Strengthening country ownership of national antimalarial policymaking: insights from Laos, Pakistan and the Solomon Islands.

Background: The concept of "ownership" in global health policymaking broadly assumes that external donors and advisors expect recipient countries to actively steward their national programmes when assistance is provided. This study specifically explored country ownership of national policy decision-making for Plasmodium vivax malaria using three case studies: Laos, Pakistan and the Solomon Islands.

Methods: Yin's comparative case study model, Kingdon's Multiple Streams policy theory guided this analysis. From 2021 to 2024, interviews were undertaken with 29 national stakeholders, external partners and relevant global stakeholders.

Results: There were four main findings: firstly, national malaria programme respondents expressed strong ownership of internal antimalarial policy processes but acknowledged nuanced influence of external donors on the national policymaking space. Second, in countries relying on external funding, antimalarial policy change is mainly triggered by the World Health Organization's (WHO) recommendations and WHO national support was identified as a key enabler of policy change. Third, external donors often influence, or outline policy directions aligned with WHO recommendations, but policy change is also driven by antimalarial tools procurement constraints. Fourth, timing of updated WHO recommendations may not align with countries' needs. Yet many malaria endemic countries face pressure from external funders, that resource national policy decision-making, to adhere to WHO recommendations, although the WHO considers its recommendations as advisory only. Overall, these external influences moderate country ownership of national policy change.

Conclusions: This study indicates that there is potential to strengthen country ownership of national antimalarial policymaking. This may require application of targeted policy acceleration levers such as better alignment of timing of global guidance with country needs and an understanding between external donors and national stakeholders that WHO guidance is advisory only and should be understood as one perspective relative to country needs.