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Overseas DevelopmentInstitute
Key points
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Policy analysis cancontribute to meeting health objectives byuntangling the complex forces of power andprocess that underpinchange.
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Health policy analysishas not been adequatelydeveloped and applied inlow and middle incomecountries.
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Building a critical massof networked researchersand policy-makersprovides the key todeveloping the field andimproving its contributionto health outcomes.
Overseas Development Institute
ODI is the UK’s leading independentthink tank on international develop-ment and humanitarian issues.
Briefing Paper 
25
October 2007
Child survival rates show slow improvement,and are worst in sub-Saharan Africa.
How can the analysis of power and process in policy-making improve health outcomes?
Moving the agenda forward
T 
he Millennium Development Goals(MDGs) Report (UN, 2007) indicates thatprogress against the goals at mid pointis patchy. Many of the key challengesthat need to be addressed relate to health:continued high rates of maternal mortality, slowimprovements in rates of child survival, anda rising number of deaths due to AIDS in sub-Saharan Africa. Many factors underlie the slowprogress. These include lack of investment inweak health systems, insufficient or poorly coor-dinated donor resources, lack of agreement oneffective technical strategies, and limited scale-up of interventions that work. An area that hasreceived less attention but contributes to slowprogress in achieving the health-related MDGsis the analysis of how and why national healthpolicies achieve less than expected, perform dif-ferently from expected, or even fail.New paradigms of health policy analysisbegan to emerge in the 1990s, focusing less ontechnical content of health policy (the ‘what’ of policy – for example whether to recommend user fees or insurance as more equitable and efficientin financing health care) and more on the actors,power and processes involved in developing andimplementing policy, and the contexts withinwhich decisions are made. These paradigmssurfaced as demand grew to understand howand why certain policies do well or do not suc-ceed and how such understanding could helppolicy-makers make strategic decisions aboutfuture policies and their implementation. Tenyears later, what do we now know about the fac-tors influencing the patterns and effectivenessof health policy change and how can we movethe agenda forward in order to improve healthoutcomes?
What has health policy analysistaught us?
Policy-making is not just about a particular deci-sion made at a certain point in time, but moreoften understood as the ongoing interactionamong institutions (the structures and ruleswhich shape how decisions are made), interests(groups and individuals who stand to gain or losefrom change) and ideas (including argumentsand evidence) (John, 1998). This means that thestudy of health policy needs to take into consid-eration factors such as the role of the state, theinterests of various actors and the manner inwhich they wield power, the nature of politicalsystems and their mechanisms for participation,and the rules of the game in so far as the infor-mal and formal policy processes are concerned.Moreover, policy analysis must also examine therole of culture and values systems and how theyare expressed as beliefs, ideas and argument, aswell as international factors which are increasinginter-dependence between states and affectingstate sovereignty over policy processes.
 
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Briefing Paper 
 Much of the health policy analysis literature todate has helped describe what has happened in aparticular policy life course and to a lesser extent hasidentified important determinants of policy change.This has contributed to our general knowledge aboutactors and processes related to health policy-makingand has also demonstrated that analysis of power andprocess can add value to those attempting to influ-ence policy change. For example policy analysis can:
1. Help explain why certain health issues receivepolitical attention
Despite political will being cited as critical in gettingdecision-makers to display serious interest in major health problems, such as congenital syphilis andmaternal mortality, we know very little about how itemerges and how it is sustained. A series of case stud-ies examining the emergence of political commitmentfor safe motherhood in five developing countries hashelped our understanding of factors explaining agendasetting and government action. The experiences fromthe case studies demonstrate that attaining publichealth goals is as much a political challenge as it is amedical or technical challenge, with eight generic fac-tors of particular importance (see box 1).
2. Assist in identifying which stakeholdersmay support or resist reform; and can thereforebe used to develop strategies to improve theprospects for pro-reformist groups
For example, Amanda Glassman and colleagues haveused policy analysis to examine the challenges associ-ated with the adoption of health reform processes inthe Dominican Republic (1999). The analysis includeda systematic examination of the support and opposi-tion for a proposed policy based on an analysis of interests (who stood to lose and gain), positions (for or against), and influence of five key groups of play-ers. Reformers benefited from policy analysis whichinformed the development of explicit political strate-gies for change. Strategies were devised to manageinterest groups, the bureaucracy and technocrats, andranged from inventing new options to create commonground, making strategic use of the media, mobilisingneutral friends, creating coalitions, and engaging theopposition in technical debate.
3. Help identify and address obstaclesthat undermine policy implementation andjeopardise national and global goals for improved health
In examining the influence of nurses and clinic coor-dinators on the implementation of South Africa’s freehealth care policy, Walker and Gilson (2004) focusedon understanding frontline staff experiences, payingparticular attention to the personal and professionalconsequences of the policy, the factors that influencedtheir responses to the policy, and what they perceivedas the barriers to effective implementation. Resultsrevealed that nurses were asked to implement a policyabout which they had not been consulted, and whoseconsequences for their routines were largely ignored.These features of the policy process as well as nurses’values, including their perceptions of deserving or undeserving patients, had significant implications for the manner in which the free health care policy wasimplemented in practice. The prospects of prevent-ing distortions of policies during implementation arereduced through communication, consultation and ashared understanding of policy goals between provid-ers, patients and policy-makers. 
4. Improve the prospects that technical evidenceis considered during policy formulation leading to evidence-based policy 
For example, Tangcharoensathien and Jongudomsuk(2004) found that Thailand’s experience of design-ing, adopting and implementing a policy of universalhealth insurance coverage relied on national capac-ity for health policy analysis and research on healthsystems which generated evidence to guide andsupport the political decisions that were involved.Policy change was brought about after commission-ing policy studies and publicly disseminating resultsregarding the feasibility of universal coverage. Alsoinfluential were social and political advocates whoworked closely with policy researchers to ensure thatthe policy changes were guided by evidence.
