Health Policy and Planning - current issue

Future directions for health policy analysis: a tribute to the work of Professor Gill Walt

Gilson, L., Buse, K., Murray, S. F, Dickinson, C. — 2008-08-13

The terrain of health policy analysis in low and middle income countries: a review of published literature 1994-2007

Gilson, L., Raphaely, N. — 2008-08-13

This article provides the first ever review of literature analysing the health policy processes of low and middle income countries (LMICs). Based on a systematic search of published literature using two leading international databases, the article maps the terrain of work published between 1994 and 2007, in terms of policy topics, lines of inquiry and geographical base, as well as critically evaluating its strengths and weaknesses. The overall objective of the review is to provide a platform for the further development of this field of work.

From an initial set of several thousand articles, only 391 were identified as relevant to the focus of inquiry. Of these, 164 were selected for detailed review because they present empirical analyses of health policy change processes within LMIC settings. Examination of these articles clearly shows that LMIC health policy analysis is still in its infancy. There are only small numbers of such analyses, whilst the diversity of policy areas, topics and analytical issues that have been addressed across a large number of country settings results in a limited depth of coverage within this body of work. In addition, the majority of articles are largely descriptive in nature, limiting understanding of policy change processes within or across countries. Nonetheless, the broad features of experience that can be identified from these articles clearly confirm the importance of integrating concern for politics, process and power into the study of health policy. By generating understanding of the factors influencing the experience and results of policy change, such analysis can inform action to strengthen future policy development and implementation. This article, finally, outlines five key actions needed to strengthen the field of health policy analysis within LMICs, including capacity development and efforts to generate systematic and coherent bodies of work underpinned by both the intent to undertake rigorous analytical work and concern to support policy change.

'Doing' health policy analysis: methodological and conceptual reflections and challenges

Walt, G., Shiffman, J., Schneider, H., Murray, S. F, Brugha, R., Gilson, L. — 2008-08-13

The case for undertaking policy analysis has been made by a number of scholars and practitioners. However, there has been much less attention given to how to do policy analysis, what research designs, theories or methods best inform policy analysis. This paper begins by looking at the health policy environment, and some of the challenges to researching this highly complex phenomenon. It focuses on research in middle and low income countries, drawing on some of the frameworks and theories, methodologies and designs that can be used in health policy analysis, giving examples from recent studies. The implications of case studies and of temporality in research design are explored. Attention is drawn to the roles of the policy researcher and the importance of reflexivity and researcher positionality in the research process. The final section explores ways of advancing the field of health policy analysis with recommendations on theory, methodology and researcher reflexivity.

Policy to tackle the social determinants of health: using conceptual models to understand the policy process

Exworthy, M. — 2008-08-13

Like health equity, the social determinants of health (SDH) are becoming a key focus for policy-makers in many low and middle income countries. Yet despite accumulating evidence on the causes and manifestations of SDH, there is relatively little understanding about how public policy can address such complex and intractable issues. This paper aims to raise awareness of the ways in which the policy processes addressing SDH may be better described, understood and explained. It does so in three main sections. First, it summarizes the typical account of the policy-making process and then adapts this to the specific character of SDH. Second, it examines alternative models of the policy-making process, with a specific application of the ‘policy streams’ and ‘networks’ models to the SDH policy process. Third, methodological considerations of the preceding two sections are assessed with a view to informing future research strategies. The paper concludes that conceptual models can help policy-makers understand and intervene better, despite significant obstacles.

The role of state and non-state actors in the policy process: the contribution of policy networks to the scale-up of antiretroviral therapy in Thailand

Tantivess, S., Walt, G. — 2008-08-13

Antiretroviral therapy (ART) is difficult in poor settings. In 2001, the Thai government adopted the policy to scale-up its treatment initiative to meet the needs of all its people. Employing qualitative approaches, including in-depth interviews, document review and direct observation, this study examines the processes by which the universal ART policy developed between 2001 and 2007, with the focus on the connections between actors who shared common interests—so-called policy networks. Research findings illustrate the crucial contributions of non-state networks in the policy process. The supportive roles of public-civic networks could be observed at every policy stage, and at different levels of the health sector. Although this particular health policy may be unique in case and setting, it does suggest clearly that while the state dominated the policy process initially, non-state actors played extremely important roles. Their contribution was not simply at agenda-setting stages—for example by lobbying government—but in the actual development and implementation of health policy. Further it illustrates that these processes were dynamic, took place over long periods and were not limited to national borders, but extended beyond, to include global actors and processes.

Changing fortunes: analysis of fluctuating policy space for family planning in Kenya

Crichton, J. — 2008-08-13

Policies relating to contraceptive services (population, family planning and reproductive health policies) often receive weak or fluctuating levels of commitment from national policy elites in Southern countries, leading to slow policy evolution and undermining implementation. This is true of Kenya, despite the government's early progress in committing to population and reproductive health policies, and its success in implementing them during the 1980s. This key informant study on family planning policy in Kenya found that policy space contracted, and then began to expand, because of shifts in contextual factors, and because of the actions of different actors. Policy space contracted during the mid-1990s in the context of weakening prioritization of reproductive health in national and international policy agendas, undermining access to contraceptive services and contributing to the stalling of the country's fertility rates. However, during the mid-2000s, champions of family planning within the Kenyan Government bureaucracy played an important role in expanding the policy space through both public and hidden advocacy activities. The case study demonstrates that policy space analysis can provide useful insights into the dynamics of routine policy and programme evolution and the challenge of sustaining support for issues even after they have reached the policy agenda.

Addressing the theoretical, practical and ethical challenges inherent in prospective health policy analysis

Buse, K. — 2008-08-13

As a function of the inherently political nature of health policy, there have long been calls for, as well as guidance on, analysis of its political dimensions to inform practice. Yet there are few accounts in the literature of systematic attention to real-time documentation and analysis of political-economy factors and feedback to engender reform. The dearth of such prospective policy analysis is perhaps understandable given the many intrinsic difficulties in such an enterprise. This paper provides an outline approach of how researchers might work together with advocacy coalitions (or other political actors) to document and analyse the efforts of such coalitions to use policy analysis to influence the policy processes—agenda setting, policy formulation and policy implementation—in which they engage. In so doing, it identifies challenges based on reviews of the theoretical, methodological and empirical literature as well as the experience of the author. The aim of the paper is to generate debate to assist in resolving the myriad challenges inherent in prospective policy analysis. The paper responds to appeals for political research which addresses the problems confronting political actors so as to guide future action-research for evidence-informed, pro-poor health policy.

How to start thinking about investigating power in the organizational settings of policy implementation

Erasmus, E., Gilson, L. — 2008-08-13

Power, a concept at the heart of the health policy process, is surprisingly rarely explicitly considered in the health policy implementation literature for low and middle income countries. In an attempt to support empirical research on power, this paper outlines some of the key insights on power from implementation theory. It then describes examples of power that might be seen in health policy implementation settings, such as hospitals, clinics and the local bureaucracies in which these are embedded, and concludes with suggestions for ways of investigating power and ensuring sound judgments are made about its existence and its influence over policy implementation.