| | Population: | Morocco: seven regions sampled:
(i) Rabat (administrative capital ministries location)
(ii) Bel Ksiri (high Cystic Echinococcus (CE) prevalence in humans and animals)
(iii) Khenifra (high human CE incidence)
(iv) Agadir (high CE in humans and animals)
(v) Laayoune
(vi) Tantan
(vii) Guelmim regions (low CE incidence in humans)
Internal stakeholders:
(i) Ministries of Health, Agriculture, and Interior
(ii) Public hospitals
Intermediate stakeholders:
(i) Collaborate with internal stakeholders e.g. The Ministries of Education (teachers), Islamic Affairs, and the media (disseminate messages concerning CE)
External stakeholders:
(i) Researchers
(ii) Private physicians
(iii) Veterinarians
(iv) Elected politicians
(v) WHO (World Health Organization) or World Organization for Animal Health (OIE)
(vi) Slaughterhouse workers; breeders; industry associations (e.g., National Association of Cattle, Sheep, or Goat breeders) |
| | Sample size: | (i) Focus group: 22
(ii) Semi-structured interviews: 164
(iii) Total: 186 |
| | Program outputs: | National Hydatidosis Control Programme (NHCP), Morocco (2007):
Dogs:
(i) Population control
(ii) De-worming
(iii) Improving slaughterhouse sanitary standards: CE surveillance at slaughterhouse. Infected offal disposal managed by the Ministry of Agriculture via the National Office for Food Safety (ONSSA)
Humans:
(i) Surveillance and treatment (managed by the Ministry of Health via local health delegations and public hospitals)
Public health education:
(i) All government ministries, but the Ministry of Education prepared an awareness brochure for children
(ii) The Ministry of Islamic Affairs delivered awareness campaigns in mosques |
| | Study design: | Qualitative case study |
| | Program outcomes and/or impact: | Multi-stakeholder analysis (2016-2018):
One day focus group (face to face in Rabat):
(i) Preliminary interview results presented, and groups (4-7 participants) formed to discuss result topics (obstacles, stakeholder coordination, and proposed improvements). One researcher moderated and one took notes
(ii) Participants
(a) Civil servants from the Ministries of Health (n = 2), Agriculture (n = 2), Interior (n = 1), Education (n = 2), and Islamic Affairs (n = 1)
(b) Researchers: The Faculty of Medicine (n = 3); National Institute of Hygiene (n=1); National School of Public Health (n = 2); Hassan II Agronomic and Veterinary Institute (n = 5); the Institute of Tropical Medicine Antwerp (Belgium) (n = 3)
Semi-structured interviews (face to face,n = 164):
(i) 91 internal and intermediate stakeholders and 22-51 external selected from focus group
(ii) Interviews transcribed into Arabic or Berber language and translated into French (common language to all researchers) or English
(iii) Interviews recorded (20-45 min), transcribed, and checked for quality assurance
(iv) Software-assisted textual analysis (RQDA-R software)
Interviews structured and coded (six categories):
(i) Stakeholder activities: priority, interests, importance
(ii) Stakeholder role: involvement, influence, and power |
| | Main findings: | Multi-stakeholder analysis (three criteria incorporated into six categories):
1. Appropriation:
(i) Stakeholders stated interests and felt involved in offal seizure, slaughterhouse development, and treatment of human cases
(ii) Neglected measures (actors did not feel involved in decision making): dog population control, dog de-worming, and raising awareness. Mostly veterinary preventative and health education measures neglected interests and involvement
2. Political agency (power over other stakeholders):
(i) Internal stakeholders (e.g., public health sector) possessed highest power, but considered the CE program low priority. Only the National Office for Food Safety (ONSSA) considered CE program a high priority
(ii) External political stakeholders: high power, but considered the program low priority
(iii) External stakeholders: abattoir workers, the WHO, and Municipal Hygiene Offices considered the program a high priority, but had minimal power
(iv) Intermediate stakeholders (e.g., the Ministry of Education) considered the program low priority and possessed little power
3. Sociotechnical agency (influence and importance to stakeholder work or income):
(i) Internal stakeholders: high influence and importance. However, the Municipal Hygiene Offices, local authorities and Ministry of the Interior (responsible for program infrastructures and local enforcement) had limited agency, due to low priority ascribed
(ii) Intermediate stakeholders: low importance, low influence, as primary role was to improve the work quality of internal stakeholders
(iii) External stakeholders: some considered programs high importance, but little influence (e.g., slaughterers and breeders’ associations). External funders (OIE and WHO) had medium influence and medium importance
(iv) External stakeholders who competed with program resources (e.g., politicians) or provided human resources (e.g., researchers, private physicians, and veterinarians) were categorized as low influence and low importance
(v) Internal actors relied upon external factors, such as the WHO, for funding support and program promotion
(vi) The current control program failed to represent the interests of external actors: OIE, abattoir workers, breeder associations, local politicians, researchers, private-sector physicians, and veterinarians
Recommendations:
(i) Create a central office: representative for each stakeholder interest, with high power and involvement, who places high priority on program
(ii) To address high number of stakeholders/complexities: assign stakeholders subgroups based upon similar interests and focus on one or more program aspects
(iii) Create a working group that represents multi-stakeholder interests
(iv) Address neglected control areas (e.g., dog population control, de-worming, and health education) |
| | Limitations: | (i) Confounding bias: seven study areas had different climate, human habits, and geography
(ii) Results from individuals within the same institution were semi-quantified and mean average calculated. While this captures common trends, it may not account for assessment of individual skill, knowledge, and world views
(iii) Research Bias: no conflict of interest statement and unclear if “anonymity” meant interviewees were blinded to respondents’ institutional affiliation
(iv) Central office recommendation suggests a representative with high power, but internal stakeholders who possessed high power considered the CE program a low priority. Thus, central office may simply continue current power dynamics |
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