Applying the One Health approach to study the policy and institutional determinants to control and prevent zoonoses in a low-resource setting

Abstract

Background

Zoonoses – diseases transmitted between animals and people – disproportionally affect low-resource countries (LRCs). The complex nature of zoonoses adds substantial barriers to implementing multisectoral policies to address them. Research on the policy process could help illuminate the significant factors influencing policy change among the complex systems involved in managing zoonoses. We applied the One Health (OH) approach to describe the policy process among the systems involved in preventing and controlling zoonoses in Peru. The study’s purpose is to (1) describe the priority-making process and the driving or limiting factors, (2) describe the process for selecting policy solutions and (3) describe perspectives about organizations’ role in zoonoses management and authority in policy-making.

Methods

We applied a case study with a qualitative research approach. We conducted semistructured interviews with policy-makers and experts integral to zoonoses programs in the Ministry of Health, Agriculture and Environment at Peru’s national and subnational levels. The final analytical sample was 59. We used a rapid qualitative method to analyse the data.

Results

Limited surveillance systems do not capture regional endemic zoonoses. Influenced by funding structures, local activities are focused on addressing national priorities instead of local zoonoses. Policies are developed at the national level through multidisciplinary work teams and multisectoral regional meetings, incorporating feedback from experts’ opinions. Local policies that regulated roles in multisectoral activities were described as more accessible solutions to address zoonoses. Hierarchical structures deter local policy-making and adaptations, and unclear rules in zoonosis management among animal and environmental systems were reported as barriers to multisectoral work. OH implementation barriers could be prevented by engaging local leaders in national priority and policy-making, as well as training and empowering local experts and technicians to propose policy changes or adaptations. Future research should focus on evaluating OH implementations over time to improve program effectiveness and sustainability.

Conclusions

By applying the OH approach, we captured the perspectives of various public organizations, including the local government, involved in preventing and controlling zoonoses in Peru. We found that structural barriers, such as national priorities surpassing local priorities, prevented addressing local issues. Hierarchical norms were also reported to hinder policy adaptations at the regional level. This study found that zoonosis management requires a multisectoral and intergovernmental approach. The empowerment of local technicians and experts was recommended to sustain multisectoral work and policy adaptations. More comprehensive research on the rules-in-use of policy-making is needed to provide recommendations for future multisectoral collaborations to address zoonoses in LRCs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-025-01408-7.

Introduction

Zoonoses – diseases caused by viruses, bacteria, parasites, and fungi transmitted between animals and people – inflict a heavy toll on the economy, health and livelihood worldwide [1]. Globally, zoonotic diseases are responsible for 2.5 billion cases of human illness and 2.7 million deaths annually, threatening farmers’ livelihoods and wildlife biodiversity with the death of infected animals [2–4]. Emerging zoonoses can become devastating epidemics if not managed or controlled appropriately [5, 6]. Some, such as human immunodeficiency virus (HIV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have propagated widely in the human population and caused high global impacts [7]. Others, such as cysticercosis or malaria, constantly affect poor communities with deprived sanitation infrastructure and healthcare systems [1].

Changes in the ecosystem and land use, urbanization, intensification of agriculture, and globalization have increased the risk of emerging zoonoses [8]. Low-resource countries are disproportionately affected owing to weakened public health systems with few resources to establish and maintain surveillance and control systems [2]. While most zoonoses are preventable in theory, the complexity of interactions among humans, animals and the environment creates substantial barriers to implementing effective policies to reduce transmission and mitigate harm.

Comprehensive approaches for surveillance, prevention and control of zoonotic diseases are needed to identify the various complex socioecological systems in which zoonoses develop. Integrated programs that include early detection through surveillance and diagnosis systems and control systems that integrate an ecosystem interface are required to prevent and control zoonoses [9]. One Health (OH) is a holistic approach that applies an ecosystem model to represent the human–animal–environment linkage to understand health factors and find comprehensive solutions [10, 11]. OH strives to achieve this through transdisciplinary research, intersectoral coordination and collaboration among the interested parties [12]. While the OH approach is promising, uptake on the policy level globally has been sporadic and inconsistent [13, 14].

