CapacityDevelopment
RESOURCE GUIDE
IMPLEMENTATION
BARRIERS
July 2014
The Capacity Development Resource Guides highlight the key technical areas of expertise needed to
effectively influence health policy design, implementation, and monitoring and evaluation. Each guide
identifies the specific skills, knowledge, and capacities that individuals and organizations should possess in
the area. The standardized indicators listed for each competency and capability map to the accompanying
Capacity Indicators Catalog, which helps to generate a tailored tool for assessing and scoring an
organization’s capacity level. Each guide also includes a list of useful resources for designing and delivering
capacity development assistance.
Addressing Barriers to Policy Implementation
DEFINITION Developing a policy is just the first step; for policies to contribute to the
successful delivery of health services, they must be effectively implemented.
Challenges to implementation are referred to as “implementation barriers.” They
can be rooted in a variety of causes, including opposition from key stakeholders,
inadequate human or financial resources, lack of clarity on operational guidelines
or roles and responsibilities for implementation, conflicts with other existing
policies, lack of coordination and collaboration between parties responsible for
implementation, or lack of motivation or political will.
RELEVANCE Policy implementation refers to the mechanisms, resources, and relationships
TO POLICY that link health policies to program action. It includes both technical and
relational aspects—not only specifying the institutions responsible for
implementation but also ensuring that the institutions have the capacity
for implementation and that the relations among institutions are conducive
for collaboration (Hardee et al., 2012). Understanding the nature of policy
implementation is important because international experience shows that
policies, once adopted, are not always implemented as envisioned and do not
necessarily achieve intended results (Bhuyan et al., 2010).
To address implementation barriers, stakeholders must assess the root cause
of the challenge and develop targeted strategies to address each barrier in
collaboration with other interested and empowered parties. Throughout the
policy development, implementation, and monitoring processes, barriers should
H E A LT H
POLICY
P R O J E C T
IMPLEMENTATION BARRIERS
be continually assessed and addressed. Implementation is an ongoing process
of decision making by key actors who work in complex policy and institutional
contexts and face pressures from interested as well as opposing parties. As such,
the motivation, flow of information, and balance of power and resources among
stakeholders influences policy implementation processes. Ultimately, overcoming
policy implementation barriers will require commitment and perseverance by a
range of stakeholders, possibly over a prolonged period (Bhuyan et al., 2010).
KEY The ability to address policy implementation barriers is a key capability for
CAPABILITIES government, policymakers, and civil society. Addressing policy barriers requires
individual and institutional skills and competencies to understand the policy
environment governing the health system, the configuration of the health system
in the context of the government structure, and the needs of beneficiaries/
clients and implementers. It requires the ability to critically assess the true
root of policy implementation barriers—whether it is sociological, political,
structural, institutional, or cultural—and to craft targeted solutions to address
them. Finally, it requires engendering stakeholder buy-in and commitment to take
action, determining resources required for the proposed solution, implementing
a solution to remove the barrier, and enacting accountability mechanisms to
ensure that barriers have been addressed (Bhuyan et al., 2010; Cross et
al., 2001).
PERFORMANCE High capacity for addressing policy implementation barriers includes being
IDEAL able to
Gather and synthesize different types of information from various sources
Elicit feedback from implementers, partners, and beneficiaries to identify
barriers to successful policy implementation and explore root causes
Identify solutions to challenges and advocate for corrective action
Maintain systems to facilitate regular reviews of implementation experiences,
share best practices across groups, and integrate lessons learned into
subsequent policies and action plans
At the highest level of performance, individuals and organizations consider—
throughout the policy process—the potential roadblocks and steps to overcome
them. Attention to barriers starts with policy design and strategic action planning
and continues during policy implementation—and thus policy monitoring—to
track outcomes, identify challenges, and be alert to unintended consequences
or inequities. In a high-functioning system, the gap between policy and practice
narrows and barriers to realizing results are identified and removed.
