland's food system and place the OFPC within the context of local food justice initiatives. Next, we outline the process by which the council prioritized food system goals before focusing more specifically on its efforts to create new zoning definitions and operating standards for UA, including both successes and obstacles to gaining the attention of city officials and moving the policy agenda forward. We conclude by reviewing the OFPC's lessons learned.

Locally grown food laws that require, or provide incentives for, purchasing food grown within a defined geographic boundary are vulnerable to challenge under the U.S. Constitution’s restrictions on local and state laws that discriminate against goods and commerce from other states, known as the dormant Commerce Clause doctrine (DCCD). Policymakers and advocates for local food should understand the impact of these restrictions and should take advantage of an important exception to these restrictions when drafting policies to encourage purchase of locally grown food. In