The coronavirus disease 2019 (COVID-19) pandemic, the emergence of other zoonotic diseases such as Ebola and the rise of antimicrobial resistance have shown that more research is needed to understand the complexity of the systems and policy processes to scale OH programs into sustainable and resilient policy solutions. Recommendations for effective implementation of OH programs highlight the importance of using a bottom-up approach to understand the community perspective and the needs at the local level [15]. However, it is also essential to understand the implementation policy context where the intervention takes part, including the policy development process, priority-making and the use of evidence-based information in decision-making to ensure strategies align with the policy and practice landscape [13, 16, 17].

Research on the policy process could help illuminate the major policy factors that influence policy change, accounting for the complexity of the systems [16]. An evaluation of the OH policy process to understand the mechanisms that link research, policy and action across sectors among OH experts found a gap in research to understand knowledge development, norms and values of the interested parties that mediate political action and social change [13, 18]. Moreover, studies that have investigated the barriers to implementing OH programs in the African policy context recommend studying the policy process to improve governance models to inform OH collaborations in low-resource settings [19, 20]. This paper aims to address the research gap by elucidating the policy processes of organizations involved in preventing and controlling zoonoses in a low-resource setting using the policy context surrounding the implementation of ring treatment to control cysticercosis in Peru as a case study.

Background of the case study of the implementation of the Ring Treatment

Taenia solium is a zoonotic parasite that causes seizures and other neurologic diseases in humans, resulting in economic loss to subsistence farmers when pigs become infected. Neurocysticercosis – infection by the T. solium parasite in the brain – contributes to 30–50% of epilepsy cases in Peru [21, 22]. Neurocysticercosis is more prevalent in rural low-income communities with poor sanitation, open defecation practices and no corrals. An implementation research project was conducted in the endemic region of northern Peru to adopt the Ring Treatment (RT), a public health program to control the transmission of T. solium and prevent cysticercosis from 2019 to 2024. RT is a targeted approach in which an antiparasitic drug for taeniasis is delivered to clusters of households around the home where an infected pig or meat was identified [23]. RT has been found to reduce the prevalence of taeniasis in humans and cysticercosis in pigs as much as mass treatment interventions but requiring fewer drugs to achieve the control gains [23].

RT implementation requires a bottom-up approach to implementing a solution from the local level and building top-down connections during the implementation process. Official directives from the health system’s leadership must also be established, policies to assign funding implemented and reporting systems adapted to register RT activities [24]. Parallel formative policy research at the national and regional level is needed to understand the zoonosis policy structures and the institutional rules of the diverse organizations. Figure 1 includes the country’s policy context of the RT case study.

Fig. 1.

Country’s policy context of the implementation of the ring treatment case study [23, 25–32]

Theoretical framework

The theoretical foundation for this research is the OH approach and the social–ecological systems (SES) framework [33, 34]. SES emphasizes the interactions between actors and ecological systems mediated by governing arrangements [35]. In the context of zoonoses, SES allows identification of the different scales (e.g., international, national and subnational), sectors (human, animal and agricultural systems) and disciplines (e.g. epidemiologists, policy researchers and veterinarians) that form part of the micro and meso elements of the disease transmission and mitigation system [36].

The institutional analysis and development (IAD) framework for policy analysis provides a guideline for policy research. IAD encourages input from multiple disciplines and sectors in policy design to understand the use of information and incentives for policy adoption and assess how policies fit in a particular context. Institutions are the rules, norms and strategies adopted by individuals operating within and across organizations [40].

The scheme shown in Fig. 2 represents our research conceptual framework and the components of the IAD framework, highlighting the main components studied. It also shows how the SES and OH frameworks informed our study research design of applying a multisectoral and multigovernmental approach33–35, 38, 39. This study is part of a policy analysis paper series that examines the community attributes, conditions, rules-in-use and interactions, with the primary goal of informing new policy initiatives and future multisectoral policies to address zoonosis in low-resource settings. This paper describes the conditions and rules-in-use that affect the policy action situation, the social space where policy actors interact, solve problems, make decisions and experience the effect of those actions. Conditions represent the resources, capabilities and processes needed to produce goods or services, and rules-in-use represent formal and informal rules that affect behaviour in the action situation (Fig. 2).

Fig. 2.

Conceptual research framework informed by the institutional analysis and development framework, social–ecological systems and One Health33–35, 38, 39

On the basis of recommendations from the literature regarding contextual policy factors needed to inform multisectoral collaboration [13, 18, 41], this paper investigates the policy conditions and the rules for policy-making among Peruvian governmental organizations involved in the prevention and control of zoonoses, including regional directorates in two regions of northern Peru. The main research objectives are: (1) to describe the priority-making process and the driving or limiting factors, (2) to describe the process for selecting policy solutions and (3) to describe perspectives regarding the organizations’ role in the prevention and control of zoonoses and authority in policy-making.