5. Establish more realistic expectationsconcerning incremental pro-poor change
A synthesis of lessons learned of donor approaches to
Box 1: Politics matters – Generating political priority for maternalmortality reduction
Shiffman (2007) analyses the extent to which maternal mortality emerged on the po-litical agenda in five developing countries (Guatemala, Honduras, India, Indonesiaand Nigeria) and attempts to answer the question of why policy makers prioritisecertain issues and how support for an issue can be generated and sustained (in thiscase with budgetary allocations). From the case studies, a number of key factors areidentified as having helped maternal mortality emerge on the political agenda:• International agency priorities, resources and medical technologies are critical butadvances in maternal mortality is a national political challenge.• Local context matters and generating will is not a formulaic process.• Advocates are more likely to be effective in moving political elites to action if they:a) coalesce and form a cohesive policy community;b) bring into their community well connected and influential politicalentrepreneurs (individuals have been critical in mobilising governmentpolicy action in Indonesia and Honduras);c) develop credible indicators to show policy-makers the extent of the problem;d) organise large scale focusing events to galvanise support for the issue; ande) present clear policy alternatives to show the problem can be dealt with.• Political transitions can alter priorities and change the way policies are developed.Democratic change in Nigeria has created political space for social issues, suchas maternal mortality reduction, to appear on the national agenda. In Indonesia,democratic transition and reform (decentralisation) has weakened safe mother-hood policy with provinces and districts placing less political priority on thematernal mortality, in favour of more visible and vote winning issues such as roadbuilding.
 
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Briefing Paper 
understanding political factors shaping developmentoutcomes (such as the Swedish International Devel-opment Cooperation Agency’s power analysis andThe UK Department for International Development’sDrivers of Change) reports that political analysis hasgenerated knowledge and provided a shared lan-guage and understanding of the impact of politicaland institutional context, and stimulated thinkingabout pathways of change. These studies have alsocontributed positively to improved aid effectivenessby highlighting the risks of alternative strategies andinvestments, help set realistic timescales for change,and encourage a more incremental approach that canimprove implementation of programmes.
What is the state of health policy analysis?
Although health policy analysis can increase our understanding of the complexities of health policyprocess and provide insights as to how best tointervene in developing and implementing policy,this kind of analysis remains underdeveloped andhas limited application in low and middle incomecountries. Despite a number of well designed stud-ies offering authoritative and useful findings, theexisting body of published health policy analysis issurprisingly small and the bulk of it is analyticallyweak; typically describing ‘what’ has happened in aparticular setting rather than explaining ‘why’ it wasthe case.A review of published literature in the field (Gilsonand Raphaely, 2007) shows that a very limited number of conceptual frameworks and theories are used byhealth policy analysts (see Box 2, page 4). Most stud-ies are ‘inductive’ in nature, ‘cherry picking’ elementsof theory for the purpose of the study, rather than‘deductive’ with studies being set up to test a theory’sapplication. Far too little formal comparative work isundertaken and there are few cases of bodies of workrelating to specific policies across a number of coun-tries or to a range of policies within any one country.Surprisingly, despite the central role it plays in deter-mining policy change, the concept of power remainsunder-researched in health policy analysis.Furthermore, the results of health policy analysisare not reported in the key medical journals whichhave the widest readership and impact. Given theconsiderable difficulties in undertaking rigorous policyanalysis research, largely as a result of funding, dataaccess and reporting constraints, the thinness of thefield is understandable.In short, despite ten years of calls for more healthpolicy analysis which elucidates the determinants of policy change, the field remains in its infancy and isfailing to deliver what it potentially could.
What ought to be on the health policy analysis agenda?
A workshop in London in May 2007
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brought together over 25 health policy analysts from Asia and thePacific, Africa, Middle East, North and South Americaand Europe to exchange ideas about the use of theo-retical and conceptual frameworks, and methods andapproaches, to investigating and understanding policyprocesses, the use of policy analysis to support policychange, and the approaches of development partnersto policy analysis.While the health policy analysts naturally arguedthat their research agenda is potentially long, threeareas stand out as being particularly rewarding:
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Make better use of the existing, often descriptive,body of policy analysis through:
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synthesis of existing case study material using the-oretically robust and well-structured approachesto synthesis of findings;
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lesson learning from country case studies thathave a common topic focus or common frame-work; and
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lesson learning from all the health policy analysisstudies carried out within a single country.
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Ensure that future research on agenda setting andpolicy implementation:
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places greater emphasis on comparative studies;and
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increases the use of theoretical concepts and/or analytical frameworks that underpins analysis.
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Focus more explicitly on the methods for doing policyanalysis, by:
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increasing the methodological diversity withinpolicy analysis by drawing more extensively onexperience from other fields whilst paying greater attention to the benefits and limitations of differ-ent methodological approaches; and
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enhancing ‘reflexivity’ in relation to both the rela-tionships between researchers and policy actorsand the manner in which the findings from policyanalysis are used to engage with policy actors.Policy analysis remains an underutilised tool in healthdevelopment. Concrete steps are being put in placeto plug this gap (see www.odi.org.uk/pppg/politics_and_governance/events/Health_Policy_Analysis).With seven years remaining to reverse and improvehealth-related MDGs, academia, think tanks, donors,government officials and policy activists would dowell to take another look at its potential and how itmight be best applied. In particular policy-makersshould: 
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Pay more attention to the politics of policy change.
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Consider the development of political strategies toengender change.
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Invest more in understanding these politics throughbetter resourcing of policy analysis.
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Ensure active collaboration with researchers andpublic health advocates so as to generate better quality and more relevant policy analysis.
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