In the ideal, the following would exist:
Policies translated into effective operational rules and guidelines
Efficient allocation and coordination of human and financial resources to
achieve policy goals
Regular systems to review policy and program decisions (e.g., mid- and end-
term reviews, multisectoral forums), with broad-based participation
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IMPLEMENTATION BARRIERS
individual competencies
KNOWLEDGE OF
Local and national policy environment, laws, and the configuration of the health IB 1
system within government structures
Specific aspects of the policy to be implemented, including policy goals, strategies IB2
and action plans, roles of different institutions and stakeholders, and available
resources
SKILLS TO BE ABLE TO
Collect, analyze, and present quantitative and qualitative data to identify barriers and IB3
develop evidence-based solutions
Engage diverse stakeholders in constructive policy dialogue to identify and address IB4
barriers at the appropriate level (national, district, facility, etc.)
Understand the socio/political/structural/institutional/cultural root of policy IB7
implementation barriers and craft targeted solutions to address them
Conduct cost analysis that aligns budget allocations with the actual resources IB6
required to implement policies
Draft operational policy guidance and rules to implement change IB8
Communicate evidence-based recommendations and influence decisionmakers to IB5
take corrective action
Monitor and document the policy implementation process and impact of adopted IB9
solutions
ATTITUDES/VALUES/ATTRIBUTES
Elicits stakeholder buy-in and commitment to ongoing engagement IB10
organizational capabilities
TECHNICAL ABILITY TO
Develop implementation plans that include clearly defined policy goals, strategies, IB11
action plans, monitoring mechanisms, and operational guidelines
Integrate best practices and successful approaches to overcoming barriers into IB12
organizational and decision-making processes
Capacity Development Resource Guide 3
IMPLEMENTATION BARRIERS
RELATIONAL ABILITY TO
Leverage multisectoral partnerships and resources to collectively address complex IB13
barriers at the appropriate level and facilitate implementation (national, district,
facility, etc.)
Provide training, technical assistance, and mentoring to other organizations on IB21
addressing implementation barriers
ORGANIZATIONAL OPERATIONS AND MANAGEMENT TO SUPPORT
A knowledge management system to share best practices in policy implementation IB15
and lessons learned internally and externally
Regular interactions among staff responsible for program implementation, monitoring IB16
and evaluation, and management
Allocation of sufficient resources (time, money, staff) for policy implementation and IB17
regular reviews and monitoring of the implementation process
Allocation of resources required to take corrective action to alleviate identified IB18
barriers and/or communicate recommended action for other organizations
Mechanisms to ensure compliance with policy directives and understand incentives IB19
for compliance as well as sanctions for non-compliance
Systems to routinely collect and analyze quantitative and qualitative data from various IB20
sources (e.g., periodic assessments, activity appraisals, client satisfaction surveys)
and stakeholders (beneficiaries, implementers, and policymakers)
Roll out of new policy directives throughout the organization along with adequate IB14
training, supervision, resources, and support for their implementation
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IMPLEMENTATION BARRIERS
Multi-directional feedback loops involving beneficiaries, implementers, and
policymakers
Mechanisms to ensure follow-up and compliance with policy directives (e.g.,
national monitoring board, national policy unit, incentives for compliance,
sanctions for non-compliance)
Systemic monitoring and evaluation of the impacts of policy formulation and
implementation
ILLUSTRATIVE Provide technical assistance on systems and process analysis for anticipating
CAPACITY- and mitigating against potential roadblocks during the policy formulation and
STRENGTHENING action planning processes
ACTIVITIES Support costing exercises that encourage aligning budget allocations with the
actual resources required to implement policies and programs
Train local decisionmakers (e.g., district health officials) on operational policy
issues and tools and techniques to analyze barriers
Provide technical assistance to develop monitoring and evaluation plans
that track both outcome and process indicators, including qualitative and
contextual information
Assist a multisectoral team of stakeholders to adapt and apply a proven
policy monitoring tool or checklist
Assist with the establishment of feedback mechanisms to gather information
from as well as report back to implementers and beneficiaries
Incorporate systems to document and share programmatic lessons learned
into organizational capacity development plans
Assist government and other stakeholders to carry out annual or mid-term
reviews and integrate findings into subsequent action plans
RESOURCES Australian Public Service. 2011. Public Sector Innovation Toolkit: Barriers. Canberra: Department of
Innovation, Australian Government). Available at: http://innovation.govspace.gov.au/barriers/.