Methods

We used a case study with a qualitative research approach. The selected case study is the policy and institutional context surrounding the RT implementation project.

Participants

Participants included policy-makers and key informants integral to zoonoses programs in Peru at national and subnational levels; specifically, we included the Ministries of Health, Agriculture and Environment, all located in Lima. At the subnational level, we included the Regional Directorates of Health and Agriculture from the regions of Tumbes and Piura, where the implementation of the RT was underway. Experts in zoonoses prevention and control from educational centres and research institutes, as well as national and international organizations nominated by others, were also included.

We used purposive and snowball sampling. The base sampling frame was obtained from the directory of the Department of Vector-Borne and Zoonotic Diseases of the Ministry of Health and the National Agrarian Health Service. Informants recommended by interviewees and decision-makers identified during the implementation of the RT were also included. During RT implementation activities, we delivered a presentation introducing our study to national and subnational zoonoses policy-makers and invited their participation. Final sample included national experts who had middle- or low-level influence in decision-making but had the most knowledge regarding the zoonosis policy-making landscape. At the regional level, we interviewed experts who had high-level influence in decision-making such as regional program directors or managers. We prioritized those with more nominations and considered leaders in policy-making and multisectoral collaborations for zoonosis prevention and control.

We completed 77 interviews. We excluded 2 incomplete interviews and 16 interviews with representatives of external organizations owing to insufficient information about the country’s policy-making process or zoonosis prevention and control (academia, education, international organizations and elected authorities). The final analytical sample was 59 completed interviews.

Data collection

The guide used in the semistructured interviews aimed to elicit descriptions of policy processes and community attributes [41, 42]. It also included some questions from questionnaires used in the formative evaluation of the implementation case study with district-level healthcare leaders. The research team conducted five in-person interviews with Ministry of Health and Agriculture representatives to validate the interview guide in the region of Lambayeque, a city in northern Peru. The research team listened to the interview recordings and, after discussion, improved the language and the order of questions. Questions related to rules for policy-making included boundaries of organizational responsibilities and rules for identifying solutions, policy development process, interests behind policy change or adoption, systems influence (democracy, media and governance) on policy decisions and priorities, experience with multisectoral collaboration and mechanisms for accountability. The interview guide is available in Spanish and English in Additional File 1.

Interviews were conducted in Spanish by native Spanish speakers, as this is the primary language at the study site. The data collection team consisted of three interviewers and one operations manager who worked on various projects in the Tumbes region and had experience gathering quantitative and qualitative data. Data were collected from June to November 2023. Potential participants were invited to participate in the study through email, phone and official letters upon request. Subsequently, individuals were contacted by telephone to schedule the interview. Consistent with local research practices, we did not offer compensation or incentives for participation.

All research participants signed a consent form. We completed most of the interviews in person; some were done via video conference call when requested by participants. Interviews were conducted by a single research assistant and lasted an average of one hour. The sessions were recorded using a digital audio recorder or video recorder in case of a video conference call, after obtaining consent from the participant. A native Spanish speaker transcribed the semistructured interviews in Spanish, and identifiers were assigned to guarantee anonymity in the data analysis process. Ethical approval was obtained from Oregon Health and Science University (IRB ID: STUDY00024870) and Cayetano Heredia University (IRB ID: 209853).

Data analysis

We used a rapid qualitative method (RQM) to analyse the semistructured interview data [43]. RQM involves synthesizing the data into summaries and matrices instead of in-depth manual coding [43]. The analysis team consisted of two coders: the leading analyst (L.D.) and a local analyst (V.C.C.). In the initial phase, the team read all the transcripts, documented initial impressions, and selected the final analytic sample by removing transcripts with incomplete data regarding information about zoonosis policy-making. Then, each coder summarized three transcriptions independently. The coders jointly reviewed the summaries, discussed differences in coding or unclear code descriptions and agreed on the level of detail to include, such as page or line identifiers. The team conducted three rounds of initial coding and discussion on a subset of the data until both coders agreed and were comfortable splitting the data and coding independently. The resulting summaries from this initial phase were condensed into merged summaries. In the next phase, the main analyst (L.D.) split the remaining transcripts and assigned the coder, making sure that both coders had representative groups of transcripts from all organizations. Coders met frequently to discuss questions.

The final phase consisted of creating a matrix that categorized synthesized data to find patterns and identify similarities, differences and trends among groups of participants [44]. The leading coder developed a matrix with columns representing the main domains (e.g. policy solutions and priority-making process) and each row representing a participant. The matrix was grouped by ministry and government levels. Each coder completed the matrix independently, summarizing the main ideas per summarized transcript in each domain. The resulting matrix helped identify overall themes and contrast information among ministries and government levels. Most of the analysis was done in Spanish; only the final resulting matrix, overall themes and quotes included in this paper were translated into English.

Results

Table 1 presents information on the participants’ organization and government level. At the national level, 25 participants worked at the Ministry of Health, affiliating with various national institutes such as the Peruvian Center for Diseases Control and Prevention, the National Institute of Health and the Directorate of Medicine and Supplies. Eight people worked with the Ministry of Agriculture, four reported affiliations with the Agriculture Health Service Unit and four with the Forest and Wildlife Management Unit. Two participants worked at the Ministry of Environment. At the subnational level, interviews took place in two regions, Piura and Tumbes, with 19 participants affiliated with the Regional Directorate of Health and five affiliated with the Regional Directorate of Agriculture.

Table 1.

Description of organization and government level of participants

	N
National level	35
Ministry of Health	25
Ministry of Agriculture	8
Forest and Wildlife Management Unit	4
Agriculture Health Service Unit	4
Ministry of Environment	2
Subnational level	24
Regional Directorate of Health	19
Regional Directorate of Agriculture	5
Grand total	59

Table 2 lists the main themes that characterize participants’ perspectives regarding the priority-making process, the organizational process for selecting strategies and the rules regarding the organization’s role in developing and implementing policy for the prevention and control of zoonoses among participants from the Ministries of Health, Agriculture and Environment and the Regional Directorates of Health and Agriculture of Peru. In the following sections, we summarize and compare participants’ perspectives. A more detailed description of each theme by organization and level of government can be found in Additional File 2.

Table 2.

Main themes of policy process and rules among participants from the Ministries of Health, Agriculture and Environment

Priority-making
Type of process	Driving or limiting factors
- Priorities are decided at the national level with some feedback from regional experts – The process is based on the assessment of metrics with data captured by health systems – Passive animal surveillance systems receive reports from farmers and producers – There is adoption of multisectoral approaches to inform prioritization	– An unstable political environment and high turnover limit capacity and inhibit multisectoral work – National priorities surpass subnational priorities – International organizations promote the translation of programs into policy and influenced the priority-making process – Emergent zoonotic events shift priorities to generate new guidelines

Policy solutions
Type of process
– The process requires various cycles to obtain feedback from relevant parties. It is influenced by expert opinions – Solutions are developed at the national level and informed by evidence-based information and international standards – A lengthy policy process inhibits the updating of guidelines for disease treatment – Regional adaptations are made based on local research and case studies from neighbouring countries – There is a curative bias in human health programs. Agriculture solutions are focused on preventive rather than control strategies

Rules
Organization’s role in preventing and controlling zoonoses	Authority in policy-making
– The responsibility to control and prevent zoonoses is shared. Still, the Ministry of Health should convene and coordinate collaborations – There are undefined roles regarding the management of infected pets and wildlife among Ministry of Agriculture and Environment – The Ministry of Agriculture’s focus on using and transforming resources may be a barrier to OH application – Local organization such as regional governmental organizations, municipalities and prosecutorial offices are essential for addressing complex public health problems	– There are hierarchical rules in the policy-making process of national and local guidelines. The process must involve local authorities and community leaders – There is a need for a clear definition of responsibilities for multisectoral work in policy documents – The regional policy landscape is less complicated than the national to developing guidelines for multisectoral work – There is conflicting information about what subnational organizations can do in policy-making

Objective 1: the priority-making process and the driving and limiting factors

Priority-making process

The Ministries of Health, Agriculture and Environment participants described the priority-making process as reactive, with no institutional strategy to address emergent events preventively. Moreover, they reported that priorities are decided, and strategies are developed, at the national level. National guidelines inform the regional list of priorities, and programs’ annual goals are established for each region. The Ministry of Health’s national and subnational-level participants reported evaluating the disease burden utilizing data captured by the health information systems. Factors such as economic impact, morbidity, mortality and lethality were considered. Directives at the national level include a formal list of zoonotic diseases subject to national surveillance, which also informs program funding assignments.