Bhuyan, A., A. Jorgensen, and S. Sharma. 2010. Taking the Pulse of Policy: The Policy
Implementation Assessment Tool. Washington, DC: Futures Group, USAID | Health Policy Initiative,
Task Order 1. Available at: http://pdf.usaid.gov/pdf_docs/PNADX728.pdf.
Brinkerhoff, D. and B.C. Crosby. 2002. Managing Policy Reform: Concepts and Tools for Decision-
Makers in Developing and Transitioning Countries. Bloomfield, CT: Kumarian Press. Available at:
http://books.google.com/books/about/Managing_Policy_Reform.html?id=r-py_7AVh6oC.
Cottingham, J., E. Kismodi, A.M. Hilber, O. Lincetto, M. Stahlhofer, and S. Gruskin. 2010. “Using
Human Rights for Sexual and Reproductive Health: Improving Legal and Regulatory Frameworks.”
Bulletin of the World Health Organization 88(7): 551–5. Available at: http://www.ncbi.nlm.nih.
gov/pubmed/20616975.
Cross, H., K. Hardee, and N. Jewell. 2001. “Reforming Operational Policies: A Pathway to
Improving Reproductive Health Policies.” Occasional Paper No. 7. Washington, DC: Futures
Group, POLICY Project. Available at: http://www.policyproject.com/abstract.cfm/706.
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Fretheim, A., S. Munabi-Babigumira, A.D. Oxman, J.N. Lavis, and S. Lewin. 2009. “Support Tools for Evidence-Informed
Policymaking in Health 6: Using Research Evidence to Address How an Option Will Be Implemented.” Health Res Policy Syst. 7
Suppl 1. S6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20018113.
Hardee, K., L. Irani, R. MacInnis, and M. Hamilton. 2012. Linking Health Policy with Health Systems and Health Outcomes: A
Conceptual Framework. Washington, DC: Futures Group, Health Policy Project. Available at: http://www.healthpolicyproject.
com/pubs/186_HealthPolicySystemOutcomesConceptualALDec.pdf.
International Health Partnership. 2011. Monitoring, Evaluation and Review of National Health Strategies: A Country-Led Platform
for Information and Accountability. Geneva: World Health Organization. Available at: http://www.who.int/healthinfo/country_
monitoring_evaluation/documentation/en/index.html.
National Institute for Health and Clinical Excellence (NICE). 2007. How to Change Practice: Understand, Identify, and Overcome
Barriers to Change. London: NICE. Available at: http://www.nice.org.uk/media/AF1/73/HowToGuideChangePractice.pdf.
Suggested citation: Health Policy Project. 2014. “Capacity Development Resource Guide: Implementation Barriers.”
Washington, DC: Futures Group, Health Policy Project.
ISBN: 978-1-59560-029-5
This resource guide is part of an Organizational Capacity Assessment (OCA) suite of tools. The USAID-funded Health Policy
Project developed the suite to help organizations assess and strengthen their capacity to contribute to improved health
systems and health outcomes. The tools include an overview of the OCA approach, a facilitator guide, a series of capacity
development resource guides, and a Capacity Indicators Catalog. The suite is available at www.healthpolicyproject.com.
The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development
under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in
collaboration with Plan International USA, Futures Institute, Partners in Population and Development, Africa Regional Office
(PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood
(WRA).
The information provided in this document is not official U.S. Government information and does not necessarily represent the
views or positions of the U.S. Agency for International Development.
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