The Ministry of Agriculture’s participants informed that a passive surveillance system of notifiable diseases from decentralized offices was used to capture or receive reports from various sources, including producers. The Ministry of Agriculture listed the impact of zoonoses on livestock production, international trade and the country’s economy as the main factors influencing their organization’s priority-making process. Proposed activities to be implemented in regions are based on goals from established zoonosis programs such as influenza, rabies and tuberculosis, which have a standard procedure regulated at the national level. Participants also reported that the needs of small- and medium-sized producers influenced the priority-making process. Activities are focused on prevention, such as vaccination campaigns and informational workshops about high-risk diseases in the region. Participants from the Ministry of Environment report that their organization does not have active surveillance systems to look for specific cases or strategic planning regarding wildlife zoonosis control and prevention. There are no guidelines or rules about what must be monitored or captured.

Multisectoral approaches are utilized in priority-making, with the participation of representatives from various ministries at the national and subnational levels. Interviewees also reported taking part in a multisectoral prioritization of zoonoses that applies the OH approach. It was also reported that feedback from regional partners and the community was integrated by organizing regional meetings to discuss problems and confirm cases reported in the system. Civil society, such as scientists, professional organizations, university leaders and community-organized groups, also participate. At the subnational level, multisectoral regional meetings are held to prioritize diseases, applying the perspective of social determinants of health. Almost all regional directorates participate in classifying and prioritizing diseases.

Driving and limiting factors

The Ministry of Health’s participants reported that the unstable political environment and conflict of interest limited work to address zoonoses. High turnover among policy-makers and leaders was a barrier to sustaining communication or building bridges. They also reported that self-interest was prioritized over technical or evidence-based information. One said, “There is an imbalance between economic power and the country’s needs; everything is about profit”. At the subnational level, participants reported feeling apathy among local authorities. Also, high turnover among professionals was reported as a barrier to the continuity of work and coordination with people from the municipalities. Changes in authorities or political conflict are a distraction and a barrier since it is “like starting from scratch”.

Participants from the Regional Directorate of Health reported that national priorities precede regional priorities. Regional activities focused on addressing national program goals that have assigned funding. One participant said, “Everything is formulated in the national operational plans, leaving no room to include more problems [at the regional level]”. They felt local leaders feared doing something new and that policy-makers focus on the diseases with the most political impact and significance. Some participants also reported that decision-makers were interested in solutions that help address various factors. They said, “The [authorities] think that finding a ‘synergy in two policies’ is a good strategy. Activities that addressed sanitation resolved leptospirosis and dengue; they have been successful”.

At the national and subnational levels, participants from the Ministries of Health and Agriculture considered international organizations such as the World Bank as promoters for translating programs into policy. They also described the Pan-American Health Organization as an essential advisor for developing or updating national norms and supporters of projects to address zoonoses, such as hydatidosis, resulting in the creation of a multisectoral commission.

Participants from all three ministries reported that outbreaks that became emergencies incentivized new regulations and guidelines. Owing to the avian influenza emergency, international, national and regional meetings took place, and guidelines were created to manage infected wildlife in the national territory. Also, the COVID-19 pandemic and the avian influenza outbreak generated the need to monitor and systematize information and apply an ecosystem approach to health. This shift in priorities resulted in the creation of a protocol with a multisectoral collaboration that includes mechanisms and methodologies to detect and treat infected animals and guided activities to control the influenza emergency.

Objective 2: the process for selecting policy solutions

The Ministries of Health and Agriculture’s participants described a standard process for selecting and defining interventions or strategies in a policy that includes various review cycles to obtain feedback from all interested parties. However, participants from the national level reported that “it is not a systematic process or method aligned to international standards”. Participants also stated that experts’ opinions influence the selection of solutions and the development of policy documents. Some participants recognize that this practice can be harmful and a serious problem. They said that, even though the process includes a review of the literature of scientific evidence, experts could influence and may make the last decision on what is included in the policy document on the basis of their “judgment, opinion, or experience”. Participants think the process should be based “solely on evidence from systematic reviews or meta-analyses”.

Participants from all three ministries described that a robust accumulation of evidence about an intervention’s effectiveness was needed to include it in a policy. International organizations help update policy documents and provide recommendations for pilots to evaluate and select the strategy that obtains the best results. Multisectoral collaboration meetings, such as the National Commission for the Prevention of Zoonoses, have generated guidelines backed by scientific research. Some participants reported that the OH approach has been applied to develop the latest policies. However, participants believe that it is a lengthy policy-making process. Work to establish specific protocols or technical documents is organized by disease. Owing to the required process, some regulations have taken more than 10 years to develop and have not yet been approved.

There are intergovernmental meetings, including national and regional leaders, to identify solutions and implementation adaptations in the regions. The meetings include technical experts and representatives from sectors that may be relevant to the implementation phase. The national level provides guidelines and coordinates actions with regions to address outbreaks. National regulations and operational procedures are adapted to the context, and when updates are needed, new guidelines are shared with regional experts for feedback. Participants at the subnational level reported there are macro multisectoral regional meetings to propose strategies to address various diseases, including zoonotic diseases. Research and pilot studies inform local regulations. Participants reported that researchers had disseminated studies with them and had influenced changes in local guidelines. Participants believe that the main barrier to testing new solutions is the requirement for scientific evidence to support their effectiveness, which may work in a different context. Pilot studies have been proposed to address that barrier.

Lastly, Ministry of Health participants believe there is a “curative bias” in health policy-making, which aims to treat people instead of taking a preventive approach. They said policy-makers recognize this issue, but it is not reflected in practice. The Ministry of Agriculture participants reported that, in their organization, solutions are focused on prevention rather than control, mainly focused on capacity building and education. Policy solutions include training, health education, vaccinations and surveillance based on reports of infected cases.

Objective 3: organizations’ role in preventing and controlling zoonoses

Perceptions of organization’s role in control and prevention of zoonoses

Ministry of Health participants believed the responsibility to control and prevent zoonoses is shared. Still, the Ministry of Health should convene and coordinate collaborations as zoonoses require a social determinant of health approach, which relies on other organizations’ responsibilities. At the subnational level, participants expanded on a similar idea of shared responsibilities: “It is shared, agriculture should be included, there is an issue with breeding grounds, in rice fields, banana fields, so, we have mosquitoes. The issue of basic sanitation, water, and sewage is quite scarce”.

Participants from all three ministries reported there are unclear roles regarding animal management. They stated that the law does not specify who is responsible for the animal reservoir, and some roles are still undefined, such as managing infected pets or wildlife. Participants from the Ministry of Agriculture believed that their organization has an educational role rather than a therapeutic role in zoonosis control and prevention. They said their institution is responsible for providing educational guidance for preventing and managing infected livestock and advising producers and farmers about correctly managing infected animals or culling but do not provide treatments. The Ministry of Environment participants also reported unclear rules on their organization’s role in preventing and controlling zoonosis, especially in managing wildlife zoonoses. However, they said they support other ministries creating policies to address zoonosis.

Participants described that the Ministry of Agriculture’s focus on activities related to the use and transformation of resources may be a problem when applying OH approaches. Farmers are reported to exert some influence on the policy agenda, prioritizing funding for diseases mainly affecting animals. However, participants recognize the value of the OH application in expanding perspectives. One participant from the Ministry of Agriculture said, “We as health authorities have our responsibilities regarding animal health. But now, with this new approach, ‘One World, One Health,’ I believe this is a new way to reengineer and see that we all have to participate […] to work together to see that health is the priority in every sense of the word”.

Lastly, participants at the subnational level through local organizations such as regional governments, municipalities, and prosecutors are essential for addressing public health problems. Engaging with farmers or producers is challenging if the city or the justice department is not involved in enforcing rules or incentivizing preventive behaviour, such as addressing an infectious disease outbreak that requires animal culling.

Authority to develop policy

Participants from the Ministries of Agriculture and Health reported that there are hierarchical rules to propose policies. They said that policies are developed at the national level, and some adaptations can be made at the regional level. Participants explained how this structure hinders addressing regional priorities, “Unfortunately, the diseases that are reported at a regional level or that are worked on are mostly decided in Lima where they make the decisions, so we cannot take action on a new policy or action that should be done”. Also, participants reported that hierarchical norms within an organization could be a barrier to policy-making, for instance, the sub-unit of Zoonotic Diseases Prevention and Control that needs to coordinate with other units of higher rank and that some may consider “not a pair”. One participant explained, “You need to be very technically empowered so that you can [call for collaboration], which is a limitation.”

Participants from the Ministry of Agriculture also reported that there is a need for a clear definition of responsibilities for joined work in policy documents, which could help define obligations without overstepping on functions, as they are not allowed to require the participation of other sectors. They thought clear roles for collaborations would incentivize more involvement from different sectors and local governments and assign funding directly for coordination activities.

Participants at the subnational level also believed that the policy development process needed to involve local authorities and community leaders. One interviewee said, “The process should involve regional leaders, including the community leaders or ‘apus,’ to help make the connections for later implementation work; local leaders’ words are like a law”. Public policies should flow “through the veins of the local governments”. Participants at the subnational level also thought that the regional context was less complicated than the national one for policy-making that involved other sectors. Participants reported working closely with regional directors, especially when developing regional policies that transcend sector boundaries. Regional policy-making related to zoonoses and vector-borne diseases mainly aims to incentivize the participation of external agents such as schools and police. One participant expanded on this: “The ordinance on Dengue had health theory and economics components, and involvement of institutions such as UGELES [school unions], police stations, parishes, fire stations, banks, all to contribute to prevention”.

However, there is conflicting information about what the subnational level can do in policy-making. Some participants reported that their primary role at the regional level was to solely implement operational plans following national guidelines. They said, “Plans, surveillance schedules, program implementation, regional prioritizations are made, but always within the framework of the national regulations; we cannot deviate from it”. In contrast, other participants described some space for regional policy-making: “We do not approve our policies here, but they can be proposed. […] We could issue the evidence in a document endorsed by the general management and send it to the [national level]”. Thus, regional health leaders’ empowerment and technical capacity building were recommended to propose policies.

Discussion

Our case study describes the policy process for prioritizing and selecting policy solutions, as well as rules regarding policy-making, among the various public organizations involved in the prevention and control of zoonoses at the national and subnational levels of Peru. By applying the OH approach as a foundational framework, we captured the perspectives of the various public organizations and levels of government involved in preventing and controlling zoonoses in Peru. As demonstrated by the COVID-19 pandemic and the outbreak of avian influenza, there is an urgent need to identify policy context factors integral to building multisectoral collaboration to address zoonotic diseases, especially in resource-constrained settings.

Similar policy research applying the OH approach has been conducted, mainly in African and Asian countries [19, 20, 37, 45, 46]. Okello et al. [19] used the Institute of Development Studies policy framework to understand the policy process in Uganda and Nigeria around control and prevention of neglected infectious diseases and how OH solutions are influenced by international partners from North America and Europe [19]. They found that OH was accepted globally, but national multisectoral collaborations suffered from a lack of governance and needed leadership from a single organization. Likewise, we found that leaders in zoonosis management in Peru agreed that OH is suitable for addressing zoonoses but also recognized the need for governance structures with guidance from international organizations to sponsor multisectoral collaborations, including funding structures to support joint work to guarantee sustainability.

Results from this study describe structural barriers to priority- and policy-making, with the majority of decisions and regulations developed at the national level. Subnational organizations have little room to address local problems, such as the surveillance of endemic local diseases, which as a result, creates the cycle of neglected diseases not being captured in the system. The inclusion of subnational perspectives revealed that zoonosis control and prevention requires not only a multisectoral approach but also an intergovernmental approach, including local perspectives, to inform policy adaptations. Similarly, a study aimed at describing barriers and facilitators for informing the convergence of human, animal and environmental health sectors that collected semistructured interviews among policy-makers in India described high central government influence on local health policy agenda-setting and higher priority assigned to global zoonoses emergencies rather than zoonoses affecting local populations [47]. Moreover, the authors also found similar systems barriers to collaboration as our study related to hierarchical systems structures that created power imbalances among experts working in lower subunits within an organization [47]. Our study also found these barriers to inhibit policy-making at the subnational level. Recommendations from our study and similar research aimed at identifying the best strategies to operationalize OH include strengthening leadership capacities and empowering local experts and technicians to promote policy changes or adaptations [45]. It is also essential to integrate surveillance and information systems among animal, human and environmental systems to capture the real burden of neglected endemic zoonoses in rural areas, build collaborations among government, academia and educational organizations to inform on problems undetected in governmental surveillance systems as well as provide scientific evidence of effective interventions that could be translated into public policies. This paper illustrates the policy context for the prevention and control of zoonoses in Peru, and illustrates the application of policy research frameworks to study policy processes in a low-resource country [48, 49]. Studying Peruvian policy networks locates and describes views from human health, agriculture and environment experts and policy-makers and informs future collaborative strategies. It is the first step to understanding which systems could be efficient and effective in facilitating intersectoral collaboration and coordination and informing efforts to scale OH programs in low-resource countries [13].

It is also vital to inform contextual factors from low-resource countries not identified in contemporary theories built with data from high-resource countries. Health systems’ characteristics in low-resource settings influence policy differently; the state assumes multiple functions as a provider, purchaser and regulator, and potentially even in managing research [48]. As described by the literature on adaptation needed in policy frameworks for studies in low-resource settings, we found structural factors such as hierarchical structures, power dynamics and more diverse health policy actors, including for-profit and not-for-profit organizations and international agents shaping national policy and excising influence from outside countries’ borders [48, 50, 51].

This study has some limitations. The political environment in Peru is rapidly changing, led by political crises and health emergencies such as the outbreak of avian influenza. Organizations may experience changes in policy processes or roles when addressing zoonoses, so study results only capture the policy process for the period when data were collected. Snowball sampling could have missed isolated experts with perspectives not captured in this study. Recommendations resulting from our analysis are the most valuable insight. Despite not having feedback from participants in the analysis and interpretation process, local coders helped verify and validate the analysis process and the interpretation of results. Lastly, this study did not apply all seven rules-in-use from the IAD framework. The resulting themes were mainly around rules of roles and authority for policy-making and implementation. Future studies could provide a more in-depth analysis of the rules-in-use for establishing collaborations applying the IAD framework.

Conclusions

Endemic zoonoses cause a high burden to low-resource countries, and emergent zoonotic diseases that are not well managed are a global risk. Understanding key experts’ and policy-makers’ perspectives is critical to informing scaling-up strategies and improving sustainability. Applying OH, this research studied the policy conditions to prevent and control zoonotic diseases among experts and policy-makers of relevant public organizations at the national and subnational levels in a low-resource country. Results indicate that, although evidence-based information and multisectoral meetings were reported to be used in policy-making and decision-making, structural barriers such as hierarchical norms hinder policy development or adaptations from the regional level. Passive surveillance systems do not capture the real burden of regional zoonoses, and funding systems prioritize diseases selected at the national level instead of local problems. Training and empowering local technicians and experts were recommended to support regional collaborations and policy-making. There is also a recognition and awareness that comprehensive approaches such as OH, which promotes multisectoral collaboration, are the best approach for addressing zoonoses. Research implications from this study include a more comprehensive analysis of the rules-in-use of policy-making and collaborations to provide recommendations for future multisectoral collaborations to control and prevent zoonoses in the South American region.

Abbreviations

HIV

Human immunodeficiency virus

IAD

Institutional analysis and development

LRCs

Low-resource countries

OH

One Health

RT

Ring treatment

RQM

Rapid qualitative method

SARS-CoV-2

SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2

SES

Social–ecological systems

Author contributions

L.D. designed the study, supervised data collection, analysed the data, prepared figures and tables, and wrote the main manuscript text. E.K. verified the analytical methods, provided feedback on the analysis, and contributed to the final manuscript. V.M. provided feedback and contributed to the final manuscript. V.C. collected data, analysed the data, and contributed to the final manuscript R.A. collected data, analysed the data, and contributed to the final manuscript P.V. collected data, analysed the data, and contributed to the final manuscript S.O. supervised the findings of this work, provided feedback, and contributed to the final manuscript. J.G. supervised the findings of this work, discussed the results, and contributed to the final manuscript.

Funding

This study was funded by the US National Institute of Neurological Disorders and Stroke, grant number NIH R01NS080645, and the Fogarty International Center of the National Institutes of Health (grant number D43TW009345) awarded to the Northern Pacific Global Health Fellows Program. Publication costs were supported by startup funding provided by the Oregon Institute of Occupational Health Sciences at Oregon Health & Science University. Seth O’Neal MPH for the Cysticercosis Working Group in Peru.

Data availability

Additional File 2 provides a more detailed description of the results for each theme by organization and level of government. The datasets generated and/or analysed during the current study are not publicly available because they could include identifiers.

Declarations

Ethics approval and consent to participate

All research participants signed a consent form before participating in the study. Ethical approval was obtained from Oregon Health and Science University (IRB ID: STUDY00024870) and Cayetano Heredia University (IRB ID: 209853).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.